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National Health Service History
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| Background | Year | NHS Events |
| Gordon Brown PM Global financial crisis Burma cyclone/Chinese Earthquake Beijing Olympics Russian/Georgian conflict | 2008 | Alan Johnson SOS Regional (Darzi) reviews Final Darzi Review Report, High Quality Care for All |
| Israeli invasion of Gaza strip Barack Obama President of USA Parliamentary financial scandals UK Population 61 million Copenhagen climate conference | 2009 | NHS Constitution Mid-Staffs Report on poor quality health care, Basildon & Colchester Care Quality Commission takes over from Healthcare Commission Andy Burnham SOS Financial stringency Swine flu and mass immunisation Prime Minister's Nursing Commission |
| Haiti earthquake | 2010 | |
| 2011 | ||
| 2012 | ||
| 2013 | ||
| 2014 | ||
| 2015 | ||
| 2016 | ||
| 2017 | ||
The decade opened with a world wide financial problem that steadily escalated. A crisis in the USA caused by "sub-prime" mortgage loans repackaged as 'derivatives' on which there was default, escalated into global economic difficulties. Recession turned into depression, tax revenues fell and social security payments rose. For two years the housing market showed falling prices. The biggest wave of British immigration slowed in 2008 as the country became less attractive to Eastern European migrants although future estimates of population suggested a significant continuing rise. The election of a new US president, Barrack Obama, lifted the mood but did not solve financial problems or those of the middle east or terrorism. Labour had been in power throughout the sixth decade of the NHS but during 2009 its poll ratings fell Public sector workers considered or took strike action. The United Nations eight millennium development goals, combating hunger, child mortality and AIDS, were unlikely to be met as rising food prices and the cost of oil pushed millions more into poverty. Natural disasters such as an earthquake in Haiti stretched Aid agencies. The projections for the future development of the NHS were increasingly depressing. Interest in the Conservative party's health care policies increased, for example an independent body to run the NHS, and re-negotiating the GPs' contract.
Health services internationally were hit by a perfect storm. On the one hand money was going to be tight, on the other people's expectations were increasing in a "me too" society where high earners in a celebrity culture of sport, media and banking were only too apparent. Technology was providing a growing number of expensive goodies, radiotherapy was far more precise and effective, imaging of a quality unbelievable only years previously and some forty new drugs for cancer were in the offing, each costing some £2-3,000 a month. The population was aging, bringing increased costs, and death was somehow seen as optional, to be postponed if enough money was spent. How could one pay for the triumph of medicine?
The 60th anniversary in 2008 was more widely commemorated than the muted celebration of the 50th. Health Service Journal listed the 60 people considered most influential - Bevan being the undoubted winner. Few among the many publications celebrating the anniversary dealt with clinical developments or the service to patients. Most dealt with macro issues of politics and funding. The Chief Executive of the NHS, David Nicholson, produced his illustrated annual report on the state of the NHS that was far from humble. The King's Fund produced data briefings. The House Magazine (of the Houses of Parliament) produced an anniversary supplement with articles commenting on the qualities of the Secretaries of State of the last 30 years together with articles by those ex Ministers. Frank Dobson attacked the current health policies of his party as not only unpopular but wrong in its accent on the market place. Alan Milburn believed that devolution had not proceeded far enough and suggested that the better local authorities might undertake health service purchasing. The King's Fund produced an analysis of changing workload, finance and waiting times over 60 years. The braver souls predicted the future of the service, some urging major changes in finance and organisation that were unlikely to occur. The Nuffield Trust published Rejuvenate or Retire, views of the NHS at 60 in which senior figures mused on the past performance and future possibilities of the NHS. There was basic agreement that it should remain taxpayer-funded, free at the point of use. Even those who believed in the insurance model did not think it would happen. When the question of radical alterations had been raised 20 years previously with Mrs. Thatcher, Sir Kenneth Stowe then Permanent Secretary, recalled her saying "There is no constituency for change." Most agreed that the purchaser-provider split was vital, that the private sector must provide important competitor services within the NHS and that more decisions should be taken locally.
The four UK Health Ministers restated the principles of the NHS.
A comprehensive service available to all
Access to services based on clinical needs and not on the ability to pay
Aspiration to high standards of excellence and professionalism
NHS services must reflect the needs and preferences of patients, their families and their carers
Working across organisational boundaries with other organisations in the interests of patients, communities and the wider population
Commitment to the best value for taxpayers' money, making the most effective and fair use of finite resources
Accountability to the public, communities and patients that it serves.
Twenty years previously the Conservatives had introduced a Patient's Charter largely enshrining existing principles and patients' rights. Now Labour consulted on a constitution for the NHS, an idea that had been trawled by the BMA in a report in 2007. This pulled together existing rights, responsibilities and pledges in one document, the right for patients to make choices about their NHS care, including choosing their general practice and expressing a preference for a particular doctor. It would be reviewed every 10 years and be accompanied by a handbook. The draft reaffirmed that the principles of the NHS. It included the right to drugs and treatment recommended by the National Institute for Health and Clinical Excellence, if approved by the patient’s doctor, and "to expect local decisions on funding of other drugs and treatments to be made rationally following proper consideration of the evidence." It was a helpful summary of rights, pledges and responsibilities. When it was published largely unchanged from the draft in January 2009 the pubic response was one of lethargy. The Chief Executive's report for 2008-9 said little about the economic crisis all now faced, though towards its end the report said "we will need to release unprecedented levels of efficiency savings between 2011 and 2014 – between £15 billion and £20 billion across the service over the three years."
Some drivers for change clustered around the work and reports of Lord Darzi. Centred on quality, these influenced health service policy, involved clinicians nationwide in
considering what a quality health service should look like, drove commissioning and encouraged developments already in the pipeline. Darzi had chaired the London Modernisation Committee and at the request of NHS London examined metropolitan problems. As a national adviser he had been involved in the analysis of local problems. Subsequently as a Minister (2007-2009) he gained national influence. Darzi summarised his hopes as evidence based prevention, quality, behavioural change making things happen, and clinical leadership. He started a national series of enquiries, the effect of which was clearest in London, but also involved the other ten regions. His proposals attracted support - but also criticism not least from family practitioners. Quality was not something new - the medical profession had always had it in mind and for 20 years many, particularly in the USA, had been interested in "contracting for quality". But Lord Darzi did place quality centre stage in the NHS and even after his retirement his ideas remained policy.
London reports | National Reports | |
| The Case for Change (2006) | ||
| Saws and Scalpels (clinical change 2007) | Interim Report (October 2007) | |
| A Framework for Action (July 2007) | High Quality Care for All - The Next Stages final report (June 2008) | |
| A local hospital model for London (November 2008) | ||
| Stroke & Trauma consultation (February 2009) | An immense number of working papers were also produced, not listed here |
Internet was now a major source of information for professionals and the public alike. Even 19th Century archive material, such as the British Medical Journal, was available online at PubMed. Patients had reliable sources of information from the NHS website (NHS Choices), but also from a patient's perspective on Health talk online.
The NHS’s two primary national websites, NHS Choices (www.nhs.uk) and NHS Direct (www.nhsdirect.nhs.uk) were united to provide a comprehensive online health information service. Originally established with different objectives, NHS Direct providing health advice and information whilst NHS Choices promoted well-being and informed decision making about healthcare providers, they would be united and include a self help guide, a health encyclopaedia, frequently asked questions and an online enquiry service. While 'Dr Foster' had lost the contract to develop NHS Choices, it launched its own hospital and consultant guide that had far more specific information on hospitals and individual consultants.
Pressure for radical revision of the NHS IT programme increased with the publication of the second report of the Public Accounts Committee. The completion date was set back once more to 2014-5 and hospital trusts might receive permission to install their own system if it was compatible with the national network and the NHS one remained unavailable. Suppliers and the government were locked in contractual disputes and the philosophy and ambitions of the programme were now openly questioned. At the end of 2009, following pilot trials, the first Summary Care Records (a secure electronic summary of core information such as medications, allergies, adverse reactions and key health information derived initially from the patient’s GP record and added to as necessary by other healthcare staff ) began to be rolled out across the country. Patients were asked if their records could be included - less than 1% opted out.
However in the Pre-Budget Report the cost and scope of the multi-billion-pound NHS IT programme was scaled back. Part of the National Programme for IT (NPfIT) would be shelved to reduce public spending to get borrowing back under control.
| Alan Johnson 2007- 2009 (Labour) |  | |
| Andy Burnham June 2009 - (Labour) | NHS 2010–2015: from good to great. preventative, people-centred, productive. (Operating framework 20100. |  |
The 6th decade had seen programmes of system reform that included four important innovations, the creation of foundation trusts, greater NHS use of the independent sector, provision of more choice for patients, and payment by results. R G Bevan wrote that 'healthcare systems had three main goals, to control total costs, to achieve equity in access by need and to achieve excellence in performance (short waiting times, satisfied patients, and good outcomes). BMJ 2008;337:a935. To achieve these goals economic instruments were needed. Since 1976 the NHS had controlled costs with a cash limited budget and sought equity by distributing funds to populations in relation to their needs. The problem was improving the performance of providers. Before 1991 the NHS had a hierarchical integrated model in which the same organisations were responsible for meeting the needs of their populations and for running providers. Such organisations could be funded equitably for their populations or for the performance of providers, but not both. The internal market with a purchaser-provider split, in which purchasers were funded for their populations and contracted with independent providers, was an attempt at an answer. England had tried four variations of this model in its efforts to improve provider performance, competition between 1991 and 1997; partnership between 1997 and 2000; publishing performance in "star ratings" between 2001 and 2005; and again competition, from 2006 with an attempt to reform the system, changing the methods of payment.
In its report in June 2008 "Is the Treatment Working" the innovations were examined by the Audit Commission. It was early for judgement, for the development of foundation trusts and patient choice was behind schedule, detailed information was lacking on choice, and the scale of independent sector treatment centres was limited. However the Commission summarised its findings.
Progress with implementation of reform policy | Aims | Have the aims been met yet? |
FTs – 73 out of 171 acute and specialist trusts are FTs (a further 26 mental health trusts are FTs) | Stronger finances, greater efficiency | FTs started from a good financial position and have improved further. Income growth has been a significant contributor to the increasing surplus. Efficiency savings have also been made. FT application process has helped non-FTs improve financial management and financial stability. |
| Service improvement | FTs perform well, but they started from a better position than other trusts. Impact on any improvement is unclear. |
| Patient responsive services | Role of FT governors and membership is still developing. |
| Increased independence for providers | FT status allows autonomy and use of cash balances to deliver service improvements. |
PbR– Implementation by acute and specialist trusts, where the policy has been largely mainstreamed. Little implementation beyond the acute sector. By April 2008, all acute trusts reached 100% PbR price and purchasing parity adjustment phased out for all PCTs. | Fairness and transparency of funding | There is now a clear link between activity, income and expenditure, removing the need for much local price negotiation. |
| Efficiency | Day cases have increased and lengths of stay have fallen, particularly for elective inpatients. Where changes have occurred, PbR seems to have reinforced rather than driven change. |
| Faster access to more appropriate, patient responsive services | Increase in overall activity, but particularly short-stay activity such as day cases and non-elective short-stay admissions. However, other policies will have also contributed to these changes. PbR has encouraged PCTs to focus on demand management. |
| Increased focus on quality | Not a primary driver in changes in quality to date, although, while emergency readmissions are increasing, there is no evidence that PbR has resulted in a negative impact on quality overall. Rewarding quality is likely to be a focus in the future. |
PBC– Limited progress. | Better services closer to patients | PBC has only had a limited impact on service redesign to date. |
| Better use of resources to purchase services for patients | PBC has only had a limited impact on commissioning of services to date. |
| Reduced inequalities of outcome | There is potential to deliver this if PBC moves forward. |
Plurality and patient choice– Limited introduction of ISTCs. Variable availability of patient choice. | Greater choice of provider for patients | Greater choice is available for most patients. |
| Stimulating competition | The fear of new providers has stimulated some change. |
| Improvement in quality | Information does not yet exist to enable patients to make a decision based on quality of outcome or to determine whether quality has improved as a result of patient choice. |
| Increasing capacity | ISTC programme has increased capacity but progress has been slower than expected. |
| Tackling health inequalities | No evidence that choice or ISTCs have reduced health inequalities. |
Workforce contracts– Fully implemented. | Flexible workforce | Mixed progress has been made. The contracts have introduced some flexibility, but implementation has alienated some staff. |
| Delivering different services in new and better ways | Contracts have supported but not driven service redesign. |
| Increased productivity | The new hospital contracts resulted in an increase in costs without an associated increase in productivity. |
| Improvements in quality of care | Measures of quality did not improve significantly after introduction of new contracts, although it would be difficult to attribute any change to this. |
| Resolving recruitment and retention issues | Problems were largely solved in advance of new contract implementation. |
Scotland, Wales and Northern Ireland had different approaches to health care within their territories. In 2009 Nuffield reviewed their experiences, suggesting that England was comparatively more efficient. The NHS in England spent less on healthcare and has fewer doctors, nurses and managers per head of population but that it was making better use of the resources it has in terms of delivering higher levels of activity, crude productivity of its staff, and lower waiting times
The (Darzi) initiatives were the next stage of reform and sought to improve quality in three ways, by publishing information on clinical performance, by varying tariffs according to quality, and by piloting ways to achieve better integration of primary, community and hospital care.
Central to the Darzi programme was commitment to quality of clinical care and a high level of clinical involvement. Clinicians by the hundred were involved in trying to define the gold standard of good care in their fields, and many of these were prepared to lead change locally even when the going became rough. In May 2008 Lord Darzi published ‘Leading Local Change’ (The Next Stage Review) and his final report, High Quality Care for all, appeared at the time of the 60th anniversary. It was followed by separate strategies on primary and community care, workforce issues (A High Quality Workforce), and informatics. There was repetition of. achievements and policy already announced - but also new slants such as the accent on quality and engagement with clinicians. A major effect of the clinical slant of the Darzi proposals was to modify the way hospital (and community) health services might be organised. See Hospital services
The proposals |
|
Hospital and GP budgets directly linked to quality of patient care | Payments to hospitals conditional on the quality of care as well as the volume under a commissioning for quality and innovation scheme. Quality measures will include infection rates, clinical outcomes, patient experience and patient-reported outcomes But fines may penalise struggling trusts further. High cost of the proposals |
Legal rights for patients to choose a GP practice and to express a preference for a certain doctor | But availability and convenience of services are likely to determine choice as much as quality |
Legal right to access any appropriate drugs approved by the National Institute for Health and Clinical Excellence (NICE). Health trusts must “explain” their decision to refuse treatment if not approved by NICE | Patients will get new drugs more quickly but this may increase pressure on budgets and trigger lawsuits from those who go without |
Legal right to seek treatment in the rest of Europe if faced with an “undue delay” in | This is already the case in EU law, but it is uncertain how long the waiting time has to be to enact this right |
Personal care plans to 15 million patients with long-term conditions such as diabetes and asthma. A pilot scheme will give 5,000 patients the opportunity to control their own healthcare budgets | Enables more people to be treated at home and prevents repeat visits to hospital. However, it would not be workable without community nurses to support them |
Ten regional “vision” documents, published in the last two months, and local health consultations will determine specific changes | Most documents add little to current, accepted, policies. Local consultations will introduce at least 150 new GP-led health centres (also known as polyclinics). Doctors leaders say this, and plans to consolidate some hospital units such as maternity and A&E, may lead to the loss of local services |
A review of doctors’ postgraduate training, focusing on the first two years after graduation from medical school | Hopes to improve specialist training, but cuts to European working hours still threaten to limit the time junior doctors can spend training and overseas trained doctors present major competition to those trained in the UK and Europe |
Proposal for an NHS Constitution | Details unclear |
Sources include - The Times 1 July 2008 |
Tackling health inequalities remained high on Labour's agenda (see section on Public Health). It has been suggested that the the function of Ministers is to bring the random into politics. Andy Burnham who became Secretary of State in 2009 seemed to be a cast-back to Frank Dobson and the old left. There was a belief within the NHS that different parts of the Department of Health did not speak to each other and policies seemed increasingly chaotic. The use of competition to drive innovation, quality and choice was losing its momentum. Speaking to the King's Fund in September 2009, Burnham said that the NHS as opposed to the independent sector, was the 'preferred provider' even apparently when delivering a demonstrably poorer service. There were suspicions that health service unions had influenced the Secretary of State. So what did Labour want? Paul Corrigan, an architect of the Blair reforms, saw competition a driver of change to quality and efficiency. Andy Burnham was arguing that the achievement of reform meant working to improve existing services, where they were 'good enough'. The policy of "world class commissioning" implied that everything must be geared to improving the patient's experience.
HSJ 2009, 29 October, 5th Where was this policy if there was, in effect, no choice? The Competition Panel looked at the issue. At a time of financial stringency, Labour said the NHS would have to pay for treatment in the private sector if patients were not treated in the NHS within target times. Medical manpower policy was similarly in turmoil. In the Home Office the decision of the Secretary of State, Alan Johnson (late of the Department of Health) to sack Professor David Nutt, the chairman of the Advisory Committee on Misuse of Drugs apparently because the committee's view did not agree with his, opened up a national furore about government's wish to listen to outside expertise and "its rather poor understanding of science". (Lord Winston)The Panel was established in 2008 chaired by Lord Carter of Coles to consider potential breaches of the principles of co-operation and competition for example by looking at proposed mergers to ensure that a monopoly situation did not arise and the way health services were promoted and advertised. However while competition could be a spur to efficiency, when services were duplicated or overlapped, might make service rationalisation more difficult. High quality care could, in many cases, only be achieved by cooperation between providers.
A :Labour government policy statement "Building Britain's Future", which covered many public services was published in March 2009. It contained a number of pledges some of which aimed to turn targets into entitlements. These would be enforceable (but not legally) and many represented initiatives already in progress, for example hospital treatment within 18 weeks, access to a cancer specialist within 2 weeks, and free health-checks on the NHS for people aged 40-74. The 2010 operating framework (From Good to Great) reiterated the need for a preventative people centred service, within the cold financial climate.
When the NHS was established in 1948 Bevan established a Central Health Services Council to advise the Ministry of Health. Consisting of the great and the good, it met seldom. However the subcommittees it established were influential. Later other high level strategic advisory committees were established, none of which persisted long. In the wake of the final report of Lord Darzi’s Next Stage Review, advised by Cambridge Business School, a new National Leadership Council was formed in 2009 with the remit to develop leadership across healthcare with a particular focus on standards, certification, the development of the right curricula and assurance), able to commission development programmes.
The relationships between the Department of Health and the NHS had passed through a number of patterns over the years. In 2009 a collaborative board, bringing together the two, was established as a subgroup of the NHS Management Board, the NHS Operations Board. Chaired by the Department's Director of Finance in included the chief executives of the ten SHAs, and senior Department of Health Staff, including the NHS Medical Director. It would oversee the current Operating Framework that defined priorities and resources, and take the lead on frameworks for the future.
PCTs were now powerful in the improvement of services, and their reconfiguration. Longstanding doubts about their abilities as commissioners were managed by the introduction of "World Class Commissioning", an initiative with targets attached by which the trusts were judged. Commissioning would become the driver of change and in London the PCTs grouped themselves together into 6 segments to consider how to plan for better services along Darzi lines. Because their name gave the public little indication of their role, many PCTs rebranded themselves, for example City and Hackney PCT became "NHS City and Hackney".
By August 2009, five years after the concept was launched, 122 Foundation trusts had been established with more in the pipeline, about half of all acute trusts (46%) and mental health trusts (54%) having gained foundation status. William Moyes, the executive chairman of the regulator, Monitor, felt that their performance had been impressive, though he regretted that more trusts had not gained this status. Whether the performance was due to foundation status, or whether it was the best trusts that had achieved this, was a matter of debate..Monitor provided a diagram of the process and a map of their presence.. Trusts wanted Foundation status to be regarded as the quality brand in health. A small élite were now exploring the full limits of their potential, with a handful aspiring to be truly world class. One mental health trust that had good relationships with its matching local authority took on the community health services in its area, for example district nursing. Foundation trusts, as a whole, performed significantly better than other trusts in league tables. Government had wanted all trusts to achieve foundation status by 2010; they had not done so. Suggestions that FTs should take over "failing trusts" to improve their performance were seldom accepted. Heart of England FT had difficulties in absorbing the Good Hope Hospital, and FTs were wary of the risks involved.
Increasing financial problems led tightening of the criteria for Trusts wishing foundation status. Trusts applying had to show that they could cope with a very low growth rate. It was clear that a significant number of trusts, some twenty, would not meet the criteria and achieve foundation status, let alone do so by the dates government had wanted. Government's suggestions, that trusts merged, or were acquired by other (foundation) trusts, closed, were franchised to the private sector, or had management replaced found little favour with anyone. What trust wished to jeopardise its reputation by taking on a trust with near insuperable financial problems? At least in London it was clear that many existing trusts would not meet government deadlines for foundation status and in May 2009 the East of England SHA offered up the first trust for merger or acquisition, the Bedfordshire and Luton Mental Health and Social Care Partnership trust
Each year the Department of Health sent out the Operating Framework, outlining the resources for PCTs and the national priorities. Allocations were based on a complex formula involving population, needs, targets and the distance from targets. An Advisory Committee on Resource Allocation kept the formula under review and changes produced winners and losers. The introduction of a weighted capitation system might have significant results, perhaps favouring the elderly, as opposed to children or deprived areas. Labour - and the Conservatives also in their advance planning, looked at the tariff system for potential savings. Tariffs were based on average national costs; should they be based instead on the lower costs of the most cost-effective centres to increase incentives for cost-cutting? Primary care trusts were allowed to link payments to local quality improvement goals by commissioning for "quality and innovation" A proportion of providers’ income would be conditional on quality and innovation, through the Commissioning for Quality and Innovation (CQUIN) payment framework.
A new financial crisis was now looming driven by rising costs and increased public explanations. It was the latest in a series that had affected the service since 1948. (See article by Nick Bosanquet in Health Service Journal). In 2007 the projected rise in the NHS budget in real terms from 2008/9 to 2010/11 had been 1.9% a year. As the 2008 financial crisis bit, and billions were poured into banks such as Northern Rock, HSBC and RBS, the Treasury looked at the possibility of clawing back much of the £1.6 billion under spend in 2007/08. Projected growth in 2008 was to be 1.2% between 2011/12 and 2013/14. The 2009 budget included large reductions in public service expenditure in which the NHS would play a major role. Though presented as savings from improved commissioning, it still amounted to less money going into the NHS. Public debt would overhang services for ten years or more. The impact on the NHS was not long in coming. In his Annual Report the NHS Chief Executive, David Nicholson, warned of the future ahead. “We need to move away from the NHS being built for growth to being able to sustain itself in a prolonged limitation on resources. We’ve had one or two years that were difficult. We’ve never had three or four years.” In early 2009 four chief executives in the London area resigned within a week, including that of the Royal London and West Middlesex hospitals. Financial problems and failure to meet access targets were responsible. Monitor saw the recession as slowing the progress of hospitals towards Foundation status. It continued to ensure that foundations were capable of handling the pressures and some trusts withdrew their applications. Soon it was being suggested that NHS allocations might fall by some £20bn over the next few years, and primary care trusts were encouraged to plan on the basis of such massive reductions.
A report commissioned by the Department of Health from McKinseys, presented in March and leaked in September 2009, said that to achieve its planned £20bn savings by 2014 the NHS in England would need to slash its workforce by 137,000. HSJ editions September 2009 This would mean the NHS losing 10 per cent of its workforce. The report, considered by many to be a rational assessment of what would be needed to achieve planned savings, revealed the brutal reality of the true cost to the NHS of the collapse of the banking system. It recommended a range of “potential actions in the next six months” including a recruitment freeze, an immediate reduction in medical school places to avoid oversupply and an early programme to encourage older GPs and community nurses to make way for “new blood/talent”. Acute services would take the brunt of the cuts. Some savings could come from clinical efficiencies, but not enough. Though all political parties had said that NHS finances would be protected, the report clearly had the Department of Health's support and had been shared with SHAs and senior management as as an important contribution to policy. When leaked, the Department did not question the accuracy of the leaked document, but attempted to disown the recommendations. Andy Burnham, the Secretary of State said “The McKinsey work… is not in any sense an NHS plan of action. They are just making some suggestions which will be looked at with many other ideas" Some calculations of the scale of cutbacks - over 50% of London acute hospital work - seemed completely infeasible. Individual hospitals with historic difficulties in balancing their books faced substantial problems. Achieving Foudation Trust status was impracticable and one, Hinchingbrooke, a district general hospital in Cambridgeshire, was offered by tender to private or NHS management. No NHS organisation was prepared to take on the task of restoring a hospital with a £40 million deficit to financial and clinical health, and the managerial effort that would be needed.
The NHS had to plan for a health service in a cold climate. Tariff payments made under Payment by Results would restrained, perhaps setting the level at the costs incurred by the most efficient providers, rather than average costs. If there was a £20 billion shortfall, was the answer to bacon-slice and reduce every service, or to slash and burn removing whole swathes of the NHS? A pay-freeze for consultants, GPs and senior managers was imposed in 2010. For 20 years Wennburg, in the USA, had suggested that reduction in the variations in service provision would save money - though there was little sign of major success in altering the differences even in his home states. The Dartmouth Health Atlas identified conditions where the rate of surgery differed greatly. | Ten Common Conditions with Widely Varying Use of Discretionary Surgery • Early Stage Cancer of the Prostate • Early Stage Cancer of the Breast • Osteoarthritis of the Knee • Osteoarthritis of the Hip • Osteoarthritis of the Spine • Chest Pain due to Coronary Artery Disease • Stroke Threat from Carotid Artery Disease • Ischemia due to Peripheral Artery Disease • Gall Stones An Agenda for Change |
Some believed that massive savings could be achieved by the transfer of care from hospital into the community, for example by the use of polyclinics or federated practices, again without much evidence. The Department of Health made small sums available to support the Transforming Community Services (TCS) programme so that they could provide modern personalised and responsive care of a high standard. In hospital it seemed that savings could result if the lead consultant saw patients early after admission, and regularly thereafter. Ministers decried "slash and burn" approach but the operating framework for 2010 required a 30% reduction in management costs in PCTs and SHAs, and acute trusts would be paid only 30% of tariff costs above the activity level of the previous years in the hope that this would constrain hospital care and encourage care in the community. Tariff costs would not be increased for inflation.
If the starting point was evidence that something worked safely and provided value for money for society and the individual, where did that leave complimentary medicine? The UK's only professor of complementary medicine wrote that some within that field were ready to resort to intimidation and legal action in a way that was downright scary. The financial stringency revived discussions on rationing, prioritisation or allocation of resources, effectively three synonyms. Should clinicians take the lead, should conditions be excluded that did not seem to work to concentrate on those that did, should one look at the "reasonableness" of decisions, and what part did the market have to play?
Healthcare Commission & Commission for Quality of Care
Council for Healthcare Regulatory Excellence
National Institute for Clinical Excellence
Quality was now high not only on clinicians' agenda, but on that of the NHS organisationally. Lord Darzi said in High Care Quality for All, in 2008 that "Quality will be the organizing principle of the NHS." The final Darzi report in 2008 also placed emphasised quality as "at the heart of everything we do". Healthcare providers were required by law to publish ‘Quality Accounts’ just as they published financial accounts. Trusts began to assemble the material they would need for the year 2009/10. The need was clear; in 2009 the Patients' Association published a report Patients not numbers, People not statistics with poignant stories of poor ward care and failure of communication. The association's helpline received many calls from people wanting to talk about 'the dreadful, neglectful, demeaning, painful and sometimes downright cruel treatment their elderly relatives had experienced at the hands of NHS'. Claire Rayner, the President of the Association, herself once a nurse, had campaigned on this issue for decades.
For over twenty years organisations had wrestled with the problem of "how to contract for quality". The introduction of tariff payments was partly based on the view that if all providers charged the same, those "purchasing" services would do so on the basis of quality. On the principle that if you cannot measure something, its existence is questionable, a new industry developed in "metrics" - what was quality, how did one recognise it and how was it measured? Structure, process and outcome had long been recognised as facets of quality, now effectiveness, safety and patient experience were seen as groupings for assessment.
Over 60 organisations in the UK had some claim to inspection or regulation and continuous improvement of quality of health care was an international movement. In 2008 a National Quality Board was established for the NHS and first met in March 2009. Very much a body of the great and the good, it brought together the Department of Health, the Care Quality Commission, Monitor, NICE and expert and lay members from Royal Colleges and consumer organisations. It was the only place where the many regulators came together in one room. The board's most "tangible" work would be to publish an annual report on quality, specifically comparing the English health service with other countries. Its aim was to bring together senior people interested in improving quality, to align and agree the NHS quality goals, whilst respecting the independent status of participating organisations. At a more local level, the Department of Health’s first publication on quality for 2009-10 designated 24 hospital and four ambulance trusts as having their “performance under review”. Thirty hospital trusts and four ambulance trusts were identified as not meeting minimum standards under the NHS performance regime.
The US remained in the lead in quality developments. Its Joint Commission introduced patient reports on the safety of care and examined patient care pathways, alongside its 50 year old accreditation programme. Its annual report showed steady improvements. (see also its fact sheets and video on line) The expansion of clinical knowledge made it essential not only to work in teams, but to accept that medicine's complexity had overwhelmed the ability of individuals to manage it, however expert and specialised. As a result, basic steps were missed and patients died. In aviation, simple pre-flight check lists had saved many planes. The introduction of a surgical check list in 8 hospitals world-wide showed a reduction of death rate from 1.5% before the checklist was introduced to 0.8% afterwards. 19 checks before anaesthesia, before skin incision and before the patient left theatre showed that gaps in teamwork and safety practices were substantial in countries both rich and poor.
Keiran Walshe, professor of health policy and management at the Manchester Business School said that in a health service that was increasingly plural and less hierarchical, there was a growing need for good, effective regulatory scrutiny and oversight. Don Berwick used a more punchy phrase, "you need policemen even in heaven".
That this could not currently be relied upon was demonstrated at Mid Staffordshire Foundation Trust. In its last days the Health Care Commission, in March 2009, published one of its most swingeing reports into substandard care at the trust which, having had a large financial deficit, had been given new management and had corrected this in part by staff reductions, including nursing. The financial problems were solved but at the cost of a failure to address quality which had been longstanding. Mortality data from Dr Foster had suggested problems subsequently confirmed by HCC visits. That foundation status had been granted in 2008 when problems were already being investigated, made clear the lack of communication between Monitor, the SHA and the Healthcare Commission and there were arguments about the accuracy of data. There and in a number of other trusts with similarly high mortalities coding problems were blamed. The regulatory organisations blamed each other - no one emerged well from the affair. Theoretically, because of excess mortality at the hospitals, as many as 400 people might have died over a period of years when there had been "appalling" emergency care in understaffed departments inadequately skilled, with deficiencies in ward staffing, equipment and management. Professor Sir George Alberti, national clinical director for urgent and emergency care, began a review of the trust's accident and emergency services and in July 2009 the Secretary of State (Andy Burnham) asked Robert Francis QC
to consider what additional action is necessary for the new hospital management.........
Robert Francis' report, The Mid Staffordshire NHS Foundation Trust Inquiry, submitted in February 2010, said the board showed a lack of urgency, and relied on data systems rather than patient experience. The Board tended to restrict itself to strategic issues and had too little contact with operational matters. The overwhelming problems seemed to be the provision of basic nursing care. "The experience of listening to so many accounts of bad care, denials of dignity and unnecessary suffering made an impact of an entirely different order to that made by reading written accounts." Targets seemed to come before quality, and compassionate care was often lacking. There was a reluctance by staff at all levels to persist in raising concerns.
The report called for NHS board members to be regulated against a national set of standards, a review of training, appointment, and support and accountability for executive and non-executive directors, to “create and enforce uniform professional standards for such posts”. The Secretary of State accepted all the recommendations and proposed further action, inviting Mr Francis to undertake a further independent examination of the role of the supervisory and regulatory bodies.
Three key recommendations accepted by the government were
The publication of standardised hospital mortality ratios (HSMRs), for example on the NHS Choices website was a blunt but useful indicator of quality. A concept developed earlier in the USA, the indicators had their critics but were welcomed by patient organisations. The HMSR, was derived from Jarman's work and Dr Foster an independent organisation collecting data from hospitals on a voluntary basis, (see chapter 6) is a statistical calculation that measures the overall rate of deaths within an NHS trust and compares it with a national average as a benchmark. The SMR focuses on the medical conditions associated with 80% of deaths in hospitals. Variations were significant, for example and Dr Foster showed that mortality rose slightly in the first week of August when new doctors took up their posts; a similar effect was seen in the USA in July when the same thing happened. As the national mortality rates fell, individual hospitals that had improved but less than their peers, found to their concern that their rates were higher. | Mortality rates: a history
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Dr Foster's annual hospital guide in 2009 had given hospitals a safety index, and while it was to be expected that hospitals low on the list would challenge the methods used, some critics were eminent independent statisticians and public health physicians. Media comment, including The Times, and ministerial statements made Dr Foster's data a matter of public interest. Some hospitals had not taken the process seriously and others had found the questions misleading and sometimes irrelevant to issues of patient outcome. Sometimes a low rate was associated with clear clinical shortcomings. Sometimes it was not. There were now an increasing number of hospitals that scored low on the ratios, and an increasing number of organisations competitively in the quality assessment field. After a tendering process in 2010, the contract to provide HSMRs passed to IMS, "a premier source of global pharmaceutical marketing intelligence". The DH and regulators were engulfed in the row because many of the Dr Foster ratings contradicted trusts’ performance according to the Care Quality Commission and foundation trust regulator Monitor, calling those systems into question. NHS medical director Sir Bruce Keogh asked NHS North East chief executive Ian Dalton to lead a group to agree a method for calculating hospital standardised The specifications of the indicators would be standard, open and published by the NHS Information Centre, "owned by the NHS" - to ensure parity of use and interpretation by all users including the public.
In October 2008 the Commission published its third and last health check assessment. For the second consecutive year, annual improvement is evident. In particular, there was roughly a 10 percentage point increase in both the proportion of trusts scoring excellent for quality of services, and the proportion of trusts scoring excellent for use of resources.
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Waiting times for cancer treatment, a significant problem for the NHS, had come down. Ambulances were responding faster. MRSA rates were falling, though not all trusts were improving as they should. Problems remained in primary care, such as access to GPs and the provision of choice. Regionally, performance in most areas had improved, less so in London. Sir Ian, in a letter to staff, regretted that relationships between the Commission and the Department of Health had been fraught.
"Given the highly politicised nature of any discussion of the NHS, government both saw the need for the regulator and at the same time felt uncomfortable about it, particularly when it brought bad news." Sir Ian said. "Regulation was sometimes seen as part of the problem rather than part of the solution". At the end of its existence (2004-2009) the Commission produced a legacy report. It believed that it had played an important part in the improvement of quality of care, a view shared by the majority of trusts that thought that the annual health checks had improved quality. Investigations into serious failings had improved safety. The handover from the Healthcare Commission to the Care Quality Commission was far from smooth.
Following the decision by the Department to merge the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission into the Care Quality Commission, this was established in April 2009. Baroness (Barbara) Young was appointed Chair but resigned within a year. The CQC differed in that it had enforcement powers and in the ultimate it could close an organisation by withdrawing its registration which the Healthcare Commission could not do directly. The CQC "would be rooted in 'transparency, independence and risk-based inspection". Outcomes would be a major focus and the CQC would judge its own success against them. The existing system would be replaced over the next two years by a regulatory system based upon "periodic reviews" of commissioners and providers. As it united health and social services, assessment of local authorities and primary care trusts would be aligned. Six groups of issues would be assessed
Involvement and information
Personalised care, treatment and support
Safeguarding and safety
Suitability of staffing
Quality and management
Suitability of management
The CQC wished people to be at the centre of what they did and to look at boundary issues and problems, how health and social care worked together, and at care pathways for people might not know which “box” they were in but just wished the system to work for them smoothly.
It was sponsored by, paid for by and accountable to the Department of Health, though some money came from those regulated. Regulation must increase quality and while the CQC had tough powers it wanted to work with people, rather than rely on punishment. The financial fines it could levy were comparatively small and were more there to attract attention and achieve publicity and embarrassment, than as punishment in financial terms. It was hoped to provide a wide range of information for patients and commissioners; to spread good practice; and to use insights to improve public policy While the Commission would want to make its statements on the basis of good evidence and thoughtful analysis, criticising the health service inevitably meant criticising government.
The CQC would use information from a variety of sources (declarations, audit, views of patients and staff and its own inspection programmes) and provide rolling quality and risk profiling to identify which providers it needed to spend time with. It was hoped to involve service users in the course of inspection.
It hit the ground running. While CQC temporarily registered all 338 trusts, it made registration of 21 subject to conditions for inadequate infection control, legally enforceable and to be met within agreed timescales or enforcement action would follow. In its first assessments in October 2009 the CQC raised concerns about the 20 trusts rated “weak” on Quality and a further 27 that had not been higher than “fair” for Quality and Financial Management in the last four years and which faced a tough challenge to meet requirements of the new registration system which CQC would introduce in a year's time. It was "clear that many have significant work to do to and a short time in which to do it. They should be in no doubt that we will take firm action if we deem it necessary". In January 2010, all trusts in England, would be legally bound to be registered with the Commission. From 2011 this requirement would include NHS primary care providers, including GPs and dentists, who had not previously been subject to regulation by the Healthcare Commission. The sheer number of providers of health and social care made this a massive undertaking (King's Fund Brief on regulation)
The 2009 hospital assessments, based on the Healthcare Commission system, showed a number of trusts' performance to be poor. Dr Foster ratios also pointed to problems. A spot check at Basildon and Thurrock showed major problems of hygiene and higher than expected death rates. There were also concerns about the nearby Colchester Foundation Trust whose chairman was summarily removed by Monitor. Anxiety was great enough to lead the Department to ask the CQC to check all trusts for problems and the CQC chair, Barbara Young, retired unexpectedly. She was not prepared to give reasons. She seemed to have lost confidence in the government’s health check approach to assessing hospital performance and perhaps wanted a greater ability to influence matters. The complexity, overlapping contributions and arguments both academic and political about how inspection, regulation and assessment should work, made the whole issue too hot to handle effectively.
Council for Healthcare Regulatory Excellence
The Council for Healthcare Regulatory Excellence (CHRE) is the overarching, independent body overseeing the regulatory work of nine regulatory bodies
In 2009 NICE reached ten years of age. Controversial from the outset, survival alone was something to celebrate. It remained under challenge. The threshold for deciding which drugs were cost-effective enough to use was arbitrary. Some thought it too low, others too high. NICE did not stop the use of less cost-effective interventions already in use. How should drugs be handled when companies chose to submit no evidence? In the absence of an inquiry by NICE they continued to be used. Its unpopularity with the drugs industry could be contrasted with its popularity with governments around the world.
Sometimes decisions were reviewed and revised as in the approval of ranibizumab (Lucentis) for age-related wet macular degeneration. Sometimes patients wishing to receive life aiding drugs found that they were denied them by NICE guidance. When with the support of their doctors they tried to purchase them they were sometimes denied NHS treatment as government did not wish to see a difference between those who could pay, and those who could not. Public outcry at the refusal to let people spend their own money on their health led to the commissioning of a review. In 2008 draft guidance by NICE that four drugs, which could prolong life but not cure, should be denied on cost effectiveness grounds rarer cancers was criticised by oncologists who felt that any restriction of prescribing on the grounds of cost was reprehensible, and that NICE should be abolished. Other commentators, professional and lay, believed that there had to be some limit to the costs the NHS was expected to pick up. The Chair of NICE, Sir Michael Rawlins, wrote "It really is time that some of my clinical colleagues woke up to the realities confronting all healthcare systems. An ageing society, technological advances and public expectations are placing demands that all countries are struggling to meet. Countries do not have infinite sums of money to spend on health and the amount they can afford is largely governed by their wealth as reflected by their gross domestic products. The debate is not about whether - but how - healthcare budgets can be most fairly shared out among a country's citizenry."(HSJ 18 August 2008) He thought that the prices charged by drug companies were excessive - so others - in support of the pharmaceutical industry - replied with some justification that only an industry with the profit incentive would produce new drugs, quoting the steadily appearance of drugs for AIDS.
NICE was caught, inevitably, in a media storm. On the face of it firm implementation of national guidelines might ensure a consistent deal for patients across England, if not in Scotland, Wales and Northern Ireland. But the consistency might be refusal for, as its Chairman Sir Michael Rawlins said, NICE had to take account of all who depend on the NHS (not just patients suitable for treatment by the drugs it considered). PCTs wished to retain their right to decide what was and what was not an exceptional case to avoid tying up resources that would otherwise be used on better value therapies.
One issue was the time it took before NICE published its assessments. The government proposed
a faster system for referring drugs and healthcare technologies to NICE,
a new NICE committee to increase its capacity to assess new drugs;
more "horizon scanning" to help identify new drugs and issues early;
guidance for PCTs on how to deal with requests for drugs not yet assessed by NICE
A new system to encourage patient participation, LINks, was introduced in 2008. Each local LINk was related to a matching local authority that provided social services, the LINk covering both health and social services. It was
•A network of local individuals, groups and organisations •Covers all aspects of publicly-funded health and social care •Offers participation of the local community •Built on existing networks & community activity •Independently funded •Supported by a ‘Host’ organisation (appointed by the local authority). | |
LINks had the right to be consulted about services and, in many instances, to enter premises and inspect services. Where they had concerns, they could ask organisations to respond to their anxieties. The establishment of these new organisations was halting LINks varied widely in their attitudes, some believing in cooperative working with local trusts, others being intrusive run by people with long standing grievances, special interests, or political views, often critical of the NHS in general and their local services in particular.
A new chapter was opening for medicine, cancer probably being in the lead although other specialties were following. Drug therapy was converting fatal diseases into chronic ones, to be controlled if not cured. Though many drugs had emerged before the molecular basis of their activity was understood, unless that was known they might be used inappropriately - for example only a quarter of patients with breast cancer benefitted from Herceptin. Drugs that hit a particular DNA segment might, in fact, be usable in several diseases. If the money spent on drugs was to be made to count, better diagnostic systems were needed (although there were few financial incentives for their development.) Biological markers of effectiveness were required, molecular level signatures of response, so that treatment could be personalised and money was not wasted on people who were not benefiting. If non-responders could be identified, some of the rising costs could be avoided.
The framework for the provision of clinical services was increasingly set on a national basis by clinical strategies proposed by the National Clinical Directors, discussed locally within the framework of service commissioning, and associated with re-configuration of local hospital services. Quality became the touchstone as services such as those for trauma and stroke were planned on a regional or sector basis.
The goal of the WHO declaration in 1978 on Healthcare for All, with its accent on primary health care, was not achieved. In 2008 a new report appeared from the same city, Alma Ata now known as Almaty, Now more than ever. The evidence was robust that better outcomes for the population at lower cost were achieved in systems that distributed resources according to health care needs, eliminated co-payments, assumed responsibility for funding and provided a broad range of services within primary care. The goals of 1978 had not been achieved, but now at least more was known about how to handle the challenges.
Though a concern for many years, Alan Johnson, the then Secretary of State, made the narrowing of 'health inequalities' one of his main priorities for the NHS. A report in July 2008 on Health Inequalities, progress and the next steps, outlined the action being taken within the NHS. Primary Care Trusts and Health Trusts were told to pay more attention to the problem. Local initiatives were started to improve access of minority groups, e.g. Roma populations, pregnant women in areas of deprivation. National targets (By 2010 to reduce inequalities in health outcomes by 10 per cent as measured by infant mortality and life expectancy at birth), the use of the commissioning process and new strategies abounded. However in February 2009 the Parliamentary Health Committee reported that while health in the UK was improving, over the last ten years health inequalities between the social classes had widened - the gap has increased by 4% amongst men, and by 11% amongst women.
The Marmot ReportA review of health inequalities was announced in November 2008 by the Prime Minister at an international health inequalities conference and commissioned from Professor Sir Michael Marmot to help government's health inequalities strategies and set objectives for future action in England. Examining existing work (including that from groups chaired by Sir Michael and WHO information) e.g. Tackling Health Inequalities: 10 Years On (DH, 2009), Fair Society, Healthy Lives was published in February 2010 and was an analysis of health inequalities in England. The review advocated the improvement of health and well being for all and the reduction of health inequalities. It wanted a focus on the early years of life, (early child development programmes, safe neighbourhoods, decent housing) social justice, health and sustainability to be at the centre of public policy for all major aspects of society were key determinants of health, not just the health services. Few could disagree with this. The Guardian said 'The Marmot report has made it clear – for better social wellbeing we must slash disparities in education, income and health.' Nevertheless life expectancy in England was at record levels and the disparity across social groups was narrowing.. Link to executive summary | Six policy recommendations to reduce health inequalities
Source : BMJ 2010;340:c684 13 February 2010 |
The geographical pattern of mortality in
In its drive for quality, the Department of Health had set targets for the reduction of deaths in the major groups such as cancer, circulatory diseases, suicide and undetermined injury, and accidents. Throughout the developed world death rates were falling, and in most cases they were doing so in England.
A "Mediterranean diet" had consistently been shown to be associated with longevity. The dominant components seemed to be moderate consumption of alcohol, low meat consumption, and a high consumption of vegetables, fruit, nuts olive oil and legumes. Faced with the 'epidemic of obesity' and pressing to reduce health inequalities, the use of financial incentives to achieve healthy behaviour was high on the agenda. Disincentives in the form of alcohol and tobacco tax were known to affect behaviour. The effect of positive incentives was less clear cut. In 2009 government launched Change4Life, a 'society-wide movement' aiming to prevent people from becoming overweight by encouraging them to make changes to their diet and levels of activity. Other campaigns related to lowering alcohol consumption, perhaps by setting a minimum price, and the use of sun beds by those under 18 in the light of the rising number of cases of skin cancer.
Alcohol misuse posed a huge clinical and public health problem throughout Europe. Those who had campaigned against smoking had a new target. In the UK alcohol consumption had risen at the same time as its costs, in real terms, had steadily fallen. In 2009 England's CMO, Liam Donaldson, had called for a minimum price for alcohol. The BMA, the Royal College of Physicians, and the Faculty of Public Health added their voices to the demand, believing that the serious effects on health and society could best be mitigated through legislation on price and marketing.
People were increasingly given greater access to medicines, sometimes by increasing the range of trained professionals allowed to prescribe (nurses, pharmacists), by allowing people who met specific criteria to obtain certain medicines automatically, or by making prescription drugs available over he counter if considered safe. Some 60 had recently been reclassified from prescription only to pharmacy only, for example simvastatin, (statin), griseofulvin (antifungal) and hydrocortisone and nystatin ointment. Professionals were particularly concerned when antibiotics were proposed for reclassification because of fears of growing antibiotic resistance.
The drug treatment of obesity had not lived up to its promise - two of the three drugs released earlier were withdrawn on safety grounds. Perhaps we should just learn to live with obesity and its hazards.
The right to write prescriptions - once the doctor's prerogative, had been extended over ten years, particularly to nurses. Out of 690,000 nurses in 2009, 40,000 could prescribe, the majority in general practice. The process had gone smoothly, nurses being cautions, many having "supplementary" rights (prescribing within a care management plan agreed in advance with a doctor. "Independent" prescribers could prescribe any medicine for any condition that fell within their area of competence. Where nurses were leading, other professions were following, for example pharmacists.
Some new drugs were costly and extended the life of those with an incurable disease, but did not affect the outcome. NICE, applying the criteria of cost effectiveness, might not approve them for NHS use. Patients faced with death which might be delayed by therapy not available within the NHS sometimes bought them personally, perhaps at the cost of thousands of pounds. However this might debar them from receiving normal NHS care at the same time. Protests in the Sunday Times led the Secretary of State to commission an enquiry. In November 2008 Professor Mike Richards recommended that the Government, NICE and the pharmaceutical industry should act to ensure that more drugs were available for NHS patients on the NHS, but that those few that still wished to buy additional private care should not lose their entitlement to NHS care as long as the private element could be delivered separately from NHS care. The speed with which such drugs were referred for assessment by NICE should also be increased. Government accepted these recommendations.
The technology available to radiologists had changed dramatically with internet, affordable high performance computers, digital imaging and picture archiving and communication systems (PACTS).(BMJ 2008: 337: a785) As a result, imaging and interpretation were no longer confined to one site. Remote assessment, already frequent in the USA, became more prevalent in the UK. Complex imaging procedures were frequently required in accident departments around the clock. Out-sourcing of interpretation was one way of dealing with increased demand coupled with a shortage of radiologists. Some English hospitals outsourced part of their work into Europe, as far away as Barcelona. Teleradiology and outsourcing had, however, their problems. Access to other test results or previous images was seldom possible, nor the easy communication with other specialties.
The steady improvement of imaging and nuclear medicine equipment provided better images and increasingly smaller radiation doses. The combination of CAT and positron emission (PET) scanning improved the diagnosis of heart disease and cancer. As the quality of imaging improved, unexpected findings were increasingly encountered, often of clinical relevance and unrelated to the purpose of the imaging. MRIs were usually requested to solve a specific clinical problem, but other small lesions, such as meningiomas, might be found. A new imaging system, laser based optical tomography, provided a new way of looking at the skin to a depth of 1mm.
"Organised scepticism", the requirement that scientific claims be exposed to critical scrutiny before they are accepted, had never appealed greatly to proponents of alternative medicine. Some of them believed that scientific principles just could not be applied to forms of therapy that were intensely individual, though others were keen to accept the trappings of tradition, the white coat and the appellation "doctor". Promotional materials were quick to reference studies that, when examined, proved either to be poor in quality or to be selectively or inaccurately quoted. Occasionally people whose scientific claims were questioned turned to the law to attempt to silence critics, rather than engaging in scientific debate. Sometimes they succeeded, but not always. The editor of the New Zealand Medical Journal , when chiropractors threatened to sue over an article asked them to 'provide evidence, not your legal muscle.' A US judge dismissed a device manufacturer's law suit by saying that the dispute should take place in the pages of the journal, not in a Court.
Government, however, went to consultation in 2009 on proposals for statutory regulation of Acupuncture, Herbal Medicine, Traditional Chinese Medicine and Other Traditional Medicine Systems. In 2010 the House of Commons Science and Technology Committee reported that as there was so little evidence for homeopathic treatment, the Government should stop allowing the funding of homeopathy on the NHS, and the funding of homeopathic hospitals - hospitals that specialise in the administration of placebos- should not continue.
Microbiologists had new tools at their disposal for molecular assessment now made it possible to assess more accurately which strains were responsible for outbreaks.
The risk of pandemic influenza had led to warnings of disaster for years, though neither severe acute respiratory syndrome (SARS) nor the small outbreaks of 'bird flu' in the Far East had affected Europe significantly. How to deal with the threat of an epidemic had been the subject of detailed planning, the NHS being urged to make preparations to keep the service running at a time of mass illness. In 2009 an outbreak of Swine flu (H1N1) with many deaths in Mexico created world wide anxiety. Early on CDC Atlanta said it was probably impossible to contain it and its advice was designed to slow spread, not to contain it. "Communities, businesses, places of worship, schools and individuals can all take action to slow the spread of this outbreak." Some countries reacted incoherently, for example slaughtering pigs en masse. Within weeks dozens of countries had cases, but they were most mild in nature. Indeed the normal victims of flu,. the over 65s, were less likely to contract the disease because of pre-existing immunity. The US Federal Government and manufacturers rapidly began to develop a vaccine against the novel H1N1 flu virus. In England antivirals such as Tamiflu were initially used prophylactically for contacts but this strategy of containment failed and the number of cases slowly increased, mostly in the young. Deaths occurred particularly in those with lowered resistance because of other diseases. Pregnant women and young children seemed particularly at risk but while the number of cases was much the same as those in a "normal" year, deaths did occur. In July 2009 the Chief Medical Officer, Liam Donaldson, spoke of a worst case scenario of 65,000 deaths. Fuelled by government and the media, public anxiety and the pressures on primary care grew. In July 2009 100,000 cases were recorded in a week. A National Pandemic Flu Service was launched (GPs were taken out of the equation)and a phone line and web site were established although it was soon clear that less than one in twenty callers actually had the disease. Having bought a million doses, the service made antiviral drugs available directly to the public if they gave a history suggestive of infection . Comparatively few picked up the drugs for which they had asked. A revised assessment by the Cochrane collaboration threw doubt on the ability of oseltamivir to reduce complications in otherwise healthy adults. 90 million doses of the newly developed vaccine were ordered and in October 2009 vaccination began. The take-up was understandably low. Serious illness other than influenza might be misdiagnosed and some undoubtedly suffered because diagnosis of their real illness was delayed
While the Secretary of State, Andy Burnham, maintained that England had come through the epidemic because of the strength of plans, this was clearly not so. Nobody seemed to have considered the possibility of a pandemic so mild that it would cost fewer lives than normal seasonal flu. In January 2010 the weekly case rate was below 5,000, and the total deaths in the UK about 360. Only a third of the vaccine purchased was used, and attempts were made to dispose of the surplus. Post-mortems began; had public health doctors over-reacted? Had the pharmaceutical industry created a panic to increase the sales of their vaccines? Had money been wasted? Would anyone believe predictions again? It was hard to say any one decision was wrong, but once the concern was there, one step followed another with grim inevitability. (Hawkes N, BMJ 2010;340c:789)
The number of new cases of variant CJD continued to decline. Only one new case was reported in 2008 and one additional death.
A significant outbreak of Escherichia coli 0157 in September 2009 originated in a Surrey farm open to the public, where animals could be fed and petted, and involved over 90 people, many of them children, some of whom were seriously ill and requiring renal dialysis. Found on almost 40% of cattle farms, risks might be minimised but could not be eliminated.
Methicillin resistant staphylococcus aureus (MRSA) first appeared in 1961 (methicillin was developed in 1951) but it was several decades before it became a problem. In the 1992 the number of strains that were resistant in hospital practice reached some 50% Now similar strains became more common in the community, in young fit people, sometimes with sports and soft tissue injury. Clinicians outside hospitals now had to be aware of this increasing hazard.
By the beginning of the decade there were more than 25 antiviral drugs from 6 therapeutic classes available for the treatment of AIDS. In developed countries multiple drug regimes were normal and most people who took medication achieved durable viral suppression. A new issue emerged, an increased incidence of disease in long term survivors. Classic AIDS related conditions were becoming less common but compared with a normal population "non-AIDS related" conditions were more prevalent. Heart disease, cancer and liver disease and conditions related to aging, were among these. These complications appeared most likely when treatment did not restore cell counts to the normal range. The care of patients with AIDS was becoming more complex.
In the 1970s many haemophiliacs had been infected by HIV as a result of substandard blood products. Lord Archer had reported on this in 2008 (Chapter 4) and in May 2009 the government response increased financial compensation and expressed regret. While a press release was issued, unusually the response was placed in the House of Commons library and not published on Internet.
As a result of lower levels of immunisation against measles, the numbers of cases continued to rise exceeding 1000 in 2008. Targeted immunisation programmes were introduced to deal with local outbreaks. Immunisation against human papillomavirus (HPV), a virus that causes cervical cancer, was offered to 12-13 year old girls from September 2008, and before long 70 per cent of 12-13 year olds had had their first of three vaccinations, a high rate of uptake. It was decided to more rapidly to cover 13-17 year old girls.
In the UK immunisation against influenza was recommended annually for the elderly and those at special risk. In the US it was now recommended from 6 months to 18 years.
Medical genetics was beginning to come of age. For twenty years there had been increasing knowledge of the genetic causation of some diseases, opening the path for the development of treatment. Now, instead of just being interesting, genetics was leading to therapies that altered the patient's genetic structure, as in eye disease. Human embryonic stem cells could now be developed to the point of differentiation into different tissues in sufficient quantities for use in animal trials.
Women with a BRCA1 mutation have an 80% chance of developing breast cancer and a 60% chance of developing ovarian cancer during their lifetime. In 2009 the first baby was born in the UK as a result of pre-implantation genetic diagnosis and in vitro fertilisation, as a result of which not only would she be likely to avoid these diseases, but she would not pass the increased risk on to her own children.
Flexible endoscopes and colonoscopes had made it possible to examine perhaps half of the gastro-intestinal tract, but the procedure was uncomfortable and usually required sedation. A new form of investigation became possible with the development of a PillCam that could be swallowed. It combined a camera that could take 5-30 photos a second, with LED lighting, batteries and a radio transmitter. Over ten years organ-specific PillCams were developed for the oesophagus (which could look forwards and backwards), the small bowel, and the colon. The device was particularly useful in diagnosing bleeding of obscure origin, and cancer of the colon in people who refused conventional colonoscopy.
Changing demand for surgical procedures brought forth new subspecialties. Bariatric surgery, the reduction of the capacity of the stomach in an attempt to treat obesity that was life threatening and had not responded to simpler dietetic measures increased rapidly year on year, so that by 2008 some 10.000 such operations were being carried out annually, mainly in the NHS but also in the private sector.
Two new minimal access techniques were under development. Natural orifice endoscopy used a natural cavity such as the rectum or vagina as an access point, avoiding the need for an external scar. Single port laparoscopy involved, instead of several stab incisions providing surgical access, a single one at the umbilicus, again avoiding scaring. Appendicectomy, cholecystectomy and even partial colostomy were possible in this way which its protagonists thought was safe in well trained hands, virtually scar less, and of reasonable cost..
The scope of tissue transplantation was widening. Over the previous ten years intestinal transplants moved from an experimental to a more regular procedure, usually performed for people with a short gut as a result of Crohn's disease or the removal of tumours. In intestinal failure, the intestines can't digest food or absorb the fluids, electrolytes and nutrients essential for life. Patients with intestinal failure who developed life-threatening complications from total parenteral nutrition (nutrition into a vein) could now be considered for gut transplantation with or without other organs such as the pancreas and liver, with a good chance of 5 year survival.
A pioneering biomedical engineering operation in which tissue grown outside the body could be used, also took place. After many years careful laboratory, immunological and animal work, a joint team from Bristol, Spain and Italy collaborated in the removal of a main bronchus largely blocked by tuberculosis that had led to lung collapse, and its replacement with a new piece, without the need to use drugs to suppress tissue rejection. They began with a 7 cm segment of trachea from a 51 year old woman who had died of a brain haemorrhage. After stripping the trachea of all its potentially antigenic cells, the scientists reseeded the cartilage scaffold with cells from the recipient—a culture of epithelial cells from her own right bronchus for the inside of the graft and chondrocytes transformed from her own stem cells for the outside. They grew both types of cell in specially adapted cultures before being transferred to the graft over four days in a newly developed bioreactor. Many months after surgery she remained in good health.
An increasing understanding of how important it was to the very severely injured to be treated in a major trauma unit handling many such cases, led to pressure for reorganisation of the service. According to a National Audit Office report our death rate was 20% higher than in the US. London, in advance of the rest of the country, established a metropolitan wide trauma service based on four major trauma centres, The Royal London Hospital, Whitechapel, King’s College Hospital, Denmark Hill, St George’s Hospital, Tooting and St Mary’s Hospital, Paddington to which ambulances would preferentially take such cases.
The conflicts in Iraq and Afghanistan had been accompanied by the development of new forms of weaponry, in particular IEDs (improvised explosive devices). These, often laid by roads, led to severe injuries often characterised by severe blast damage, flying debris, crush injuries and major burns. Blast injuries to the brain were common and military surgery techniques developed rapidly to deal with these problems. The effectiveness of the medical care was such that 90% of those seriously injured now lived, albeit often with horrendous injuries. In Germany there was a tertiary care hospital and to this injured soldiers were rapidly evacuated.
The earthquake near Port-au-Prince in Haiti in January 2010 showed how a disaster, if it decapitated a country by removing its centre of government, health service, police and transport facilities, could create vast difficulties for international relief effort. Organisations such as Médecins Sans Frontièrs (MSF) struggled to provide aid in a country with no functional port and minimal airport facilities, in the face of some 200,000 deaths and vast numbers of crush injuries.
For some 20 years coronary angioplasty had been available and increasingly centres had been using it in the acute phase of a heart attack. In 2008 the Department of Health recommended that primary angioplasty should take over from thrombolytic drugs as the first line treatment for myocardial infarction, as it was associated with lower mortality and better long term outlook if carried out within 3 hours of onset. Ambulance services collaborate closely with their receiving hospitals and networks, the focus shifting from provision of early thrombolytic treatment outside hospital to identifying those patients with a heart attack who might benefit from primary angioplasty, and transferring them rapidly to an appropriate hospital. Cardiac Networks (also known as 'heart and stroke networks' since they facilitate improvements in stroke care) were made up of clinicians, managers, commissioners and patients who work together to coordinate every aspect of patient care .
Steady progress was made with total implantable artificial hearts. The Jarvic 7 (first used in 1982) was replaced by the CardioWest™ Total Artificial Heart, developed in Tucson Arizona. By 2009 this had been used in over 800 patients. Often used to buy time in a seriously ill patient while a heart transplant match was found, it was used at the Cleveland Clinic early in 2009 for the world's first Total Artificial Heart to double heart and liver transplant. This artificial heart transplant was successful 4 times out of five, and the subsequent success of heart transplantation was one-year and five-year survival rates of 86 and 64 percent.
Carotid endarterectomy was effective in the prevention of stroke in patients with recent symptoms of carotid stenosis, and in younger patients without symptoms. In skilled hands the risk of stroke and death from operation was no more than 3%. Clinical trials of stents showed that the short term hazzards were not as good as after surgery, with more ischaemic events. Results were improving, but open operation was still safest.
Technological improvements led to the development of better diagnostic equipment, for example simpler equipment to test for glaucoma, or to image the retina. Multifocal lenses were tried in the treatment of cataract, but did not prove wholly satisfactory. Drugs for the treatment of glaucoma, Avastin and Lucentis, were approved for general use by NICE and success was reported in the use of stem cells in the treatment of a rare form of inherited blindness, Leber's congenital amaurosis.
Age related macular degeneration, earlier treated by laser, was increasingly managed with an anti-vascular endothelial growth factor drug (administered into the vitreous), representing the era of biological medicines for the management of neovascular disease. Stem cell treatment was also under development.
Medical genetics now provided new approaches to diagnosis and treatment. In 2009 the mapping of the entire genome of two patients with cancer (lung and malignant melanoma) showed that each had tens of thousands of abnormal mutations. Which were related to the cancer was not clear, though it was calculated that there was a mutation for every 15 cigarettes smoked. It was however likely that as more patients were mapped, relevant mutations would be identified, opening a route to the development of new drugs and better treatment.
To the hundred or more drugs already in use for cancer, some 40 more were heading towards a licence, mostly effective and all expensive. Most derived from new knowledge of how cancer cells worked, and it became essential to develop new tests of effectiveness. Each year the American Society of Clinical Oncology reviewed the studies of the previous year, to record the steady expansion of knowledge of cancer and its treatment. In 2008 its report listed many advances in that year, often small but in total increasing the chance of a favourable outcome. They included
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Malignant melanoma of the skin was now the most common cancer in young women, increasing significantly over the previous ten years. The increase seemed associated with tanning and sun beds, and warnings of the health risks did not seem to be taken seriously by the young.
Screening for bowel cancer by testing faeces for blood was introduced in 2007 and was scheduled to cover the whole country by the end of 2009. Computer simulation suggested that it might save 2500 lives annually in the UK.
Radiotherapy techniques advanced, and proton beam therapy became available at Clatterbridge Hospital, Wirral. Other hospitals were invited to bid for funds for it. Proton Beam Therapy (2009), then being used at a dozen centres in the USA, could cure tumours without damaging vital organs. Because of their relatively large mass, protons do not scatter much in the tissue; the beam does not broaden much and stays focused on the tumour shape without much damage to surrounding tissue. All protons of a given energy have a certain range; no proton penetrates beyond that distance. Although applicable to comparatively few patients, some, especially children, with highly specific types of cancer that occur in the retina, base of the skull and near the spine, this form of treatment could be better than conventional radiotherapy as it targets the tumour precisely, giving better dose distribution and not harming vital organs.
Hopes of better treatment for multiple sclerosis, a serious and disabling disease of the brain, were raised in 2008 by a trial of a monoclonal antibody Alemtuzumab, that targets CD52 on lymphocytes and monocytes. It reduced the risk of sustained accumulation of disability compared with a previous drug, but had dangerous side effects. Thrombocytopenic purpura developed in three patients, one of whom died.
Childbirth had never been safer. Antenatal care was reviewed, additional screening tests added and complex systems introduced to monitor antenatal and intrapartum care. However technology was used not only to improve health care, but to avoid legal claims. All babies had to be perfect, so caesarean section rates remained high. Recordings of babies' hearts were kept indefinitely by some units, as in their absence a future claim by parents of a handicapped child would be hard to defend. Babies had electronic tags to make abduction difficult. In a society characterised by some as "me too", patients would complain if their requirements had to wait while others received attention.
Probably because of the increasing number of pregnancies in older mothers, the number of cases of Down's syndrome was increasing - from 1,075 diagnoses in 1990 to 1,843 by 2008 in England and Wales. Because of improved antenatal screening more Down's pregnancies were spotted and more abortions took place.
Neonatal intensive care
More babies needed neonatal care because of:
The survival of small babies was steadily improving as the details of care, monitoring and biochemistry, were better understood. Below 23 weeks gestation the outlook was poor, but after that with each succeeding week results were better. At 26 weeks babies stood an excellent chance of survival, particularly if they were delivered in, or rapidly transferred to, a large and experienced intensive neonatal care unit. Such units might have 4 or more neonatologists (spending more than half their time on the specialty and ventilating perhaps 8 or more babies at a time) were uncommon but had significantly better results than the smaller, more common, paediatric intensive treatment units. Transfer before delivery was best when a mother went into premature labour, but the capacity of labour wards sometimes made this difficult. In 2009 the Department of Health issued a "tool kit" of recommendations aimed at developing clinical networks and increasing the quality of care.
Neonatal screening
Screening of the newborn for metabolic disease has started in the 1960s with tests for PKU (phenylketonuria). Additions were soon made and the list expanded in England to include congenital hypothyroidism, cystic fibrosis, sickle cell disease, and Medium Chain Acyl CoA Dehydrogenase Deficiency. It was also easy to screen for galactosaemia and in North America the list of conditions for which screening was undertaken could be far larger, including biotinidase deficiency, congenital adrenal hyperplasia, homocystinuria, maple syrup urine disease and tyrosinemia. One private clinic would test for 20 different conditions, and genetic testing added to the possibilities.
In 2005 the National Audit Office showed that stroke services were in a parlous state, and stroke became a national priority. Extra stroke physicians were funded, with the aim of admitting all patients to dedicated stroke units. If patients with symptoms of stroke were to receive the rapid imaging necessary before thrombolysis, within half an hour of admission, reorganisation of services was necessary. In most parts of the country thrombolysis would spread to every district general hospital. In London, however, a few hyperacute services would be established, supported by stroke recovery units and transient ischaemic attack services for possible minor strokes.
Over recent years there had been a major drive to ensure that all dying patients, and their relatives and carers, received a high standard of care in the last days and hours of their lives. The Specialist Palliative Care Team at the Royal Liverpool University Hospitals and the Marie Curie Hospice, Liverpool developed the Liverpool Care Pathway for the Dying, (LCP). The LCP was recognised as a model of best practice and was recommended in the NICE guidance on supportive and palliative care for patients with cancer (2004) as a way of identifying and meeting the needs of dying patients. It prompted staff to consider the continued need for invasive procedures and whether current medications really were conferring benefit. The clinician has the opportunity to follow the LCP guidance or to record the reason for decisions to determine a plan of care that deviated from this. It required regular assessment and involves continuous reflection, challenge, critical decision-making and clinical skill. The LCP, though widely welcomed, was criticised in some quarters.
How many beds? Between 1955 and 1995 the number of beds for mental illness and learning disability fell from 150,000 to fewer than 55,000. Over the next ten years there was a further reduction of 30%, care increasingly being delivered by community based teams. While the number of admissions (perhaps for depression or dementia) fell, the number of those admitted 'involuntarily' increased by 20%, particularly for drug and alcohol problems. Admissions for psychosis remained roughly constant. The case-mix of inpatient facilities was changing as the number of beds continued to fall, and increased use was made of private facilities contracted to the NHS. BMJ 2008;337:a1837
The steady rise in the number of people with dementia, the costs incurred and the doubts about the effectiveness of treatment led in 2009 to the publication of a national dementia strategy, Living well with dementia. It aimed to ensure better knowledge and earlier diagnosis of dementia, and to improve care. Better and more coordinated local services, including memory clinics, were required. Little advance, however had been made in the prevention or treatment of the condition. Pressure groups commissioned studies showing that there were far more patients than had been estimated, perhaps some 800,000, and called for more research into the increasing problem.
Progressively the way primary care was provided was changing. Government continued to see advantage in supporting community based services. The 2008 Transforming Community Services (TCS) programme aimed to improve them and provide modern personalised and responsive care of a consistently high standard. In London in particular, where accommodation was often poor, the polyclinic concept was slowly developed partly under the influence of Lord Darzi. It aimed to combine GP and routine hospital care with a range of health and support services such as benefits support and housing advice. General practices, a walk in clinic, investigations such as breast cancer screening and consultant sessions in for example cardiology and ophthalmology, might be co-located. Services such as X-rays and blood tests would be available. They were open from 8am to 8pm every day including at weekends and available to people even if they were not registered there. Some were developed around existing systems but others were new, for example Heart of Hounslow, and the Loxford Clinic in Redbridge. The Loxford Clinic opened in 2009 providing the premises for a practice, consulting rooms for specialties such as dermatology and ophthalmology, modest imaging facilities but no parking. With a capital cost of £6.5 million and equipment a further £2.5 million, whether the large building was an effective use of resources was not clear. There were high hopes that the initial expenditure on establishing the clinics would lead to major savings by encouraging the transfer of work from a high cost hospital environment to a community setting. There was little hard evidence for this belief and an evaluation was commissioned.
Over 10-20 years the number of salaried doctors steadily increased until, in 2009, probably some 40% were on a salary and, indeed, very many were locums. Salaried practice often suited young doctors female and male, and large and business-like partnerships might take advantage of the situation. While the British Medical Association had a model contract, only a third of salaried doctors used this. Primary care trusts (PCTs) were having an increasing influence on practices. A practice might find the PCT willing to fund new staff members in the practice team, for example a physiotherapist providing open access to patients or a psychotherapist. They could bring pressure on practices to extend their hours of opening as well as use the quality and outcomes framework as an incentive.
The Alterative Provider Medical Services Contract (APMS) allowed primary care trusts to contract services from groups outside the NHS, including commercial and voluntary organisations. PCTs were slow to do so, mainly using the system to fill specific requirements but by 2008 some 100 practices were being run by alternative providers and it was GP-led companies that had been most successful in bidding for these contracts. Corporate providers and social enterprises had been successful in a minority of cases. GPs had an inbuilt advantage in that while they might be strangers to the complex process of tendering, they had local knowledge and the financial advantage of remaining within the NHS pension scheme. Some supported this development as encouraging innovation and challenging the existing pattern of delivery; other saw it as an aggressive commercial take-over of general practice. The policy risked spending money on services in places where they were not really needed, or destabilising local practices providing a good service.
In the attempt to improve the quality of primary care, ideas could get muddled. Pressure for "polyclinics" which could bring practices together and at the same time, provide backup and facilities that would enable some transfer of care from hospitals, could be confused with an another initiative to increase competition, GP led health centres, which might be far smaller. In December 2007 government required every PCT to tender for a general practitioner led health centre including walk in services for unregistered patients. The first such centre opened in Bradford in November 2008. Blanket instructions to establish particular types of facility could conflict with local needs.
Concern continued over the provision of services out of hours since NHS GPs had transferred their responsibilities to primary care trusts. Complaints about the service increased substantially. Because it was hard to recruit local doctors, PCTs and the organisations with whom they contracted might look far and wide for staff, often to Europe. Reports suggested that at best only one in four of people requesting a visit got one; it might be far fewer and "telephone diagnosis" was common. The population covered by an out of hours deputy might vary from 30,000 in some areas to 300,000 in others.
It was hardly surprising that failures of the system might be dramatic and attract national interest. The death of a patient given ten times the normal dose of heroin by a German locum led the Care Quality Commission to investigate the arrangements in 5 PCTs and, recognising a wider problem, to "encouraged PCTs across the country to scrutinize in more detail the out-of-hours services they commissioned". The Times (4 February 2009) described the out of hours service as a disaster and an avoidable one, as a result of the way the Department of Health had, during contractual negotiations, allowed out of hours care to move from GPs to PCTs at minimal cost to the doctors. A review by the Department of Health and the RCGP (strangely described as 'independent') laid the responsibility on SHAs and Primary Care Trusts, largely absolving GPs from responsibility. The Conservatives promised re-negotiation, to return responsibility for care to local doctors.
The quality and outcomes framework, introduced in 2004 and accounting for some 15% of primary care costs and up to a third of a practice's income, was improving the process of care at least as far as the conditions covered by the framework. There was some evidence that other aspects of care were sacrificed in the process. Essentially a contractual system of financial incentives for the delivery of quality care, it covered clinical care, organisation, patient experience and additional services. Significantly, practices in deprived areas achieved similar levels of cover to practices in more affluent areas. The framework was altered regularly under the supervision of primary care academics, overseen by the RCGP and lay representatives, and from 2009 incorporated advice from NICE. From a focus on structure and process in common chronic conditions, it increasingly took account of disease prevention and outcomes.
Most GPs did not take their own phone calls out of surgery hours and there was a reliance on various systems of triage. Studies suggested that the decisions taken by "triagists" varied and that a substantial proportion of decisions were wrong. Outcome studies did not reveal many problems as a result, possibly because most calls were only about trivial matters. Advice was given after asking too few questions, and without properly interpreting the answers. There were significant dangers to patients and the protocols used were hard to assess because they were not publicised, nor available on-line allowing them to be studied.(BMJ 2008:337: a1167) The Healthcare Commission, reporting on emergency and urgent service in September 2008, found gaps and variation in performance. In 65% of areas, out-of-hours GP services met the requirement that they started telephone assessments within 20 minutes of a patient’s initial contact if a patient’s needs were urgent, and within 60 minutes otherwise. In some areas, less than 80% of assessments are started within these timescales. NHS Direct exceeded the target for starting telephone-based assessments within 20 minutes for urgent calls (priority 1) and 60 minutes for other urgent calls (priority 2) in 95% of cases. It achieved this for 98% of priority one, and 99% of priority 2 calls. The Commission suggested the piloting of a single telephone number for urgent care services which had the potential to ensure fewer people attend the wrong services. The delay patients experienced, in general greater than in earlier times when the GP or his deputy immediately picked up the phone, was one possible cause of increased strain on A & E Departments.
Substitution of nurses for doctors in primary care, increasingly common, might be cost effective and outcome studies suggested no great differences between the two types of practitioners in fields such as the follow up of patients with long term illnesses. Nevertheless the characteristics of GPs and nurses differed,. Doctors, said a BMJ editorial, needed to deal with uncertainties and take risks, while nurses were more attuned to following protocols and providing hands on care.
As a result of the devolution of health service management to the four nations of the UK, marked differences were emerging in hospital services. It was not just differences in the money available to spend. Policies led to different incentives. In England targets to improve performance, payment by results and the increasing emphasis on the provider/commissioner split and patient focus gad driven change. Scotland had abolished the internal market and had integrated boards purchasing and providing primary and secondary care, Wales was looking at the Scottish model and Northern Ireland continued with its integration of health and social services. Compared with the others, England had shorter waits in A and E in part because the reduction of waiting times seemed associated with a greater rise in attendances than elsewhere. Proportionately more patients were discharged rapidly, within a day of admission, in England.
The beds available for patients overnight continued to fall, with about 85% occupancy of acute beds, and 90% in geriatric wards.
| Year | Acute | Geriatric | Maternity | Total |
2006/07 | ||||
| 2007/08 | 101,080 | 20,700 | 8,441 | 130,221 |
| 2008/09 | 100,892 | 20,796 | 8,386 | 128,054 |
The reports of Lord Darzi stimulated action in each of the ten strategic health authorities. London was about a year in advance of the others, and because of the number of the hospitals and the concentration of the population could produce systems difficult to replicate elsewhere.
Healthcare for London, a programme run by the London PCTs branching off from the SHA, and which had produced the first Darzi review a year before SHAs elsewhere in the country, published more substantive proposals in November 2008. While written for London, it seemed likely that the proposals have a national significance. Stating that the District General Hospital pattern of the 1960s was no longer relevant because of the development of services in the community (e.g. polyclinics) and the need for the care of some conditions such as heart attacks and strokes to be centralised, it set out the basic content of a modern local hospital.
"A local hospital, serving a population of around 250,000 would include a 24-hour accident and emergency (A&E) department, paediatric assessment unit, maternity unit, and provide inpatient emergency care alongside critical care services. In addition to other clinical services, it could also include a 24/7 polyclinic at its front door, treating non-urgent cases and providing direct access to diagnostics tests and outpatients. This will prevent many unnecessary trips to A&E departments. There is not a one-size fits all local hospital as the range of clinical services must be driven by local need."
The document considered how patients with a variety of conditions, urgent or more routine, might pass through the system from the community, a polyclinic, a local hospital or a major one. It produced financial models that indicated how the income of hospitals might change as the pattern of work altered, models that revealed funding gaps when allocations to the NHS seemed likely to be reduced. However, there was a belief that substantial savings could be made if care could be moved into the community. Polyclinics were seen as central to a reduction of the demand for, and the cost of, hospital services - particularly in London. The London School of Hygiene and Tropical Medicine would undertake a two year evaluation of the early polyclinics.
Content of a local hospital | |
A&E department (24 hours) | Critical care facilities, level 3 (managing patients that require ventilation) |
Paediatric assessment unit (18 hours) | Outpatient services |
Urgent care centre (treating minor illness and injury) | Maternity services with a special care baby unit |
Emergency surgery for non-complex cases (12 to 16 hours a day e.g. abscesses, internal bleeding, bowel obstruction) | Diagnostics (including X-ray, ultrasound, CT scans) |
Medical cases requiring a hospital stay (e.g. pneumonia, heart failure, liver disease) | Pathology (blood tests, etc) |
Planning for reconfiguration of services such as stroke and heart attack, under the Regions' "Darzi" proposals, was a delicate balancing act. London issued a consultative document making the case for 4 trauma units and 10 hyperacute stroke units in February 2009. Ambulance services would have to triage patients effectively. Having gone to consultation, in July 2009 the London PCTs agreed major service changes
Four Major Trauma Centres | Eight Hyper Acute Stroke Units |
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Some reconfiguration of services was taking place quietly and steadily. Moorfield's Foundation Trust continued to open off-site units of which there were 11 by 2008. Hospitals would approach Moorfield's for assistance in maintaining a viable ophthalmic services, both sides benefiting. Clinical networks developed at a professional level with little management involvement. NHS London's reconfiguration agency, Healthcare for London, opened consultation on the reconfiguration of major trauma and acute stroke units in February 2009. The consultation confirmed four sites for major trauma units, the Royal London, King's College Hospital, St Mary's and St George's. Hyperacute stroke units were envisaged at Charing Cross, King's College, Northwick Park, St George's, Princess Royal, University College, The Royal London and Princess Royal hospitals.
The development of academic health science centres steadily proceeded. The Imperial College Health Care Trust, early in the field, was in no doubt that the UK was losing its position as a leader in biomedical research, in part for want of government support. It thought the NHS had always been poor in translating research into service and patient outcomes lagged far behind other western countries. It saw academic health science centres as key to the future of the NHS, and indeed that it was itself pre-eminent in this field, and the only organisation in the UK likely to be able to compete on a global scale.
Academic Health Science Centres had been supported in the Department of Health's Next Stages review. An international panel chaired by Sir Ian Kennedy would select the organisations to be designated academic health science centres allowing the government to identify the university and NHS partnerships best able to make the most of the synergies between research, education and health services to translate research into better care. These would increase the speed at which research is taken "from bench to bedside and back again".
Independent sector treatment centres were failing to deliver full value. Though paid above tariff levels, few seemed likely to deliver more than 90% of the services for which they were paid during the first 5 years of their contracts. Transferring waiting list work from NHS units was sometimes used, but it seemed unlikely that all ISTCs would justify renewal of contracts or succeed when payments moved to tariff. levels. The Department agreed to meet the buy-back costs of residual assets were a centre to close.
The NHS Plan (2000) had announced a major building programme, much funded by PFI, to replace and modernise the aging NHS estate, half of which dated from before 1948. Capital stock was now better, it was now down to 20 percent with 100 schemes completed and many others underway at a cost of £12 billion. Department of Health (and Scottish) guidance now suggested that new hospital wards should contain at least 50% of accommodation in single rooms. Maidstone and Tunbridge Wells trust planned to ill replace its ageing Pembury Hospital with the NHS's first all single room acute hospital. The new hospital provided all patients - except those in the special care baby unit - with their own ensuite room. This would involve new ways of working for NHS nurses, but was welcomed by patients' organisations and might help to reduce cross infection rates.
The financial crisis made credit hard to obtain and this affected PFI. In 2009 the Treasury announced plans to lend to recession hit PFI schemes, perhaps using under spent capital from elsewhere in the NHS budget. Of 22 hospital schemes planned in England in 2007, two years later only eleven were being pursued, not just because of the credit crunch but because PFI was now well recognised to lock hospitals into decades of fixed overheads, just when policy was encouraging a shift to care outside the hospital. In some cases up to 15% of revenue was predicated in this way. The recession exposed difficulties in PFI with a lack of both public and private capital finance.
The buildings and facilities of some 15 independent treatment centres were purchased by the NHS. Though in the private sector, re-financing the capital would be hard in the recession . Costing some £200 million, some contracts with the private sector might be renewed, the NHS acting as landlord. Some schemes in Nottingham and Merseyside would cost £40 million each.
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Changes in the training system were affecting service delivery. In August 2009 the European Working Time Directive came into force limiting the average hours worked by junior doctors to 48 per week. Concerns about it included the running of the service, patient safety and the reduction in training experience. The President of the Royal College of Surgeons expressed anxiety about the effect on patient care as the teams that were rostered took over from each other. With restricted hours and and increased commitments to education rather than service, who kept the service running? With hours more than in many other countries, would competence be acquired under the new system? "Surgery is a body-contact sport, there is no question about it. You can’t be a good armchair surgeon". Bosk CL. Forgive and remember. University of Chicago Press, 1979 Nor did juniors always have the skills of their predecessors; when medical students no longer delivered babies, a new house officer who had never done so or stitched a tear was not a great help. Hospitals were increasingly employing nurse practitioners and staff grade (sub-consultant) doctors.
Responding to the independent inquiry into Modernising Medical Careers (MMC) the Department of Health published its response to Sir John Tooke's report and set up a new advisory body to operate at arms length from Ministers. NHS Medical Education England (MEE), established on 1 January 2009 to provide independent expert advice on training and education for doctors, dentists, health care scientists and pharmacists. It would be a non departmental public body supported by a secretariat from the Department of Health. Not quite the body proposed by Sir John Took in his report, it would be concerned with postgraduate training and would need to relate to the GMC. In May the Secretary of State asked MME to review the effect of the European Working Time Directive on the training of junior doctors and the anxiety that the introduction of a 48-hour working week might have a detrimental effect .The Post-graduate Medical Education and Training Board (PMETB), the independent regulator of standards of training, would assess where changes to training might be necessary as a consequence of reduced working hours.
Problems remained. Hospitals had received virtually all the salary of junior staff in training, staff who required almost continuous supervision. It was now proposed to reduce the money hospitals received in this way. With their shorter hours and educational commitments they might not represent value for money compared with other ways of providing care and trusts might not be so keen to have so many junior staff in the future.
The increasing number of women entering the medical profession, set to form the majority within ten years, made it important to consider the effect on the NHS, and of the employment opportunities in the NHS for on women. The Royal College of Physicians published a report in 2009 on Women in Medicine - the future - the report stating that
However the preferences of women doctors, as with male doctors, might not match with career opportunities. With an increasing output from medical schools, the ability of doctors from overseas to compete on level terms with those trained in the UK, and the probability that the economic down-turn would limit the expansion of medical staffing in the NHS, the labour market for doctors looked set to become much harsher. BMJ 2009; 338: 1397
Links | Nurse_education_and_staffing |
Nursing_practice | |
Nursing administration |
Early in 2009 Gordon Brown established a Nursing Commission, chaired by Ann Keen MP, a Minister and a nurse, to review nursing. Addressing the Royal College of Nursing he said "Nursing has become even more central to the future of both healthcare and all our fabric of social life in our country. Nurses are now performing operations ...are now prescribing .... running services,... as managers, nurse consultants, nurse practitioners, and ... we want nurses to be more involved and more central and more in control of what happens in the health service in the future." The Commission would "look at all the trends and all the changes and all the forces at work that are going to change our society and also change nursing in the years to come....and take the next steps to enhancing... and improving the status of nursing in our country for years to come."
Ann Keen said, 37 years after the Briggs Report, that the Commission aimed to usher in a new era that locates nursing, midwifery and care issues in a central position in policymaking and management, and stimulate wide interest in and ownership of the need to promote improvements. "We will tell a new story about the future nurse and midwife, to create a modern, realistic but inspiring public image - or plurality of images." Anne Marie Rafferty, Dean of the Florence Nightingale School of Nursing and Midwifery, King’s College London, wrote "We need to raise the bar in nursing and midwifery education, practice and research, rooting out poor performance and standing up for standards". What was less clear was the problem that the Commission was established to solve - it was hard to imagine that a similar commission would have been established to look at medicine and doctors. In October 2009 the Commission published its vision. "Its ultimate goal is that all nursing and midwifery staff fulfil their potential to help people who use NHS services, families and communities achieve the best possible health and well being......
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The report recommended protection of the title “nurse”, with only those registered by the Nursing and Midwifery Council (NMC) allowed to use the term - even though much if not most nursing was now undertaken by others, for example healthcare assistants who were responsible for much patient care as well as tasks such as blood pressure checks. These, though not "nurses" should be more carefully regulated though scant attention was paid to their major contribution to patient well-being. The commission also called for regulation of specialist nurses who focussed on particular conditions such as cancer, Parkinson’s and epilepsy. It recommended a new pledge for all nurses and midwives stating their commitment to, and accountability for, high quality and continuously improving care. The report also stressed the importance of skilled midwifery to meet the challenges of a rising birth rate and persistent health inequalities. |
Recommendations of Front Line Care
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The large NHS nursing force required a substantial proportion of each year's cohort of young people, people who had many other options. It was not particularly successful and many student nurses were in their late twenties. Project 2000 had aimed to professionalise nursing by encouraging greater academic involvement with university diploma courses and, for the minority, degree courses. The gap between the diploma and the prevailing standards of the degree was not however great. Sometimes the aims of nursing education that included the development of nurses as people with enquiring minds who wished to change matters, conflicted with the needs of the service and the requirement for compassionate and consistent care. University nursing courses varied significantly in their quality of their intakes and in the percentage finishing their course. At one London course only 8% of a cohort completed training. Some hospitals withdrew nurse student placements from courses where the support to students was poor.
In 2009 government, in agreement with the NHS and the nursing professions, said that from September 2011 all nursing students would undertake degree courses meeting new standards to be developed by the Nursing and Midwifery Council (NMC), the professional regulator for nursing as had been the case in Wales since 2004. The Royal College of Nursing described this as "an important and historic development." Whether it would make nursing more or less attractive as a profession was hard to say. Few hospitals knew the proportion of their present nursing workforce already with a degree though nationally about a quarter did. However, for every 4 registered nurses with either a diploma or a degree (315,410 whole time equivalents in 2008) there was at least one health care assistant. The new policy would probably shift the balance towards the health care assistants and much basic nursing would continue to fall on their shoulders. While they could later enter courses leading to full registration, there was a case for greater support and possibly higher pay for well trained support posts.
In line with the attempt to measure the quality of care, stressed in the Darzi reports, Alan Johnson (the Health Secretary) suggested that in the nursing field treating patients with compassion, reducing the number of falls on wards and good hand-washing were the indicators that could be used to measure the quality of nursing care in the NHS. Compassionate care - whether patients are treated with compassion and whether they are fully kept informed of what is happening with their treatment; effectiveness including the nutritional state of patients, minimisation of pain and results of hand-washing audits. Safety could encompass indicators such as the number of falls on a ward or infection rates. The 2009 Report from the Patients' Association, Patients not numbers, People not statistics, showed how far the NHS had to go.
