Welfare Reform on the Web (August 2009): National Health Service - reform - general

The calm after the storm

A. Moore

Health Service Journal, July 9th 2009, p. 22-24

Media scrutiny means that it is becoming harder for NHS chief executives to find a new job if they leave under a cloud. The Department of Health is considering a set of performance standards for managers which could lead to some being blacklisted. There is a need for struggling chief executives to be better supported by Strategic Health Authorities and helped through difficult times.

Foundation brand carries can for series of blunders

D. West

Health Service Journal, July 2nd 2009, p. 12-13

High profile scandals have called into question the freedoms awarded to foundation trusts, and the government has moved to clip their wings. Ministers have all but ordered trust boards to meet in public, and have suggested they want powers to sack foundation directors, veto severance pay and strip them of their status when they fail.

Health chiefs hope to raise standards with Michelin-style quality mark for excellence

S. Lister

The Times, July 1st 2009, p. 19

An accreditation scheme recognising the best clinical teams within the NHS, and showing how they compare with leading hospitals in the US and in Europe is being drawn up to improve the quality of care. The best hospitals in the country will be awarded 'gold-standard' status using a system similar to the one that awards Michelin stars for restaurants. The scheme was announced on the first anniversary of the publication of High Quality Care for All, Lord Darzi's review of NHS reforms for the next decade. Other measures to improve the work of the health service include a national commitment to clinician budgets, giving doctors and nurses greater control over hospital finances.

How do you modernize a health service? A realist evaluation of whole-scale transformation in London

T. Greenhalgh and others

Milbank Quarterly, vol.87, 2009, p. 391-416

This project drew on the principles of realist evaluation to assess a major effort to modernise healthcare provision in a deprived area of inner London which had been funded by a charitable donation of £15m. Three different services - for stroke, kidney and sexual health - were selected in a competitive bidding process to receive one-third of the total budget each for a programme of whole-scale transformation. Numerous projects and sub-projects emerged, fed into one another and evolved over time. Six broad mechanisms appeared to be driving the efforts of change agents: integrating services across providers, finding and using evidence, involving service users in the modernisation effort, supporting self-care, developing the workforce, and extending the range of services. Within each of these mechanisms, different teams chose different approaches and met with varying success.

iCARE, you care and everybody benefits

J. Taylor

Health Service Journal, July 2nd 2009, p. 24-25

NHS Employers have chosen 20 trusts to lead the way on workforce equality and diversity. This article looks at Yeovil District Hospital's iCARE programme, which aims to improve conditions for staff and patients.

Investigating public preferences on 'severity of health' as a relevant condition for setting healthcare priorities

C. Green

Social Science and Medicine, vol. 68, 2009, p. 2247-2255

This study elicited the preferences of a sample of the UK general public over healthcare priority setting scenarios, using a random representative sample and face-to-face interviews. It adds to the empirical ethics literature, providing insights into the preferences of the general public regarding the use of severity of health as a basis for setting priorities, and against the meaning of a severity of health criterion in the broader sense of distributive preference and fairness, in resource allocation. Findings add to the evidence that society does not support a strict health maximisation (efficiency) objective when it comes to difficult priority setting choices.

Losing their religion

L. Hunt

Health Service Journal, July 23rd 2009, p. 22-24

On some occasions health service employees' expression of their religious beliefs at work has caused controversy and led to disciplinary action against them including dismissal. Problems have arisen when staff proselytise or witness to patients as this can be construed as harassment. Dress codes in the NHS introduced to help infection control have also been seen as sometimes contravening religious requirements. For example, the NHS 'bare below the elbows' policy can be seen as contravening the teaching of Islam.

NHS isn't ready to capitalise on gene medicine revolution

M. Henderson

The Times, July 7th 2009, p.10

A report by the Lords Science and Technology Committee has indicated that the NHS is ill-prepared to deal with the challenges that Genomics has for healthcare. It suggests that the NHS needs better provision for genetic testing, and that NHS staff need improved training in order to ensure they are up-to-date about this rapidly expanding field. The report called for a White Paper on genomic medicine to include proposals about the regulation of genetic testing and counselling by private firms.

Patient 'entitlements' look set to strengthen self policing

S. Gainsbury

Health Service Journal, July 2nd 2009, p. 4-5

The government's latest vision for the NHS replaces top-down targets with patient entitlements enforced by sanctions where standards are not met. The performance management role of strategic health authorities may be reduced and primary care trusts will be given an advocacy role to help patients seek redress if their entitlements are not met.

Patient safety

Health Committee

London: TSO, 2009 (House of Commons papers, session 2008/09; HC151)

This report claims that hospital managers are more concerned about hitting government targets, reaching financial balance and maintaining foundation status than they are about patient safety. It warns that staff are becoming 'detached' from caring for patients by 'inappropriate' regulations imposed from above. It calls for the establishment of an independent body to handle concerns about patient safety raised by staff and says that a culture of blame is preventing more professionals from raising issues. Patients are also being put at risk by confusion among overlapping regulators about which has responsibility for patient safety and by the NHS's failure to gather data about incidents.

'Patients are being rushed through A&E to hit targets'

K. Devlin

Daily Telegraph, July 14th 2009, p. 2

Statistics obtained by the Liberal Democrats suggest that hospitals are hurrying patients through casualty departments in order to meet government targets requiring them to be treated within four hours. Many show increases in the numbers leaving A&E after three hours and 40 minutes.

Private wisdom and public practice: formation and governance in the medical profession in the United Kingdom

A. Dowie and A. Martin

Ethics and Social Welfare, vol. 3, 2009, p. 145-157

A series of high profile scandals, such as the murder by GP Harold Shipman of up to 250 of his patients, has led to calls for strengthened regulation of the medical profession in the UK in order to halt the erosion of public trust. The direction of travel is away from professional self-regulation and towards the adjudication of external authorities, other than tiers of health services management, in clinical governance.

Professional competition and modernizing the clinical workforce of the NHS

G. Currie, R. Finn and G. Martin

Work, Employment and Society, vol. 23, 2009, p. 267-284

Drawing on the sociology of professions literature focused upon the case of healthcare, this article examines how legitimating strategies deployed by the professionals involved in workforce reconfiguration interact with government policies intended to modernise the NHS to create new (or reproduce existing) professional boundaries. It thus develops traditional analysis of professions as applied to contemporary healthcare by considering the impact of policy upon professional organisation.

Reducing healthcare associated infections in hospitals in England

National Audit Office

London: TSO, 2009 (House of Commons papers, session 2008/09; HC 560)

Healthcare associated infections in hospitals are caused by a wide variety of organisms and cause a range of symptoms from minor discomfort to serious disability and in some cases death. In 2007, around 9,000 people were recorded as having died with meticillin resistant Staphylococcus aureus (MRSA) bloodstream infections or Clostridium difficile (C. difficile) infections as the underlying cause or a contributory factor. The Department of Health (the Department) introduced a target to reduce MRSA across all NHS trusts by 50% by 2008 and C. difficile by 30% by 2010-11. By the end of March 2008, MRSA had been reduced by 57% and C. difficile by 41%. This report evaluates the changes since 2003-04 in the extent and impact of healthcare infections; the effectiveness, sustainability and cost of the Department's approach; and the effectiveness of action within hospitals to improve the prevention and control of infections.

Top-up fees

Health Committee

London: TSO, 2009 (House of Commons papers, session 2008/09; HC 194)

In recent years the NHS has been criticised both for not funding certain drugs and for withdrawing treatment for patients who chose to purchase privately additional drugs which the NHS refused to fund. A report, Improving access to medicines for NHS patients, which was published in 2008, made two significant recommendations. First, the NHS should make more expensive drugs more widely available to NHS patients. Secondly, the NHS should allow the purchase of additional drugs privately (top-up fees) as long as they were administered separately from NHS treatment. However there are concerns about the risks, consequent on the Report, of potential disadvantages to NHS patients including the formation of a 'two-tier' system. The Health Committee recommend that every effort is made to minimise the numbers of patients involved by:

• Speeding up the NICE assessment process.
• Increasing the work on disinvestment in the least useful treatments.
• Standardising PCTs' Exceptional Funding Request procedures including the communication of decisions and the reasons for them to patients and families.
• Instructing NICE to issue brief, understandable, accessible and well publicised explanations for lay people to explain the reasons for refusing funding for drugs, to give patients and their relatives clearly spelt out information upon which they can base their decision about paying for some but not all medicines.

Trusts still fail to give whistleblowers a voice

C. Santry

Health Service Journal, July 16th 2009, p. 12-13

The Public Disclosure Act 1998 which came into force in 1999 gave NHS whistleblowers legal protection. However, a HSJ investigation has shown that few concerns are now being raised in confidence with managers given explicit responsibility for supporting whistleblowers.

(For advice on best practice in supporting whistleblowers see Health Service Journal, July 16th 2009, p. 20-21)

The use of management consultants by the NHS and the Department of Health

Health Committee

London: TSO, 2009 (House of Commons papers, session 2008/09; HC 28)

In 2007-08 the NHS summarised accounts for the first time had separate disclosure of the amounts payable to external consultants. The totals given were £43.4 million for SHAs, £132.6 million for PCTs and £132.4 million for NHS Trusts, giving a total of £308.5 million. The Consolidated Accounts of NHS Foundation Trusts did not separately identify consultancy costs in 2007-08. In December 2006 the Treasury issued guidance for the Spring 2007 departmental reports, placing a requirement on Departments to include information on consultancy spending. The Department of Health now collects such information about its own use, but not about the NHS's use, of consultants. The NHS should know how much it is spending on management consultants. The information must be collected locally and it would be a simple matter to bring this together centrally. Making such spending subject to public monitoring might improve the way consultants are used. The report recommends that the Government collect centrally lists of:

• the management consultants employed by the Department of Health, SHAs, PCTs and acute, ambulance and mental health trusts, indicating the projects they are employed on, their duration, cost and purpose;
• the top ten daily rates paid by each category of organisation.

It is important to know whether the NHS and Department of Health are getting value for money from the contracts agreed with management consultants. However the present system of internal audit is inadequate. The report recommends that a sample of contracts with management consultants agreed by all categories of NHS organisation and the Department should be subject to external peer review. This should include an assessment of the value of the consultants' output. The external peer review might be put out to tender through the National Institute for Health Research which the Department uses in respect of R and D contracts.