The development of quality and healthcare systems in the UK

1
The development of quality and healthcare systems
in the UK

• Maggie Somekh

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Creation of the NHS1948 Beveridge report 1942

• Provides the majority of healthcare in UK
• Integral part of UK life and therefore a
  political pawn
• Private health care represents a small percentage
  of the population
• NHS is free at point of delivery 96bn budget
  providing services to a population of 60 million
  86 living in urban setting

3
Payments in the NHS

• Apart from prescription charges of 6.65 (free to
  pensioners, children and some others) there is no
  charge
• Wales, Scotland and Northern Ireland manage their
  health services separately and have adopted some
  of the ideas that the English services have.
• NHS dentistry is not now so widely available,
  there are charges for this at 15.50 for an
  examination and then further costs for work

4
Staffing in the NHS

• Employ direct most of the doctors nurses and
  clinical staff working for them, these work in
  NHS run hospitals
• GPs, dentists, opticians and other providers are
  mostly self-employed and contact their services
  back to the NHS.
• The NHS employs around 1.3 million staff

5
Modern Management in 1980s

• Griffiths Report of 1983
• General Managers appointed
• Clinicians involved in management
• System under financial pressure
• Waiting lists for operations lengthy
• 1988 Margaret Thatcher announced review of NHS

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Internal Market

• White papers
• Working for Patients
• Caring for People
• 1990 The National Health Service Community Care
  Act (in England) defined the internal market.

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Purchaser provider split

• Purchaser Provider split happened. Health
  Authorities no longer ran hospitals but
  commissioned services and some G.P.s became fund
  holders able to purchase some services
  themselves. The Providers became independent
  trusts which encouraged competition and increased
  local differences
• Contracting out of services such as catering and
  cleaning started to happen
• Huge variety in efficacy of these new
  arrangements especially amongst G.P.s

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Drivers for change

• Increases in costs of drugs and technology with
  new developments all the time
• Desire to increase standards of care
• To offer patients choice
• Aging population
• Growing recognition of the role of public health
  and that of primary care in preventative care
  e.g. smoking, obesity, teenage pregnancy, early
  diagnosis of diabetes, and heart disease.

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Primary Care Trusts

• Fundholding GPs were now well established
• Their functions for purchasing services were now
  taken over by PCTs with significant
  responsibility for commissioning services for
  populations.
• These were managed by a Board including GPs for
  the area
• The role of commissioning services which had been
  held by the Health Authorities disappeared except
  for highly specialist services and their role
  changed to one of financial monitoring and
  quality monitoring

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Clinical Governance

• Through the late 1990s, increasing interest in
  setting standards for care that are measurable
  and provide baseline for audit
• Development of risk management systems
• Complaints taken much more seriously
• No blame policy introduced to encourage reporting
  of near misses and clinical untoward incidents
• Health and Safety given high priority
• Staff health and stress levels
• Readmission rates
• Suicides
• Infection control

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• Waiting times
• Privately run clinics (Diagnostic Treatment
  Centres) taking on more and more routine
  procedures such as orthopaedics increasing heat
  in hospital departments and reducing funding
  available
• Focus on AE waiting times
• Lack of focus on some other important areas
• Up to 400 different targets to meet in early
  2000s

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Clinical Governance

• CHI (Commission for Health Improvement) set up
  1999 to monitor clinical governance in Trusts
  using star ratings to measure agreed standards
• NICE (National Institute for Clinical Excellence)
  set up 1999 to provide an evidence base for
  expenditure for effective use of pharmaceuticals
  and procedures

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Change on Change

• Having set up over 300 Primary Care Trusts to
  manage commissioning in local areas during the
  early 2000 these are now being reduced to half
  increasing their individual responsibility to
  something like that which the Health Authorities
  originally held
• Community Trusts being developed to manage the
  delivery of community based services
• Mental health trusts are being merged to provide
  large trusts serving populations of over a
  million (a large county in England)
• Acute trusts have merged in many places as
  sustaining specialist services and maintaining
  clinical governance has proved impossible

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NHS Foundation Hospitals created 2003

• Three key characteristics
• Freedom to decide locally how to meet their
  obligations
• Accountable to local people, who can become
  members and Governors
• Authorised and monitored by Monitor Independent
  Regulator of NHS Foundation Trusts

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• Free to decide capital investment to improve
  services
• Ability to borrow to support this investment
  without seeking external approval
• Establish close relationships with those who use
  service. Form of public ownership and
  accountability to ensure hospital reflects local
  needs
• Core NHS principles remain unchanged
• This change has added to the change management
  pressure across the NHS with pressure to
  implement these foundation hospitals across
  England before any change of Government.

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• Recent Developments
• Medical training has been restructured
• All staff have been given revised Job
  descriptions and placed on new pay bands
• Doctors pay has been increased and linked to
  performance
• All placing increased financial burden on the
  service and causing lay-offs of Doctors and Nurses

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• Private Finance Initiatives to build new
  hospitals have cost more than Government funding
• Ambitious plans to develop a linked IT system
  across the service have fallen behind target and
  increased dramatically in cost
• Primary Care Trusts are being encouraged to buy
  15 of their services from private and voluntary
  organisations

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Negative

• Staff at all levels are under enormous pressure
  of work
• There is a low level of misery throughout the
  service as a result of change on change
• Government does not consult with the right people
  long enough in advance of decisions about change
  thus problems with impact of doctor training
  schemes, recent pay awards and IT schemes and PCT
  size
• Health is a political pawn and governments will
  continue to try and make their name with changes
  to it
• Foundation Trusts will make it very hard to have
  anything like a coordinated strategy for a
  health service that reflects the patients pathway

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Positive

• Clinical Governance is here to stay and has made
  a difference to patient safety and patient
  empowerment
• Wastage has largely been eliminated
• Services are more timely e.g. AE , Cancer,
  waiting lists
• New arrangements for larger commissioning units
  mean a more expert team will be making decisions
• Informed choices are now made about drug use and
  new technology
• Clinicians are more involved in management
• The original Beveridge principles have so far
  held strong

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Concerns for the future

• Fragmentation of services with foundation trusts
  not seeing any responsibility to link with other
  services
• Community foundation trusts being liable to be
  taken over by private sector management
• Financial pressures leading to staff reductions
  and the problems arising from this, e.g. bed
  closures, waiting lists, pressure on beds and
  early discharges and revolving door effect on
  patients

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Dreams for the Future

• Patient involvement in planning
• More home treatment, early discharge, home
  treatment teams especially for mentally ill,
  children and elderly
• Local nursing beds for rehabilitation linked to
  home treatment teams e.g. stroke
• Focus of highly specialist services in major
  centres of expertise
• Continuing expanding role of local G.P.service
  including physiotherapy, podiatry, dieticians,
  pathology testing, visiting consultants providing
  clinics in localities and teaching G.P.s
• Increasing emphasis on health of the nation,
  healthy diet, healthy lifestyle, regular health
  checks. Education for children
• Stability for the system of provision to allow
  staff morale to improve and systems to bed down.