- Treat day surgery as the norm for elective surgery
- Improve access to key diagnostic tests
- Manage variation in patient discharge
- Manage variation in patient admission
- Avoid unnecessary follow-ups
- Increase reliability of performing interventions: a Care Bundle
- Apply a systematic approach to care for people with long-term conditions
- Improve patient access by reducing the number of queues
- Optimise patient flow using process templates
- Redesign and extend roles
Source: Health Service Journal supplement 9 September 2004
The bulk of its work was devolved and the Modernisation Agency was closed in 2005, parts being integrated into a new NHS Institute for Improvement and Innovation. The Institute continued the attempts to spread best practice, breakthrough innovations, ideas and proven improvements. Safer care, quality, the use of indicators and commissioning were among the topics it handled.
Other work to be carried on included workforce development and national workforce projects undertaken on a regional basis. Skills for Health (www.skillsforhealth.org.uk), an organisation established in 2002 concerned with assisting "modernisation" by aiding the training of people requiring new skills, was hosted by an acute NHS trust in Bristol. but had a relationship with DES. It was the Sector Skills Council (SSC) for the UK health sector. The purpose was to help to develop a skilled and flexible UK workforce in order to improve health and healthcare. It worked with professional and academic bodies and with the NHS to develop the syllabus for new roles, often involving skill substitution or a function identified as useful or necessary – many new competencies were emerging for example training healthcare assistants to act as scrub nurses. The nature of the demands and the workforce were changing, professional regulation was altering and new staffing patterns were emerging. A skilled, flexible and productive workforce was needed. Often NHS Trusts were training staff, but a form of accreditation and quality control of NVQ qualifications was necessary.
In 2004 John Reid published the NHS Improvement Plan, four years after the publication of the NHS Plan itself. This stressed the importance of the care of chronic diseases and of public health. It described a vision for the future -
- Patients able to choose from four or five hospitals by 2006
- Unlimited choice of NHS provider by 2008 and choice of private providers who meet the NHS tariff
- 15% of operations and tests to be carried out in the private sector by 2008
- Waiting times to be cut to a maximum of 18 weeks by 2008
- Maximum wait of eight weeks for referral to treatment for cancer patients by 2005
- More support for patients with chronic conditions
- Every primary care trust to offer community matrons by 2008
- Electronic booking and prescribing by 2005
- Fewer national targets
The Improvement Plan, like the NHS Plan before it, set out a multitude of initiatives. Reid summarized the strategic direction as
Delivering more care, more quickly through investment and reform
Offering people more personalized care and a greater degree of choice
Greater concentration on prevention rather than cure
Labour had not traditionally favoured choice in public services although in 1948 Bevan had made it possible for people to be treated in any NHS hospital according to their clinical need. This freedom of choice was constrained a little by the Conservative NHS Reforms and considerably more by the Labour administration of 1997. Alan Milburn felt patient choice important and the ability of people to chose where they might treated, and how, might improve the system. Mooney H & McLellan A, HSJ 2003, 9 October, 12-3 In December 2003 the government published a strategy paper “Building on the Best; Choice, Responsiveness and Equity in the NHS” .
a bigger say in how one is treated
Within a patient's electronic medical record, a "health space" to make their personal preferences and personal details known to the health team; patients to see doctors' letters about them
access to a wider range of services in primary health care
New providers in areas where primary care had traditionally been weak; nurses to treat more ailments and injuries; commuters might register with a GP near their work while receiving out-of-hours services from their local PCT
more choice of where, when and how to get medicines
wider role for pharmacies and pharmacists, expanding over the counter remedies and easing repeat prescriptions
easier hospital appointment booking
People waiting over 6 months to be offered alternative provision; ultimately patient booking on-line
better patient information
using new technology and TV
| ||source: Building on the Best; Choice, Responsiveness and Equity in the NHS|
From autumn 2004 patients waiting more than six months for elective surgery were offered the choice of faster treatment in alternative hospitals. Some Primary Care Trusts established referral management centres, to influence and control patient referrals, predominantly those by GPs, either directly or indirectly to manage demand so that it stayed within financial limits. In general such schemes saved little money and might delay or reduce the quality of patient care. The alternative providers were often in the independent sector or new independent treatment centres or trusts with spare capacity. The NHS Improvement Plan told PCTs to offer patients four or five choices and that private/independent care should feature amongst these. A Patient-led NHS published in March 2005; allowed independent providers such as BUPA to be included on the list of choices. In January 2006 general implementation began, with patient information leaflets and a web site to help people. Patients might now choose private sector hospitals that many thought were cleaner, better managed, had shorter waiting times and provided better facilities. But if money followed into private hospitals, there was a substantial threat to the budget of NHS ones.
From April 2008 GPs were able to refer patients to NHS hospitals and some independent treatment sector treatment centres anywhere in England for routine elective treatment. NHS trusts were able to advertise their services, advertising their waiting times, surgical results and infection rates. Testimonials and sponsorship from appropriate companies would also be permitted.Our Health, Our Care, Our Say.
Long anticipated, the publication of Our Health, Our Care, Our Say by Patricia Hewitt in January 2006 proposed a shift of resources from hospitals into the community. Community hospitals in areas of high population - perhaps with a different functional content and a range of clinical specialties - would be encouraged. Major hospital development should be reviewed, and 5% of health resources should be shifted from hospital to community services over the next ten years. The White Paper envisaged
Shifting expenditure from hospitals to the community and preventative services
Bringing some specialties from the hospital nearer to people, e.g. dermatology, ENT, orthopaedics and gynaecology
encouraging community hospitals that provide diagnostics, minor surgery, outpatient facilities and access to social services in one location.
Pilot a new NHS “Life Check” (initially by questionnaire) to assess people's lifestyle risks, the right steps to take and provide referrals to specialists if needed.
introducing incentives to GP practices to offer opening times to help patients in their area
Improving the services in deprived areas by additional money
Supporting people to self care by investment in the Expert Patient Programme
Developing an “information prescription” for people with long term health and social care needs and for their carers
Providing a Personal Health and Social Care Plan as part of an integrated health and social care record
More support for carers including improved emergency respite arrangements
A progress report in October 2006 discussed demonstration projects, GPs who were trained surgeons operating on hernias in upgraded surgery facilities, specialist nurses from hospital following up women who had been discharged early after mastectomy, and GPs with specialist interest seeing outpatients in place of consultants. The projects were worthwhile, but many required investment in premises or staff training, and did not seem likely to revolutionise health care or save much money. Indeed, within a year the £500 million suggested for a community hospital programme seemed to be disappearing.
Alan Johnson, took office as Secretary of State in June 2007. Within days he had set in hand a further review of the NHS.
Professor Ara Darzi had worked at the Central Middlesex Hospital in the 1990s when it was developing a groundbreaking ambulatory care unit and had joined the NHS Modernisation Board. He was used as a flying ambassador to look at local health problems, e.g. Kidderminster and Bishop Auckland, became chair of the London Modernisation Committee and a trusted adviser on health issues to Labour. He was knighted in 2002 for services to medicine. In 2006 Sir Ara Darzi was asked by David Nicholson, Chief Executive of the NHS London (the London SHA) to undertake a review of services which appeared as A Framework for Action. One of its fundamental proposals was the establishment of polyclinics to integrate primary care, support services and specialist outpatient services. Wishing to involve clinicians, he hand picked many for clinical working groups and received support both from the SHA and the management consultants, McKinsey's, who provided the secretariat for many subgroups and was probably involved in some of the writing. Around the time Gordon Brown became Prime Minister in June 2007 he attended a presentation on health issues by Ara Darzi, and when Brown selected his Ministers, Darzi was one of the GOATS, outside people to take part in a "government of all talents", and became a life peer in the House of Lords. His influence increased rapidly and it was rumoured he had the PM's mobile phone number. His views and reports came to influence health service policy, hospital system restructuring and issues of quality. Darzi, a clinician, was driven by quality. He said "I believe what I would like to be said is that I focused our minds on what matters most, with quality being the organizing principle of any health care system. It is quality that wakes me up in the morning to come to work, it is quality that my patients expect from me." April 27, 2009 in Knowledge@Wharton
Darzi, ennobled as Lord Darzi of Denham, took charge of the review established by Alan Johnson (2007-2009). The timescale was rapid - less than a year. Many SHAs were already reviewing their services. In October 2007, when a snap election was being discussed, Lord Darzi published an interim report setting out a ten year vision, Our NHS, Our Future. The SHAs' reviews in April-June 2008 were long on vision and short on detail. They followed central expectations but were less ambitious than the London report. A final report of the Next Stage Review High quality care for all appeared in June 2008 covering all regions save London.
Structural change was continuous. New organisations were formed, functions were redistributed, and soon they might be merged with others or abolished. The New NHS - Modern, Dependable began this process. The eight regional offices of the Department of Health’s Management Executive, said to be central to the system, were made redundant. [boundaries 1999]
Source - Audit Commission 2008 - Is the Treatment Working?
GP fund holding was replaced by other methods of giving primary care influence over the hospital sector, Primary Care Groups and later Primary Care Trusts. Like a pack of cards, other organisations had to change to fit in. As PCTs were given control over expenditure, the function of Health Authorities diminished and they were abolished. The organisational structure unwound till change affected every level from the GP to the Secretary of State. Mr. Milburn said that the NHS seemed top heavy, with the NHS Executive, eight regional offices, 99 health authorities and confused lines of reporting. Power would move to the front-line.
The regional offices were reduced in number to four as part of the Department of Health and co-located with other government regional functions. The Health and Social Care Act (2001) allowed the Secretary of State to form or give grants to companies to provide services formerly provided by the NHS, and to employ doctors, nurses and other clinical staff. It also made possible a new form of Trust, Care Trusts, to provide closer integration of health and social services. Broadening the range of options for the delivery of integrated care, they could levy charges, in particular for 'personal care'. Four new care trusts, in Northumberland, Bradford, Manchester and Camden & Islington, united mental health trusts and social care but comparatively few were created.
Structural reorganisation "Devolution Day" 1 April 2002
On Devolution Day major structural change took place. Some 20,000 staff were affected as authorities merged, disappeared or were re-formed. Responsibilities were reallocated and the absence of clear guidance gave an impression of making things up as one went along.
The Department of Health
From 1985, when the Department of Health accepted the Griffiths Letter and created a management cadre within the NHS, it changed its own structure dividing into an NHS Management Executive, while "wider" Departmental functions e.g. international health, remained within the remit of the Permanent Secretary. Increasingly the Management Executive was staffed by people with managerial skills from the NHS or outside it, as opposed to career civil servants. The relocation of the Management Executive to Leeds in 1992/3 increased this, and progressively the running of the NHS came to seem the most important function of the Department - and one requiring great and continuing political influence.(Greer SL, Nuffield Trust 2007) In 2000 the top jobs of permanent secretary and chief executive of the NHS Executive were re-combined. The Department was now far smaller than previously, focussed on delivering political objectives, and perhaps weaker on policy research capacity. The latter role would frequently be filled by political advisers, often brilliant but with a particular agenda. Rudolf Klein wrote that "As of May 2006, only one of the top 32 officials in the DH was a career civil servant, whereas 18 came from the NHS and six from the private sector. The shift has been from those who saw their role as being to save ministers from themselves, to those who saw it as being to deliver results. If the pathology of the former approach was conservative obstructionism, that of the latter was a readiness to run with even the silliest ministerial initiative." BMJ 2007;335:2-3 (7 July).
Its functions were to
set strategic direction, distribute resources and determine standards
ensure integrity of the system through information systems, staff training and support for development
develop values for the NHS through education, training and policy development
secure accountability for funding and performance, including reports to Parliament.
Four new Regional Directorates of Health and Social Care (DsHSCs) replaced the 8 regional offices. The new directorates, North, South, Midlands and East, and London did not map the boundaries of the previous eight regional offices. When they had only been in existence for 9 months, the Department of Health reviewed functions yet again to shrink its staff and move jobs away from London. Regional directorates disappeared, some of their work was redistributed to the 28 SHAs or to new organisations, such as the Commission for Healthcare Audit and Inspection (CHAI) and the Health Protection Agency, that were being established.
Strategic Health Authorities (SHAs)
SHAs were created taking some of the work of the erstwhile Regional Offices. They would
develop a coherent strategic framework
agree annual performance agreements and performance management agreements
build capacity and support performance improvement
28 Strategic Health Authorities also replaced the 96 remaining Health Authorities and managed the local NHS translating national policy into local strategy. The CEOs were, as a group, board brush rather than detail people, charismatic, networking, political and with a clear view of what they wished to achieve. They constructed plans, annual delivery agreements and annual performance agreements and were not be involved in operational management or revenue allocations. They shifted from being part of the provider system to regulation, to ensure that the recommendations of bodies such as the Commission for Health Improvement were acted upon. They "performance managed" PCTs and NHS Trusts on the basis of local accountability agreements and prioritized major capital plans. SHAs related to between 5 and 19 PCTs In London there were five SHAs, not unlike the inner parts of the old Regional Health Authorities (for the shire counties had been removed) reflecting the five sector scheme of Turnberg.
Strategic Health Authorities - 2002
Avon, Gloucestershire and Wiltshire
Bedfordshire and Hertfordshire
Birmingham and the Black Country
Cheshire and Merseyside
County Durham and Tees Valley
Coventry, Warwickshire, Herefordshire and Worcestershire
Cumbria and Lancashire
Hampshire and Isle of Wight
Kent and Medway
Leicestershire, Northamptonshire and Rutland
Norfolk, Suffolk and Cambridgeshire
North and East Yorkshire and Northern Lincolnshire
North Central London
North East London
North West London
Northumberland, Tyne and Wear
Shropshire and Staffordshire
Somerset and Dorset
South East London
South West London
South West Peninsula
Surrey and Sussex
Workforce Confederations that planned manpower were integrated into the SHAs, and developed 'clinical networks' (as the Regional Hospital Boards in 1948 had matched universities and university medicine). They could associate to discharge functions better fulfilled together. The five London SHAs did so, dividing certain responsibilities, for example children's services, or the Ambulance service, between themselves.
Primary Care Groups and Trusts
The organisation and management of primary care had changed little over the years. Now there were radical and progressive alterations. Organisations confusingly named as "Primary Care" had expanding responsibilities that spread into commissioning most hospital care. Labour had abolished fundholding making the formation of primary care groups a centrepiece of its reforms. The knock-on effect on the rest of the NHS structure was only slowly appreciated. Health service money was increasingly be disbursed through primary care groups and trusts. Only a minority of NHS managers had experience in primary care - most had gravitated to the hospital service. Legislation underpinned their introduction in April 1999 when Family Health Services Authorities (FHSAs) disappeared and 481 Primary Care Groups (PCGs) were established in England and fundholding ended in England.
GPs were brought together organizationally with community nurses within PCGs to integrate GPs, community health and social services. PCGs, initially subcommittees of health authorities, were a step for GPs into a corporate world. They had complex functions including the provision and commissioning of care, and were said to have a lead role in improving health, reducing inequalities, managing a unified budget for the health care of their registered populations, improving quality, and integrating services through closer partnerships.
PCGs ran for a while in parallel with their health authorities while evolving, often by merger, to become Primary Care Trusts (PCTs) with wider functions including clinical and financial responsibility for prescribing and referral decisions. The number of health authorities began to fall, driven by a progressive reduction in their responsibility for commissioning services. In the first wave in April 2000, 17 PCGs became PCTs. By 2002 there were 302 PCTs each covering populations averaging about 170,000. There was wide variance in the number of PCTs in each SHA and in their population size. Most PCT boundaries were set with coterminosity in mind, matching the boundaries with those of local authorities. In London there was always a match with local authority boundaries.
Functions of PCTs
The advantages of being big - managing risk and economies of scale - clashed with the advantages of being small, adaptable to local needs and being close to primary care. As Trusts grew bigger their discussions were increasingly concerned with broad planning issues (for example the commissioning of complex supra-regional hospital services), and less in details of individual practices and patients. PCTs were very expensive organisations and many merged for this reduced the transaction costs of contracting. When the first chief executives were recruited there was no knowledge of the major role expansion about to happen - responsibility for the bulk of NHS funding. The pool from which the appointments were made was therefore comparatively small but because of the turmoil of change, PCT staff came from many different organisations with different types of skill. In April 2003 allocations were made directly to PCTs and the health authorities were wrapped into SHAs.
The allocations to PCTs followed the earlier principals of RAWP. Four elements were used to set PCTs’ actual allocations:
Weighted capitation targets – a formula which calculates PCTs’ target shares of available resources based on the age distribution of the population, additional need and unavoidable geographical variations in the cost of providing services.
Recurrent baselines – represent the actual current allocation that PCTs receive.
Distance from target (DFT) – If a weighted capitation target is greater than a recurrent baseline, a PCT is said to be under target. If a weighted capitation target is smaller than a recurrent baseline, a PCT is said to be over target.
Pace of change policy – this determines the level of increase that all PCTs get and the level of extra resources to under target PCTs to move them closer to their targets. The pace of change policy was decided by ministers for each allocations round.
PCTs placed an emphasis on planning. "Service Level Agreements" were succeeded by "Joint Specific Needs Assessments" on the basis of which contracting was organised. Ultimately PCTs began to specify the details of what they wished to purchase, and the clinical pathways that were desired, rather than the individual procedures. They had to answer the questions "What did an area need? What did the PCT want to buy? And what was available locally?"
PCTs had to develop new and commercial commissioning skills for their decisions were open to challenge, particularly when independent contractors tendered. It was important for the PCTs to work with providers wherever possible to ensure that nobody had a nasty surprise. No more than 10% of services were commissioned regionally or nationally (because they were highly specialised), and GPs were involved through practice based commissioning, in which they had the right to advise the PCT on the services required.
Hospital trusts were least affected by devolution day. Their lines of accountability changed repeatedly as the organisations around them shifted their functions. They were accountable upwards to regional officers and later to SHAs for their statutory duties, and to health authorities and later primary care trusts for the services they delivered. The number of Trusts fell through merger; 22 trusts merged in 1998 and a further 49 in 1999. Like PCTs, Trusts were responsible for minor capital works, receiving block capital allocations for the purpose. As employers they were represented on the Workforce Confederations.
The concept of foundation trusts is said to have emerged in 2001 when Alan Milburn visited a Madrid hospital freed from detailed bureaucratic control and able to borrow money from big banks, rather than using funds under tight public control. Two central ideas were a new form of social ownership with services owned by and accountable to local people rather than to central government, and decentralization and devolution. The concept was trawled in a speech to the New Health Network in January 2002, and several trusts expressed an interest in piloting the proposals. In July 2002 acute hospital trusts were told they could apply to be foundation trusts. Legislation was necessary and details appeared in December in the circular The guide to NHS Foundation Trusts. Each Trust would have a Board of Governors representing the interests of patients, staff, local partner organisations, local authorities and the local community. The Secretary of State for Health would not have the power to direct, nor be involved in appointing their Board members. The Trust's Management Board would be accountable to the Governors, who would elect the chair and non-executive directors. It was a complex model - perhaps over complex - and not entirely to the liking of some managers.
Though part of the NHS they had greater financial and managerial autonomy including freedom to retain surplus finances, to invest in delivery of new services and the flexibility to manage and reward their staff. The Department of Health wanted trusts to be free to borrow money off the public balance sheet; the Treasury did not, fearful that trusts would run up debts that they could not handle and would need to be bailed out at public expense.
The idea split the Labour Party. Some MPs feared that foundation status would fragment the NHS and create a two-tier system in which the best hospitals could get more cash and poach staff, that it would effectively denationalise the NHS and allow back-door privatisation. Conservative, Labour and Liberal Democrat MPs all had objections. As a result Trusts' freedom was progressively constrained. While they would be able to borrow to improve services, the borrowing would be on the government's balance sheet and the departmental expenditure limits that the Treasury had agreed. Pay and conditions of service would be within The Agenda for Change, a national personnel policy. They would be accountable (through contracts) to PCTs. There would be an independent regulator (Monitor) to supervise them and decide what services should be provided and if necessary dissolve Trusts. There would be safeguards to prevent the sale of hospitals or their assets and limit the extent to which NHS foundation trusts could undertake private practice, a huge problem for some hospitals such as Great Ormond Street that had a massive international practice. Nevertheless foundation trusts would be able to redevelop and reequip themselves more easily and carry over surplus money year on year. It was now expected that the norm would now be NHS Foundation Trusts.
In March 2003 the Health and Social Care (Community Health and Standards) Bill was introduced. John Reid took the Bill through the House and many Labour MPs voted against it and it was the votes of Scottish MPs, whose constituencies were unaffected by the legislation, which saved the government when the Bill first passed the Commons in July 2003. From then until November 2003 it was passed acrimoniously from the Commons to the Lords and back again. To allay concern on Labour backbenches, John Reid asked the Healthcare Commission to carry out a review of the first 20 Foundation Trusts.
Foundation trusts remained divisive. To the proponents they would set the NHS free from the yoke of central government. To opponents they were a backdoor privatisation that would destabilise the NHS and introduce a two tier service. Some claimed that they were in the teeth of Bevan's vision for the NHS and destroyed concepts of equity and universality. Others believed that a varying quality of service from place to place was inevitable within such an immense health care system, that patient choice was required and that more freedom encouraged development and improvement of the NHS to the benefit of all. The Bill appeared the most controversial piece of legislation to come out of the government's 10 year strategy for the NHS in England and eventually passed in November 2003.
NHS Foundation Trusts differed from existing NHS Trusts in three key ways:
the freedom to decide at a local level how to meet their obligations
a constitution that made them accountable to local people, who could become members and Governors
authorisation, monitoring and regulation by Monitor
Foundation hospitals have a council of governors separate from the board of directors, chaired by the Trust chair. It is made up of governors elected by staff, patients and the public, along with representatives from the local PCT, (university) and local authority. At least half the members must come from public or patient constituencies. The governors are not responsible for the day to day management of the organisation, budgets, pay or other operational matters - executive power lies with the directors. But the governors appoint the chair and non-executive directors and determine their pay.
|Monitor, an independent regulatory body, was appointed under the Health and Social Care (Community Health and Standards) Act 2003 to assess, authorise and regulate NHS Foundation Trusts. Chaired by Bill Moyes, previously the Director-General of the British Retail Consortium, it considered applicants. One of the first Foundation Trusts, Bradford Teaching Hospitals, moved rapidly into a large and unpredicted deficit. The governors were denied key financial documents by the directors and wrote to Monitor that called in auditors and replaced the chairman and management team. Subsequent waves were delayed to ensure that PbR was taken into account. To give advance warning of possible trouble ahead, Monitor introduced systems of assessing foundation trust performance, their governance, the provision of mandatory services and financial performance. |
The first wave of 10 Trusts authorised on 1 April 2004
|Basildon and Thurrock University Hospitals NHS Foundation Trust |
Bradford Teaching Hospitals NHS Foundation Trust
Countess of Chester NHS Foundation Trust
Doncaster and Bassetlaw Hospitals NHS Foundation Trust
Homerton University Hospital NHS Foundation Trust
Moorfields Eye Hospital NHS Foundation Trust
Peterborough and Stamford Hospitals NHS Foundation Trust
Royal Devon and Exeter NHS Foundation Trust
Stockport NHS Foundation Trust
The Royal Marsden NHS Foundation Trust
In July 2005 the Healthcare Commission submitted its report on the first 20 trusts. NHS Foundation Trusts had:
increased the ability to plan and develop new services and relate to their local populations;
used their financial freedoms for capital investment and improved services, for example, offering specialist services in the community;
increased local public and patient involvement through Board membership
maintained standards of care in terms of access to and quality of care and positive relationships with local commissioners and other local providers.
They had not destabilised local health services by using unfair competition to attract staff; nor 'cherry picked’ patients who were easier to treat; had continued to invest in staff education and training; and mostly worked in partnership with other NHS services and organisations in the local health community. However there was uncertainty in the service as to whether the centre would wish to reassert authority as more and more trusts became Foundation Trusts, or whether a market would gradually become firmly established.
By the 60th anniversary of the NHS in 2008 there were 103 foundation trusts. A Foundation Trust Network was established to represent their interests, and organizationally they were maturing and delivering a sound financial performance. Monitor, surveying Trusts in March 2008, found they were working well, most governors were engaged with their Trusts, understood what was required, enjoyed good relationships with their Chairs and believed that they were making a difference. They were finding greater difficulty in engaging with their local community. Most felt they were kept well informed about the Trust's activities. While many were not using all the powers that they had, for example raising money for capital development, some were adopting stratagems to increase their critical mass by associating with other hospitals, or in the case of specialised trusts such as Moorfields (eyes) and the Marsden (cancer) developing satellite units off site. Mental health trusts, in particular, used their new freedoms to good effect.
Primary Care Trusts began to experiment with new organisational patterns, everything from commissioning confederations (Manchester, Cheshire and Merseyside) to vertical community and acute service mergers (Isle of Wight, Winchester and Cheshire). Labour's election manifesto in 2005 made a commitment to reduce management costs in the NHS by £250 million. This required a reduction in the number of organisations. Following the election a further wave of organisational change began; Creating a Patient-led NHS had promised to move money from management to the front line, (March 2005). There would be a reduction in the number of SHAs, a substantial reduction in the number of Primary Care Trusts and a reduction in the number of Ambulance trusts.
At the end of the process the organisation of the NHS was somewhat simpler
In December 2005 Patricia Hewitt (Secretary of State for Health) published Healthcare reform in England, Update and next steps. In April 2006 she announced a reduction of SHAs to ten. Co-terminosity with Government Office of the Regions’ boundaries was almost complete, to improve joint working between health and local government agencies. The role of the new SHAs, established in July 2006, was to
Develop plans for improving health services in their local area
Make sure local health services were of a high quality and were performing well
Increase the capacity of local health services - so they could provide more services
Make sure national priorities - for example, programmes for improving cancer services - were integrated into local health service plans
|The Strategic Health Authorities, July 2006|
|East Midlands||South Central|
|East of England||South East Coast|
|North East||West Midlands|
|North West||Yorkshire and Humber|
| || |
SHAs consulted on the reduction of the number of PCTs to cut management costs by around 15% and to improve co-terminosity with local authority social services departments. Value for money, co-terminosity with local authorities, and "local engagement" did not always point in the same direction. It was decided in May 2006 to reduce their number to 152. The new PCTs were established from 1 October 2006 but at a substantial cost, the Audit Commission putting it at £200 million.
SHAs looked at the reconfiguration of NHS trusts, A & E Departments, maternity and paediatric services. NHS London commissioned Ara Darzi to report on services in London.
He proposed a new distribution of services in primary and hospital care including polyclinics, (as proposed in 1920 by Lord Dawson, and in the 1944 and 1946 white papers on a national health service), local hospitals, major acute hospitals, elective centres, specialist hospitals and academic health science centres. NHS London, the London SHA, established an agency, Healthcare for London
(discontinued May 2010). It consulted on the Darzi report and the London PCTs accepted its thrust in June 2008.
In May 2008 the other 9 SHAs produced their own reviews, incorporating in their plans activities already identified as necessary, but making few specific proposals on the reshaping of services. To allay widespread misgivings Darzi published a report, Leading Local Change, that said that change would always be for patients' benefit, clinically driven, locally led, subject to local comment and that existing services would not be withdrawn until better ones were available. Nevertheless there was the impetus, at least in London, to push polyclinics forward amid increasing controversy. Most seemed likely to be upgrades of units already in existence.
PCTs were placed on notice that they must increase the quality of their commissioning - "World Class Commissioning" was their objective. The starting point was establishing the needs of their local population and many PCTs, not having in-house expertise, placed contracts (at some cost) with outside agencies.
A NHS University
Labour's 2001 election manifesto pledged to create a NHS University to assist in-house education and training of all staff. There was some hostility from existing educational bodies; medical schools and nursing departments had no wish to lose students to such an organisation. Established in December 2003 as a special health authority, it never developed a clear role. In December 2004 it was announced that it would merge with segments of the Modernisation Agency and the NHS Leadership Centre as an NHS Institute for Improvement and Innovation, assuming a role in the implementation and delivery of change in the NHSand was established in 2005 as an England-only Special Health Authority, located in the campus at the University of Warwick.
Arms length bodies
In October 2003 John Reid, Secretary of State, decided to review NHS "arms' length bodies" (ALB) to save £500 million in staff costs. The number had risen substantially since the 'Quango hunt" of the 1980s (Quasi-autonomous non-governmental organisations). Education and training, regulation, and service/back office functions, were handled by 42 bodies employing ten times the number in the slimmed-down Department of Health. In July 2004 the results of the review were published; some bodies were to be abolished (e.g. the Commission for Patient and Public Involvement in Health, only established a year or so previously.) Others to be combined, e.g. the National Clinical Assessment Authority with the National Patient Safety Agency; and the Health Development Agency with the National Institute for Clinical Excellence. Some seemed likely to be sold off. ALBs were grouped into categories according to function. Steady changes resulted in a new pattern of bodies.
There was concern that the Britain might be falling behind in research and its translation into clinical practice, in the face of major centres in the USA, the west coast and Boston, let alone China and other countries. This encouraged Imperial College with its vast educational and clinical resources to plan the establishment of a biomedical research centre (BRC). In 2006 the Hammersmith Hospitals NHS Trust and St Mary's NHS Trust integrated with Imperial College London creating in October 2007 Imperial College Healthcare NHS Trust , the UK's largest acute NHS trust.
Funding was also an issue. Following the report of the House of Lords Select Committee on Science and Technology (Chair Lord Walton), a review by Professor Anthony Culyer in 1997 and the review by Sir David Cooksey (2006) on UK healthcare research, all NHS Research and Development budgets were brought into a single funding stream. Professor Dame Sally Davies, the Department of Health's Director General of Research and Development and Chief Scientific Adviser led consultation on how a research strategy should be implemented within the NHS. Best Research for Best Health, the government strategy published in January 2006, set the goals for research and development over five years and commitment to creating a vibrant research environment that contributes to the health and wealth of England. The goals were to
improve the nation's health and increase the nation's wealth as in the ten-year Science and Innovation Investment Framework 2004-2014
Place people at the centre of a research system that focuses on quality, transparency and value for money
Respond to changes in society and the environment
Respond to the challenges in the current system
The report was followed by the establishment of the National Institute for Health Research (NIHR) and a move to a more open funding system including international assessment of Biomedical research centres to be supported at a national level. A panel of international experts chose centres in open competition as internationally excellent in research. .In December 2006 the Secretary of State announced the selection of five comprehensive Biomedical Research Centres to be supported on a national basis, three in London (Kings, UCL and Imperial) plus Oxford and Cambridge, and a further six in particular clinical fields. UCL with Great Ormond Street, Moorfields Eye Hospital, The Royal Free and University College London Hospitals came together as UCL Partners. In London selection as a Centre was a guarantee that restructuring of the service would take research excellence into consideration.
Independence for the NHS?
Should the NHS have more independence from government? The clinching argument had always been that as the NHS was funded almost entirely from taxpayers money, parliamentary accountability was essential. Tony Blair believed that independence would have major disadvantages, but others demurred including the King's Fund and the BMA. The Conservatives also called for an independent board to run the NHS and extension of the freedom of foundation trusts (June 2007). A report for Nuffield outlined options:
A modernised NHS Executive within the Department of Health to separate policy from delivery.
A Commissioning Authority - modelled on the Higher Education Funding Council for England and operating as a non-departmental public body at arm's length from ministers.
A Corporation—a fully managed national service on the BBC model comprising all publicly owned assets, including foundation trusts.
A Corporation limited to planning, commissioning, and inspecting NHS services.
Regionalised NHS—the NHS would be run by independent regions that could be non-departmental public bodies or public corporations.
NHS commissioned by local government—local authorities have responsibility for commissioning care.
NHS as a public insurance company—the NHS would be defined as an insurance company funded by taxation and would licence other organisations to commission health services.
From: Nuffield Trust. An independent NHS: a review of the options. Report by Professor Brian Edwards. London: Nuffield Trust, 2007
|The Wanless Review|
Payment by Results
Recurrent financial problems
The NHS is funded almost entirely from central taxation including national
insurance, with only small contributions from users and from other sources.
The money available to the service is determined almost entirely by central
government and funds for health care compete with the requirements of welfare,
education, the roads and the other calls upon government funds. The state
of the economy sets the framework for funding decisions, which are taken after
regular consultation between the Treasury and the Department of Health.
The NHS is "cash-limited" and not driven by demand. Demand is
constrained by supply and aims for equitable provision. Rationing and demand
management have always been a feature of the NHS. Sometimes changes are
made to the way accounts are presented. The best financial information is in a
Financial problems became a central issue and the Prime Ministers, Tony Blair and his successor Gordon Brown, were deeply involved. How much money should come to the NHS and how was it best distributed? A more commercial framework was introduced, particularly in the case of Foundation Trusts. Financial tricks that had enabled authorities to conceal deficits, such as the transfer of capital to revenue, or borrowing money from other trusts, ceased. (Timmins N, BMJ April 2007). The system became more transparent.
The growth money available to the NHS varies from year to year. The chart below shows growth under differing administrations.
The total money for the NHS
The funds for the health service are the result of annual or bi-annual negotiation between the Department of Health and the Treasury. The NHS was pressured by.
The pay structure of all NHS staff which was being "modernised"
New patterns of service, for example out of hours cover in primary care that raised costs
A shortage of nurses and doctors because too few had been trained from the 1970s - 1990s making it hard to use additional money effectively. Capacity bought in from the private sector was at a high cost
Costs of drugs and medical technology continued to rise, NICE's recommendations creating an additional pressure
The mean age of the population that continued to rise
Clive Smee, for many years Chief Economist at the Department of Health, said the arguments used to justify more money for the NHS changed over the years. In the 1980s the changing age structure was held to require an additional 1% a year for the health service merely to stand still. Inflation in the NHS seemed to run at a higher rate than in the economy more generally. In the 1990s more weight was placed upon service trends, a proxy for public expectations. From the NHS Plan onwards, better information about the performance of the NHS, particularly the poorer outlook of those suffering from cancer in England as compared with Europe, became significant. It became necessary to "catch up" after years of low investment, to provide safe high quality treatment, faster access and clean comfortable accommodation. The costs of medical advance came to the fore with NICE and National Service Frameworks that could be costed with some accuracy. Finally, international comparisons of health service costs achieved greater importance.
Since 1976 money is allocated as fairly as possible between the different regions in England. Equity between England and the other three parts of the United Kingdom was a political matter governed by the Barnett formula. The allocation formula, which took account of mortality and other factors affecting health care costs, was an improvement on the historic allocations that had gone before but was regularly criticized and modified. Even when weighted by population characteristics, allocations varied substantially from area to area by a ratio of 3:2.
Labour stuck to the Conservatives' spending plans for the NHS and money was increasingly tight. Only small additional sums were available and this had to cover existing overspends, pay claims and new services. Labour had a disarming tendency to announce the extra money available over three years, apparently tripling its generosity. The 'bad winter' that the NHS in 1999/2000 was crucial in revealing just how serious the gap between service and demand was and that Labour's first two years had not delivered substantive improvement. The sad death of a patient, Mavis Skeet, a pensioner whose surgery was cancelled four times until her cancer became inoperable added pressure. On 16th January 2000, Tony Blair told a startled Sir David Frost on television: "If this July when we work out the next three-year [spending] period we can carry on getting real terms rises in the health service of about 5%, then at the end of that five years we will be in a position when our health service spending comes up to the average of the European Union." The Prime Minister had not even discussed this with the Chancellor of the Exchequer, Gordon Brown, who was livid with anger at having been bounced into a major spending commitment.(BBC4 , 26 February 2010) After Tony Blair's statement the government accepted that major injections of money were needed and provided them. Labour kept its promise (see chart above).
World-wide, health care systems were under comparable pressures. In the US there was an acceleration in growth of expenditure in part because of the slower growth in managed care enrolment and a movement towards less restrictive forms of managed care driven by consumer pressure. Some thought that managed care was an experiment shown to have failed for the United States (2007/8) spent about 16% of its annual gross domestic product (GDP), or $6,400 per head..
When government forms a committee it is common to select people likely to make the recommendations that government wishes to see. The Treasury commissioned Derek Wanless, past chief executive of NatWest Bank and a non-executive director of Northern Rock Bank, in perhaps the most expensive report ever requested, to estimate the resources required to run the NHS in 20 years time. To assess what was needed to provide good standards of care was a new departure. From Guillebaud (1956) onwards it had been thought that there was no way of defining an acceptable standard of health service. Financial reports were concerned with getting the best service from the resources available, not what should be spent to achieve defined objectives. Wanless lead a team based within the Treasury, which worked closely with the No 10 Policy Unit and the Department of Health, so whatever the report was, it was not independent. It tried to assess the service costs of, for example, National Service Frameworks. An interim report, for consultation, appeared in November 2001. The final one, Securing Our Future Health: Taking a Long-Term View, came out in April 2002. Wanless said that there was no evidence that an alternative funding system would deliver a given quality of health care at a lower cost to the economy, the current method being both fair and efficient. He pointed to the low level of health expenditure in the UK, believed this to be related to our poorer health outcomes than some other European countries, and questioned the assumption that the pursuit of quality would be cost free. An extra billion pounds was rapidly allocated by government. There was debate about other methods of funding the NHS but Government rejected alternatives such as social insurance. Derek Wanless said that the country needed to devote a significantly larger share of national income to health care. But money on its own was not enough – it was essential that resources were efficiently and effectively used. The report saw a wider role for NICE, and an extension of the National Service Frameworks to cover a wider range of diseases. It set out projections of resources required over the next 20 years, outlining three future scenarios; an optimistic one - the money was wisely and productively used and people demanded better services but learned to look after their own health better, a pessimistic one where people were less involved with health issues and the NHS remained unresponsive, and a middle course in which there was solid progress but not all the desirable changes occurred. The projections showed the UK spending between 10.6 and 12.5 per cent of GDP on health care by 2022-23, compared to 7.7 % in 2002. The average annual real terms growth rate in UK NHS spending would need to be between 4.2 and 5.1 per cent over the 20 year period, showing the highest growth in spending in the early part of the Review period – an average of between 7.1 and 7.3 per cent a year in real terms over the first five years to allow the NHS to ‘catch up’ to standards elsewhere and to create the capacity essential to expand choice in future. Investment in new hospitals and more doctors was long term in its nature, and would not produce rapid improvements. Subsequently Wanless was asked by the Treasury to provide an update on the problems of achieving the optimistic (fully engaged) scenario, a report on population health trends appeared in December 2003, and another report in February 2004. One of his recommendations was that after five years there should be a review of how additional money had been spent. The government did not do so but the King's Fund did.
In spite of the increasing funds, the financial state of the NHS worsened. The targets and the cash had not been matched one with the other and in January 2002 the South-East Regional Chief Executive said it was necessary to eliminate an overspend of £60 million overspend by the end of the financial year. It was rumoured that the Chancellor would raise taxation to help the NHS or that Labour would move away from a fully comprehensive and free NHS. On TV in February 2002 the Prime Minister, Mr. Blair, said money would need to be found. In March the Labour Party issued a consultation document, Improving Health and Social Care, to explore the problems to be faced. Under-funding of the NHS over a number of decades was conceded; it was the size of the under-funding, rather than the method of funding, which was to blame.
In January 2002 a House of Commons health committee inquiry heard that in Croydon implementing the government's top 20 priorities would cost £70 million, at least ten times the available budget. In Lambeth, Southwark and Lewisham Health Authority NICE guidance would cost £15 million to implement, depriving patients of other equally effective new treatments, such as new anti-rheumatic drugs. Some policies would have to take a back seat in the attempt to meet the government's other top priorities. (BMJ 2002: 324; 258)
In his April 2002 budget Gordon Brown provided a huge increase in NHS funding over the next five years. There would be year-on year rises in UK spending from £65.4bn in 2002 to £100.6bn in 2007, 7.4% in real terms annually and slightly above the Wanless proposals. National insurance contributions were raised by 1% to find the money (immediately costing the NHS an additional £200 million as it was a large employer). The BMA and some medical peers had long pressed for such a supplement for the NHS form national insurance contributions.
Would the massive injection of money would achieve results? Beverly Malone, the Chief Executive of the Royal College of Nursing, looked for a big pay settlement; "the money is there and the success of modernizing the NHS is riding on the shoulders of the nurses". Other unions made similar noises. In November 2002 the UK Health Departments’ NHS management representatives’ and staff organisations’ negotiators concluded negotiations on the Agenda for Change, a package of proposals for a new pay system covering all staff, save the most senior managers and those covered by the Doctors and Dentists Pay Review Body. There would be a minimum NHS wage of £10,100 per year and a new starting salary of £17,000 for newly-qualified nurses and other health professionals. At local (PCT) level there seemed little improvement. Pay rises, changes in junior doctors' hours, and rising drug costs immediately swallowed much of the extra money available.
|Year|| ||Total net NHS expenditure (England)||% increase||% real terms increase|
|Cash|| || || || |
|resource budgeting stage 1|
|resource budgeting stage 2|
| || || ||source - Department of Health see Expenditure table (spreadsheet)|
In December 2003, a further report Securing good health for the population, commissioned by the Treasury six months previously from Derek Wanless was released with a minimum of publicity. Setting out the public health challenges to be faced it the Wanless "fully engaged" scenario was to be met, it painted a picture of a country that compared unfavourably with other major Western countries in terms of mortality and morbidity from cancer and heart disease. Derek Wanless also found wide variations in life expectancy across the socioeconomic groups. By April 2006 Wanless, now no longer working within the Treasury, had come to criticise the extent to which the money made available to the NHS had been spent on salaries, rather than on long term measures to boost health promotion and public health.
Historically lump sums had been paid to individual hospitals. Now payments received by trusts increasingly depended upon the number of cases handled, paid for on the basis of a national tariff. Known as payment by results, really payment by activity, money would move with patients. This had been the intention of the Conservative NHS reforms in 1990. In October 2002 the government issued Reforming NHS financial flows - introducing payment by results. A phased programme from 2002/3 to 2005/6 would require PCTs to
Pay NHS Trusts and other providers on a fair basis while managing demand and risk
Support patient choice by ensuring that diverse providers were funded according to where patients choose to be treated
Reward efficiency and quality
Help match capacity to demand
Reduce transaction costs and negotiating disputes over price between PCTs and acute trusts
Enable PCTs to concentrate on quality and quantity rather than price by setting national tariffs that provide fair prices
Block contracts would be scrapped and a tariff-based system would be introduced. Service Level Agreements would link funding and the volume of services; in theory removing discussions on cost should lead to concentration on quality. The basis for the system of costing had been developed in the US as diagnosis related groups (DRGs). An English version of "health resource groups" (HRGs) had been under development since the Conservatives' NHS Reforms although the inadequacy of hospital accounts at that time made the introduction of standard costing systems impossible. HRG costings would expand progressively to cover inpatient and outpatient care, and elective and non-elective services in medicine and surgery. Prices would have to vary because costs differed from place to place. However it was hoped that patient choice, quality and access would drive changes in patient flows. The national tariff would need adjustment for local market forces (high cost in London was a fact of life). There were many other factors, for example the development of new units, the higher expenses of teaching hospitals, the cost of teaching in all hospitals as the number of medical and nursing students grew, the funding of services that were complex and essential, almost regardless of demand (e.g. burns units) and whether private or NHS facilities were involved.
Tariffs operated for elective activity in 15 groups in 2003/4, and progressively expanded. Reference costs were calculated to provide the unit cost for a wide range of individual treatments. A tariff derived from them provided a national price schedule for treatment in England.
PbR introduced a moral hazard, well known in the USA, where providers (hospitals and doctors) might over-bill, while purchasers would "down code". In the US a judge in a case described the situation as "almost all doctors versus almost all major health maintenance organizations". UK providers were accused of driving up costs and exploiting the system by overcharging and purchasers of systematically obstructing and delaying payment. Other problems affected the larger teaching hospitals with their higher expenses. A new system of paying money for medical research was introduced and the large research-oriented hospitals were likely to suffer and it was proposed to change the in the way the service increment for teaching (SIFT) was paid. The historical allocations might be scrapped in favour of a simpler system that paid an average amount per student year creating winners and losers.
There was now extensive experience of many different patterns of commissioning, some with high transaction costs, others that permitted a greater degree of patient choice and responsiveness. There were few clear lessons from evaluation studies save that the NHS needed a raft of different but effective commissioning models. Commissioning at single or group practice level might be best for some services. Others needing larger populations might need a regional or national system.
source Health Foundation, Report dated September 2004
Practice led commissioning, a further initiative in April 2005, allowed Primary Care Trusts to devolve indicative budgets to practices. The practices did not hold the money, but there were financial incentives to manage referrals and commission and redesign services to make them more convenient, appropriate and cost effective. The Audit Commission reported on the second year of the scheme. (Putting commissioning into practice, Audit Commission, 22 November 2007). Those practices involved had become more financially aware of the consequences of their decisions, but in general progress had been slow and some GPs thought that they had inadequate support from PCTs in developing commissioning.
In spite of the high growth a major financial crisis developed from 2005. The increasingly commercial nature of the NHS financial system made it more difficult to hide deficits, for example by loans between authorities, often not repaid. The new system created winners and losers. In theory around 70 trusts would lose over 25% of their current income. Others would receive significantly more than they were spending. All income would reflect activity, no portion relating to fixed costs. Neither was there a guarantee that the sums payable would fall within budget allocated - the sum of the many bills exceeded the funds voted by Parliament by a substantial measure. One problem was that the estimates had not taken account of the extent to which most trusts had subsidised health care by using non-recurrent money, land sales etc. PCTs found themselves more deeply committed than they had expected and £637 million had to be redeployed from educational budgets to narrow the gap. Nursing school intakes and medical postgraduate education were cut. "Over performance" by some trusts beggared their PCTs .
Many hospital trusts, at the end of the financial food chain, found themselves in dire trouble. They were hit by under funding for the consultant contract and the money spent on buying in extra capacity at high cost to meet targets. Primary Care Trusts also had to meet the cost of the new GP contract, for the average net salary rose from 2003/5 to 2004/5 by over 30%, to more than £100,000. According to the parliamentary select committee on health, the Department of Health had miscalculated the additional costs of these contracts and possibly the Agenda for Change as well. Patricia Hewitt told the parliamentary select committee that the NHS had employed more doctors than the central planning had intended or that Trusts could afford. While NHS Employers had been involved, the Department had themselves taken many of the key decisions.
In mid-2005 an assessment suggested that six SHAs had no hope of reaching financial balance by 2008 . Eleven SHAs would need to make savings of £250 million. (HSJ 2005, 14 July, p5) A deficit of £547 million was only reduced significantly by a huge subvention created by cutting the NHS training and education budget.
When in 2006 the King's Fund analyzed where the money had gone, almost half had been spent on higher pay for staff, and another 27% on increases in capital costs, the cost of clinical negligence and on drugs, meeting the recommendations of NICE. Little was left for service development or, indeed meeting targets such as waiting list reduction.
After 5 years of historically high growth the NHS still had problems.. Why? No single reason but a myriad of activities. Massive expansion in capacity had improved access to services, there had been several structural changes, the introduction of targets that had financial repercussions, and not only were there many more staff but there was a wholesale increase in pay of every group, Consultant pay £90 million more, Agenda for Change £80 million more and GPs £300 million more than expected. Simultaneously treatment was of increasing complexity. In its programme, The Blame Game 26 March 2006, the BBC's Panorama placed the blame firmly on Department of Health policies and Ministers. A multitude of new policies, not all compatible with each other, made the task of trusts difficult. Ministers implied that NHS management was responsible for overspending as a result of factors that were way outside its control. The profession blamed government. The Department was insistent that the NHS should remain within its budget. Some hospital and primary care trusts openly delayed treatment as far as they could, while trying to remain within guidelines for speed of care. Others closed wards, and delayed payments even to partner organizations in health or social care. The Department sent management consultants into some 60 Trusts with a substantial deficit and later sent "Turnaround Teams" in January 2006 into eighteen trusts. They did little to help. Increasingly it was necessary to cull jobs. A few SHAs suspended the introduction of Payment by Results, fearing that paying hospitals for the work that they did would increase problems. By early 2006 there was disarray for a government that had indeed increased the money for the NHS substantially, only to find it absorbed by its own policies, targets and pay agreements. To make matters worse, SHAs and PCTs were heading for mergers at the very time when they were key to controlling the "overspend". As the financial crisis continued to grow, tensions arose between Ministers and civil servants and in March 2006 the chief executive, Sir Nigel Crisp, after five years at the helm, accepted some responsibility and took retirement. Sir Nigel's successor, David Nicholson CBE, giving evidence to the Committee of Public Accounts in October, admitted that the Department "could be better at costing some of our policies." The BMA blamed the private finance initiative, independent treatment centres and the employment of management consultants. Derek Wanless saw the financial crisis as a threat to health promotion and social care. The Prime Minister saw it as essential to move forward with reform before the next election loomed too closely and the flow of the additional moneys that had been provided lessened.
Patricia Hewitt, Secretary of State for Health, told MPs on 21 November 2006 "we will return the NHS as a whole to financial balance by the end of March  and I will take personal responsibility for that." This accentuated the problems for the service because of the pressure and threats on management and clinicians. In some areas debt ridden PCTs said they could not pay for services carried out. To attempt to control their budgets PCTs established teams of financial analysts to look at hospital bills; hospitals had to respond by increasing the costs of their own finance departments. Trusts might have to delay patient admissions until a time after which they might receive payment, yet meet target times for the completion of treatment. A small proportion of staff were made redundant. In the Spring of 2007, it seemed that some 15-20 NHS Trusts were in such deep financial trouble that their position seemed irrevocable within ten years. Government limitation of annual pay awards led to threats of industrial action by several staff groups. While the NHS as a whole remained in budget at the end of the financial year, there was an increase in patient waiting times as services were reduced.
Patricia Hewitt delivered on her promise that the NHS should end in overall financial balance, though 82 out of 372 NHS organisations had a combined deficit of £97million, concentrated in a small number of organisations some of which had problems hard to resolve.
Criticism mounted as to how money was being spent. The King's Fund commissioned Derek Wanless to take stock. The review, published in September 2007, concluded that increases in NHS moneys had broadly matched assumptions made by the 2002 review. Pay and contractual changes for all NHS staff groups over five years had contributed to higher input costs, with benefits yet to be fully realised. NHS Plan commitments to employ 7,500 more consultants, 2,000 more GPs, 20,000 more nurses and 6,500 more therapists (allied health professionals) by 2006 had been more than achieved, with targets exceeded by 16 per cent, 166 per cent, 272 per cent and 102 per cent respectively. Building, both of hospitals and for primary care, had made much progress. The funding increase had helped to deliver some clear improvements – more staff and equipment; improved infrastructure; significantly reduced waiting times and better access to care; and improved care in coronary heart disease, cancer, stroke and mental health. On balance the flood of cash had brought disappointing results..
From 2002 until 2007 NHS funding had risen at 7.2% per year. In October 2007 the chancellor announced that for the next three years spending would increase at 4% per year, more than had been expected but less than the increases to which the NHS had become used. The corner had, for the present, been turned. The NHS had returned to financial balance. Indeed the year 2007/8 showed an embarrassing underspend, because Trusts had become used to making economies.
Links within this section
Quality became a centre point of NHS policy. With a few exceptions, such as the maternal mortality survey, quality initiatives had been unusual in the UK. It was assumed that the 'producers' rather than the 'consumers' knew what services should be provided. Increasingly NHS had discovered the patient as an expert on the quality of services. Frank Dobson established CHI and NICE concerned with quality. It became one of the commitments of NHS Trusts on which they were assessed. The publication of morbidity and mortality data, though far from reliable, gradually increased. Chief Executives were expected to handle quality as well as their budget and their capacity. A Quality Outcomes Framework became one of the drivers of the pay of family doctors. As the theory of quality assessment developed, this was introduced into the NHS.
Quality could considered in terms of
The USA had a lead of many years in quality issues. A timeline shows the long involvement of the Joint Commission on Accreditation and the Agency for Healthcare Research and Quality (AHRQ). The Institute of Healthcare Improvement, a non-for-profit organization leading the improvement of health care throughout the world based in Cambridge, Massachusetts, was founded in 1991.
Quality of life measures, for example the pioneering SF-36 from the US, were brought to the UK. In the USA the Centre for Quality Improvement and Patient Safety within the AHRQ and in the UK the National Patient Safety Agency (UK) were taking quality seriously. Websites provided a forum and focus e.g. www.qualityhealthcare.org and www.saferhealthcare.org.uk. The work of John Wennberg and the Dartmouth Atlas showed unwarranted variations in health care delivery; variations in the rates of coronary artery and carotid artery surgery, even in the best academic centres, was a reminder of how empirical was much of clinical medicine. The literature recorded the substantial number of medical errors in routine treatment and 'near misses'. In a study of New York in 1990 the principal source of many errors were the systems rather than individuals. An extensive review by RAND Health documented shortcomings in safety and effectiveness. (Schuster MA et al, Millbank Quarterly 1998; 76: 517-63). In 1999 a major report was published by the Institute of Medicine directed at politicians and healthcare leaders as well as doctors. (Kohn LT, ed. Corrigan JM, ed. Donaldson MS, ed. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999). It was followed in 2001 by Crossing the Quality Chasm, (Committee on Quality of Health Care in America. Washington, DC: National Academy Press; 2001.) which showed that the implementation of standardised performance measures for heart attack, heart failure and pneumonia by the JCAHO in 2002 was followed by significant improvement in outcome. Williams SC, Schmaltz S, NEJM 2005 353: 255-264. A review five years after the publication of To Err is Human showed substantial progress to increase hospital safety was being made, at least in the US, often led by clinicians keen to improve patient care. Five Years After To Err Is Human: What Have We Learned? Leape and Berwick JAMA.2005: 293: 2384-2390. A further Institute of Medicine report in 2008, Knowing What Works in Health Care: A Roadmap for the Nation, proposed a national program to assess the effectiveness of clinical services and to provide credible, unbiased information about what really works in health care. It recommended that Congress direct the U.S. Department of Health and Human Services to establish a program comparable to NICE on the UK to conduct systematic reviews of the evidence and develop standards for creating clinical practice guidelines.
Qualify adjusted life years (QUALYs) and patient recorded outcome measures (PROMIS) were increasingly used in assessing the effectiveness of interventions.
In 2000, the US Health Care Financing Administration (now the Centers for Medicare & Medicaid Services) reported on 24 indicators of the quality of care delivered to Medicare beneficiaries in 1998-1999. These indicators measured delivery of services that evidence showed to be effective in preventing or treating breast cancer, diabetes, myocardial infarction, heart failure, pneumonia, and stroke. (Jencks SF, Cuerdon T, Burwen DR, et al.) Quality of medical care delivered to Medicare beneficiaries: a profile at state and national levels. JAMA. 2000;284:1670-1676. The Institute Healthcare Improvement launched its "100,000 Lives Campaign in 2004, targeting 6 interventions where quality improvement could save patients.
100.000 Lives Campaign interventions
- Deploy rapid response teams to patients at risk of cardiac or respiratory arrest
- Deliver reliable, evidence based care for acute myocardial infarction
- Prevent adverse drug events through drug reconciliation (reliable documentation of changes in drug orders)
- Prevent central line infections
- Prevent surgical site infections
- Prevent ventilator associated pneumonia
In England the clinical performance of hospitals also varied substantially. An attempt to quantify the problem by retrospective record review in 2001 showed that almost 11% of hospital patients experienced an adverse event, over half of which were preventable with ordinary standards of care. A third of the events led to moderate or greater disability or to death. The Audit Commission, in its report A Spoonful of Sugar, (December 2001) reviewed the use of medicines in NHS hospitals, found that medication errors occurred too often and their effect on patients and NHS costs could be profound. The National Patient Safety Agency, established in July 2001, produced preliminary results in 2002 from pilot trials in 28 trusts which showed over 20,000 adverse incidents over a nine-month period. The Department of Health published its own analysis, An Organisation with a Memory (2000). "Star" ratings were introduced in 2001 but dealt more with the process of its care, rather than quality and outcome. The system was refined in 2004 with the publication of Standards for Better Health, proposing a wider range of standards and the Healthcare Commission incorporated them in their annual trust health check. In 2003 the Nuffield Trust published a review, The quest for quality in the NHS: a mid-term evaluation of the ten-year quality agenda. (Leatherman S & Sutherland K, London, Nuffield Trust, 2003), examining achievement in terms of access, capacity, public perception, effectiveness and equity. The authors concluded that much remained to be done but that initiatives were moving in the right direction. The BMJ published an editorial on the report. The same authors published more than 100 charts demonstrating the UK's performance in international terms, The quest for quality in the NHS (2005, Radcliffe Publishing) (Charting a new course, 7 July HSJ 2005, 26-29).
Professional staffing ratios influenced mortality rates. In the USA research on nurse ratios in surgical units in Philadelphia showed that after adjusting for patient and hospital characteristics, each additional patient per registered nurse increased the likelihood of dying within 30 days of admission by 7%, and increased substantially nurse burn-out and job dissatisfaction. (JAMA. 2002;288:1987-1993). In the UK Professor Brian Jarman & his colleagues standardised for age, sex, socio-demographic background, key diagnoses and the number of emergency admissions. Hospital standardized mortality ratios (HSMRs) were calculated for each English Trust and the trusts presented sharply different outcomes for patients once all these factors had been taken into account. The factor that correlated best with performance was the number of doctors on the staff. Taken overall, the death rates in major English hospitals seemed to be dropping about 2.5% per year.
Publication of mortality data
For more than a decade league tables of the mortality rates of US hospitals had been published. However mortality rates and other clinical indicators at hospital or trust level were not published until 1994 in Scotland and 1999 in England. Clinical performance indicators included such items as the number of deaths in hospitals following fractures of the hip, and deaths within 30 days of admission for a heart attack. As in the USA publication was followed by protests that data might be inaccurate and misleading. In the US patients could use not only printed information but web sites to view the number of cases specific hospitals handled, their outcome and the star rating accorded to their local hospitals, e.g. www.healthgrades.com and www.healthcarechoices.org. In England politicians thought such information should not encourage patients to shop around for better treatment; later with Alan Millburn this line changed and increasingly data was published, for example on the NHS Choices website.
An independent company, Dr Foster, was established early in 2001 in the UK to exploit the mass of data produced by the NHS using a method developed by Professor Sir Brian Jarman (BMJ 1999, 318: 1515-20) to provide authoritative information for patients on health service performance. The Jarman method of comparing hospitals was based on the "hospital standardised mortality ratio", calculating the number of patients dying after a range of procedures in hospitals, adjusted for the complexity of cases and other factors. A hospital that exactly matched the national average would score 100; better results would be a figure below 100 and hospitals with substantially higher figures proved, in some cases, to have underlying problems of their clinical care. It was a sincere attempt to measure something both important and elusive. (BMJ 2009; 339: b5242) Based at Imperial College, it mined available sources of information and the Department of Health, recognising its media and presentational skills, became its main customer. It also produced material for the Healthcare Commission. The scope and usefulness of the material on its web site steadily increased, and details of the methodology used were provided. The first Good Hospital Guide appeared in 2001 providing comparative information on hospital trusts in England. Dr Foster charged for access and did not provide depth of information on individual clinicians but in 2006 the Department of Health bought a share for £12 million.
Volume and safety
A relationship exists between the volume of some procedures and the outcome of treatment. In 1996, the NHS Centre for Reviews and Dissemination published a for the procedures where such a relationship existed. It included coronary artery bypass surgery, paediatric heart surgery, acute myocardial infarction, coronary angioplasty, aortic aneurysm, amputation of the lower limb, gastric surgery, cholecystectomy, intestinal operations, knee replacement, and neonatal intensive care. This suggested that the pattern of NHS hospital services might be modified. A study supported by the US Agency for Healthcare Research and Quality showed that while hospitals with high annual volumes of certain types of procedures had lower death rates, the true association was with surgeons who had a high volume of cases
In earlier times, all that had been expected of doctors, who had been trained in a service with a strong public service ethos, was that they should do their best by their own lights. Regulatory bodies such as the GMC looked at individual competence. Colleges would inspect hospitals to see that training standards were maintained. Internationally a basic ethical principle of medicine, first do no harm, was taken seriously. The ethos of medicine was changing and the development of controlled trials, meta-analyses, guidelines and organisations such as the Cochrane Collaboration was bringing to an end an era in which clinical experience alone was seen as adequate.
Evidence based medicine was becoming an integral part of undergraduate, postgraduate and continuing educational programmes. Accurate, accessible and regularly updated sources of evidence were widely available though the process of summarising the evidence was daunting. It was often hard to show that clinical practice was greatly affected or that clinical outcomes were better, though few would disown the hypothesis that on average providing evidence-based procedures would improve clinical outcomes. The Cochrane Collaboration had been established in 1992 funded by the NHS Research and Development Programme, to help well informed clinical decisions by preparing, maintaining and ensuring the accessibility of systematic reviews. It rapidly became an international movement, as the Cochrane Library and Database of Systematic Reviews. How could stroke and its effects be prevented and treated? What drugs should be used for malaria? Studies could produce compelling evidence for a change to clinical practice. Often it was clear enough what should be done, for example elderly people should receive influenza vaccine. Student textbooks were more frequently based on good clinical studies than in the past.
The NHS and professionals were exposed increasing public scrutiny. When serious harm to patients occurred it was commonplace to hold an inquiry, sometimes a public one. In the 1970s many inquiries were held into mental illness, mental handicap and geriatric hospitals. The same issues were identified repeatedly, as if it was impossible to learn the lessons, e.g. isolation - geographical or organisational, poor leadership, bad communication, problems with NHS systems or individual's competence and obstacles placed in the way of those who raised concerns at an early stage. Occasionally the public expected too much, for example the reading of cervical smears and mammograms is not a precise science and there are always likely to be false negatives and false positives. Had the media become more active, were staff less disciplined, was the system under too much pressure? Were there interests that relished the demonstration that professionals had feet of clay? Financial problems were often involved, as in the case of delayed admissions, waiting lists and 'trolley waits'. Pressure of work and inadequate supervision played their part.
While the profession had developed reporting schemes such as that into perioperative deaths, int Bristol at least 29 babies died after heart surgery at the Royal Infirmary. This led in 1998 to a lengthy public inquiry costing £14 million, chaired by Professor Ian Kennedy, published in July 2001. There were organisational as well as clinical problems. Neither the Royal College nor the Department of Health personnel had been alert to information about poor performance and the hospital facilities were far from ideal in the number of staff and the split site. The General Medical Council (GMC) found three doctors were found guilty of serious professional misconduct. The BMJ said, in an editorial, that most chilling thought was that there could have been many similar reports about other parts of the NHS. The ingredients in Bristol occurred throughout the NHS. The NHS had no system for monitoring quality, no reliable data and no agreement on what constituted quality. "Thus the most essential tool in achieving, sustaining, and improving quality of care for the patient was lacking . . . clinicians had to satisfy only themselves that the service was of sufficient quality." The Department of Health, in its response in January 2002, accepted the majority of the recommendations. There would be a strengthened inspection role for the Commission for Health Improvement (CHI), and a new Council for the Quality of Health Care. No steps were taken to establish this Council, perhaps because Ian Kennedy who recommended it later became the chairman of the Healthcare Commission (CHAI).
The reports of the clinical work of gynaecologist Rodney Ledward, struck off by the GMC in 1998 after a public inquiry led the media to watch the cases coming in front of the GMC like hawks. The GMC received an increasing number of complaints, 1,000 in 1995, 3,000 in 1999 and 4,470 in 2000.
The conviction of Harold Shipman for serial murder dealt a further blow to confidence in the medical profession and its systems of self-governance. A GP, for many years in single-handed practice and with apast history of drug abuse, Shipman had administered heroin to many of his elderly female patients. He was convicted at Preston Crown Court in January 2000 of the murder of 15 patients, sentenced to life imprisonment and later committed suicide.
In September 2000, the Secretary of State for Health announced a public enquiry into the Shipman case. Dame Janet Smith, a High Court judge, was appointed chairman and the work of the public inquiry began in February 2001. The estimate of the number of his victims rose (the sixth report said that he had begun killing early in his medical career while in the hospital service). Comparison of his death rates with those of other practitioners, and examination of his records, suggested that there had been some 215 deaths. The Shipman report failed to recognise that he could not have been caught by the GMC - but could well have been caught by restructuring of the Coroner Service and of the cremation certificate rules. As a result, there was an onslaught on the regulation of the medical profession and massive reorganisation of the GMC - the coroners' service and cremation rules did change as well.
Regulatory reform and revalidation - and the role of the GMC
The Royal Colleges, the BMA and its General Practice Committee, favoured 're-accreditation', the regular review of a doctor's work. Surgical Colleges suggested that in future review surgeons might be reviewed by their peers every five years. The GMC unanimously voted in 1999 for a system of continuing education and regular supervision of the standards of those in practice and issued a consultation document on Revalidating Doctors in June 2000. Under Sir Donald Irvine the GMC had begun to reshape itself to restore confidence. Irvine and the then editor of the BMJ Richard Smith felt that a paternalistic profession and an inward looking system of medical regulation had dealt with only the most flagrant abuses. Smith thought that one problem was that when there was a compromise between protecting people and being fair to doctors, the GMC sided with the doctors. Without reform the GMC might find itself abolished. There was opposition from some quarters of the profession. There were no agreed standards, criteria or thresholds for 'serious professional misconduct' - difficult as appropriate medical care changes over the years. The GMC was prosecutor and jury, conflicting with the Human Rights Act 1998. The BMA and its own Central Consultants and Specialists Committee (CCSC) passed a motion of no confidence in the GMC in July 2000. The GMC revised the way complaints were screened and handled to speed the process, and aimed to work more closely with the health service. The Government went to consultation on reforming its structure and constitution, increasing the lay membership. The Medical Act 1983 (Amendment) Order 2002 was made in December 2002, allowing for changes to the GMC constitution to include 14 lay and 21 medical members, and for new elections for a council to meet for the first time in July 2003.
A system of regular appraisal and revalidation of all doctors in the NHS was agreed. The changes, outlined in A Licence to Practice and Revalidation, published in April 2003 make a licence to practise a legal requirement for all registered doctors in the public or private sectors.
The fifth report of the Shipman Enquiry stated that the GMC had "fundamental flaws", criticized the reforms undertaken by the GMC as lacking sufficient rigour and said that in 3-4 years time the GMC should be evaluated. If it was not operating satisfactorily by then, it should be considered whether the GMC functions should be undertaken by a different body. The report made more than 100 recommendations. These included:
A telephone helpline for patients and health professionals to raise concerns about doctors' performance or conduct
A central database of information about every doctor in the United Kingdom to which primary care trusts and employers would have access
Improved monitoring of prescribed drugs
The GMC to be accountable to parliament
The GMC's constitution to be changed so it has more appointed members who are "not beholden to an electorate" and do not see themselves as representing doctors
Patients to have the chance to refuse to be treated by a doctor who is subject to conditions.
Source BMJ 2005, 330, 10.
The GMC's system of revalidation was criticized as unlikely to do the job and it was put on hold by Government pending a further review. Sir Liam Donaldson, the government's chief medical officer, was asked to review the role of the GMC. Published in July 2006 for consultation, he proposed
- introduce extensive changes in the structure, functions and governance of the GMC;
- remove the GMC’s role to adjudicate in fitness to practise hearings;
- create a new independent tribunal to hear fitness to practise cases;
- devolve some direct medical regulation to local level introduce a standard definition of a good doctor that would be incorporated into all NHS contracts;
- measure the risk of poorly performing doctors across diverse roles, working patterns and practice settings;
- change the management of under-graduate education;
- extend medical regulation to students;
- improve public access to well-managed, meaningful information about doctors.
- introduce specialist certification within a framework of revalidation, a well established process in the USA.
Based upon the consultation, the following February the Government issued a white paper Trust, Assurance and Safety, The Regulation of Health Professionals in the 21st Century (Cm 7013)
- introduce extensive changes in the structure, functions and governance of the GMC;
- remove the GMC’s role to adjudicate in fitness to practise hearings;
- create a new independent tribunal to hear fitness to practise cases;
- devolve some direct medical regulation to local level introduce a standard definition of a good doctor that would be incorporated into all NHS contracts;
- measure the risk of poorly performing doctors across diverse roles, working patterns and practice settings;
- change the management of under-graduate education;
- extend medical regulation to students;
- improve public access to well-managed, meaningful information about doctors.
- introduce specialist certification within a framework of revalidation, a well established process in the USA.
Based upon the consultation, the following February the Government issued a white paper Trust, Assurance and Safety, The Regulation of Health Professionals in the 21st Century (Cm 7013)
The key proposals considered by a working group established by Sir Liam Donaldson that reported in July 2008 were
- professional regulators independent of Government and led by an equal partnership of independently appointed professionals and members of the public;
- all health professionals to demonstrate periodically that they are fit to practise by revalidating their professional registration; all doctors wishing to practice to hold a licence renewed every five years.
- moving from the criminal standard of proof to the civil standard with a sliding scale in fitness to practice cases;
- a stronger role for the medical Royal Colleges;
- a system of regional GMC Affiliates who will provide support to local employers in addressing concerns about doctors and independently quality assure local revalidation processes.
In general the proposals were accepted, with a view to implementation over the next three years. The General Medical Council would establish a programme board to support the development of revalidation processes anf consider the practical issues around implementation.
Professional regulatory reform in the UK: a brief chronology
GMC publishes Good Medical Practice, setting out the duties of a doctor
Medical (Professional Performance) Act 1995 gives the GMC new powers to deal with problems of poor performance
Health Act - powers to reform professional regulation through statutory orders without new primary legislation
Department of Health publishes Supporting Doctors, Protecting Patients, which calls for a fundamental review of professional self regulation
Medical Act (Amendment) Order approved allowing GMC powers to make interim suspensions, restricting restoration of erased doctors, and widening membership of conduct committees
NHS Plan proposes a UK Council for Health Care Regulators to coordinate professional regulatory bodies
Bristol Royal Infirmary inquiry recommends creation of a body to oversee professional self regulation and Department of Health publishes proposals for such reforms in Modernising Regulation in the Health Professions
General Social Care Council established through the Care Standards Act 2000 to regulate the social care workforce
General Dental Council reforms its governance and structure
Replacement of the United Kingdom Central Council by the Nursing and Midwifery Council and replacement of the Council for Professions Supplementary to Medicine by the Health Professions Council.. Passage of the NHS Reform and Health Professions Act 2002, creating the Council for the Regulation of Health Professions (CHRP) with statutory powers of oversight over the regulators.
Medical Act (Amendment) Order 2002 approved enabling introduction of revalidation, new fitness to practise procedures, and changes in governance for GMC
Council for Healthcare Regulatory Excellence) established
First referrals of some fitness to practise decisions to the Appeal Court on grounds of undue leniency.
Introduction of regulation for operating department practitioners by the Health Professions Council.
GMC introduces new fitness to practise rules with a single complaints process to replace separate conduct, performance, and health proceedings.
Shipman Inquiry fifth report extensively reviews both old and new GMC fitness to practise procedures and criticises GMC for failing to protect the public and instead acting in the interests of doctors.
Department of Health consults on proposals to establish a new regulatory body for complementary therapies, initially focused on acupuncture and herbal medicine and on proposals to extend statutory regulation to all healthcare support staff (paralleling the regulation of social care workers by the General Social Care Council)
Department of Health suspends adoption of new revalidation procedures by GMC and announces two reviews of medical and non-medical professional regulation
Government publishes White Paper Trust, Assurance and Safety - the Regulation of Health professionals in the 21st Century, setting out plans for future regulation and followed by legislation.
Report of the CMO's Working Party, Medical Revalidation - Principles and Next Steps
Source: Walshe K, Benson L BMJ 2005; 330: 1504-6, GMC News, March/April 2008, DH website
The second and third reports of the Shipman Enquiry dealt with the police investigation, the system for death and cremation certification and for the investigation of deaths by coroners. In 2004 government announced a new system of certification. Each coroner's area would have a medical examiner playing key role in verifying the cause of deaths. Deaths would be verified by a doctor, paramedic, or senior nurse, who would then complete a verification form. The doctor who had treated the dead person in the immediate past would issue a certificate of the medical cause of death. After that the medical examiner would seek information from the family to confirm the cause of death and authorise burial or cremation, without having to refer the death to the coroner.
In 1992 the Cadbury Report had identified principles of good governance in organisations, integrity, openness and accountability. This was taken further in the Nolan Report (1997) and other subsequent management orientated documents. Government saw clinical governance as a tool that would deliver quality. It drew on the wide range of quality techniques and initiatives developed world wide over the previous years.
‘Clinical Governance’ entered the NHS vocabulary. The Commission for Health Improvement was charged with reviewing how far hospitals had implemented it. Clinical governance seemed to involve corporate accountability for clinical performance, alongside the other managerial responsibilities.
An early definition
A system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.
BMJ 1998; 317: 61-5
According to the Commission for Health Improvement (2001) the purpose of clinical governance was to ensure that patients received the highest quality of NHS care possible and it covered the organisation’s systems and processes for monitoring and improving services, including:
- consultation and patient involvement
- clinical risk management
- clinical audit
- research and effectiveness
- staffing and staff management
- education, training and continuing personal and professional development
- the use of information about the patients’ experience, outcomes and processes
It should ensure
- continuous improvement of patient services and care
- a patient-centred approach that includes treating patients courteously, involving them in decisions about their care and keeping them informed
- a commitment to quality, which ensures that health professionals are up to date in their practices and properly supervised where necessary
- the prevention of clinical errors wherever possible and the commitment to learn from mistakes and share that learning with others
Clinical governance reflected a fundamental change in powers and responsibility of managers and consultants; consultants could no longer regard themselves as free-floating entities; trusts and consultants had mutual responsibilities. However some saw the process as jargon-rich and progress was in any case slow. After three years a report from the West Midlands Region suggested that while structures and systems were in place, as yet there was little real difference in clinical activities and attitudes. Walshe K, Scope to improve. HSJ 2000, 26 Oct, 30-1. Ensuring adherence to National Service Frameworks, for example, required the collection of substantial quantities of data by GPs, appropriate computer systems and data entry. Mandating quality through central initiatives had not been especially successful in other countries; was it likely to be more effective in Britain? Inevitably implementation varied from place to place. With good leadership, local projects to improve patient management might multiply, or it might seem removed from the day to day concerns of clinical staff and incapable of answering questions such as "how can we improve procedures for a normal delivery"
Pathologists who had, for decades had routinely kept blood specimens, histological slides and pathological preparations found that this practice was unacceptable to some, once it was public knowledge. At Alder Hey Hospital, matters had gone further. A report by Michael Redfern QC showed that a huge collection of organs had been built up without full parental consent being obtained, or in some cases even sought. Sometimes organs, for example the thymus, had been 'harvested' and made available to pharmaceutical companies. 500 parents joined a legal action for compensation. A related enquiry by the Chief Medical Officer, Liam Donaldson, showed that more than 105,000 body parts were stored in English hospitals and medical schools, half dating from more than 30 years previously. This was no surprise to any British trained doctor, part of whose professional education had consisted of the study of preserved specimens showing the marks of disease, though at times the retention of organs had gone far beyond that required for bona fide research. In April 2000, Mrs. Elaine Isaacs discovered that, without her knowledge or consent, the brain of her late husband was removed after a coroner's post mortem and given to Manchester University for research purposes. Following investigation Dr Jeremy Metters, Her Majesty's Inspector of Anatomy, concluded that the protocols for the research, between 1985-1997, did not take proper account of the Human Tissue Act or the Coroners' Rules. New legislation was introduced to ensure that informed consent was obtained from patients or relatives.
The costs of negligence
The costs of settling legal actions for clinical negligence were rising. Pressure to put more people through the system and old equipment in outdated buildings did nothing to improve quality. Traditionally the costs of compensation had fallen on the individual clinician and his insurance, but it shifted first to the hospital concerned, and in April 2001 to the NHS Litigation Authority. Much money went to very large compensation awards to provide long term care for badly damaged patients, for example infants brain damaged at birth. A substantial backlog of claims existed, estimated by the National Audit Office to exceed £4 billion. The costs led Labour, in 2001, to review how compensation was handled, though the withdrawal of legal aid led to a plateau in claims. The Chief Medical Officer was asked to report and in June 2003 he published Making Amends. It was proposed that doctors would be under a duty of candour to report mistakes, there might be teams of investigators to assess claims, with a maximum of £30,000 compensation in most cases. The right to legal action would be removed once compensation had been paid.
A consultation paper in the first year of Labour's administration, A first class service, (1998) heralded a positive shoal of related activities and new bodies. Government was becoming increasingly impatient with professional self-regulation, and the time taken by GMC procedures to come to a final decision. High profile cases stimulated the introduction of new measures to monitor performance and to ban swiftly doctors who were dangerous and incompetent, challenging the medical profession’s traditional independence. Under the National Health Service Reform and Health Care Professions Act 2002 the government established the Council for the Regulation of Healthcare Professionals chaired by Jane Wesson, previously Chair of the National Clinical Assessment Authority (NCAA). The Council, which was called for in the Kennedy Report, would have members from the professions and others (in a slight majority) representing public interests and the NHS. It would oversee
General Chiropractic Council
General Dental Council
General Medical Council
General Optical Council
General Osteopathic Council
Health Professions Council
Nursing and Midwifery Council
Pharmaceutical Society of Northern Ireland
Royal Pharmaceutical Society of Great Britain
The Council decided to change its name to the Council for Healthcare Regulatory Excellence, because it would better reflect our role and purpose and avoid possible confusion with bodies of a similar name. Government was becoming increasingly involved in the quality of services, anathema in the early years of the NHS. It was also an issue in the White Paper, The new NHS - Modern - Dependable (1998), Labour proposing a statutory duty to provide high quality care. A raft of bodies now vied for the right to assess the quality of care. The Commission for Health Improvement was followed by the Commission for Healthcare Audit and Inspection (CHAI). The National Audit Office and the Audit Commission had been involved for a while, and a range of new organisations was established. Organisations with a remit to pore over the workings of the NHS were proliferating. There might be more people looking at the doing, than doing the doing..
Labour created five regulatory agencies
The National Institute for Clinical Excellence
The Commission for Health Improvement (successor body the Healthcare Commission)
The Modernisation Agency
The National Patient Safety Agency
The National Clinical Assessment Authority
|Types of quality programmes|
- Whole organisations, e.g. total quality and continuous quality improvement programmes
- Collaborative teams in different organizations
- External review and accreditation programmes
- Changing practice, e.g. guidelines and national service frameworks
- National or local quality initiatives and strategies
adapted from Øvretveit J & Gustafson D, BMJ 2003; 326:759-61
All were well resourced, most were ultimately accountable to central government, and they were part of a wider movement towards regulation and audit. Because of the high salaries paid, they attracted staff from trusts and added to their burdens. They might duplicate their demands; for example both CHI and the National Audit Office checked out clinical governance, a situation remedied by the creation of the Healthcare Commission, (the Commission for Health Care Inspection and Audit) from April 2004. As the number of organisations concerned with quality and regulation spiralled, the need for coordination became apparent. In 2004 the main organisations involved came together and agreed a Concordat aimed at bringing order to the chaos.
Source :Kieran Walshe, The rise of regulation in the NHS. BMJ 2002;324:967-970
|Name||Who it regulates||Date established||Annual budget (£)||Mission or purpose||How it works||What it is|
|National Institute for Clinical Excellence (www.nice.org.uk)||NHS in England and Wales||Apr 1999||10.6m (2001-2002)||To provide patients, health professionals, and the public with authoritative, robust, and reliable guidance on current "best practice"||Uses teams of experts to review health technologies and interventions and produce guidance which is then disseminated||A special health authority, set up by statutory instrument (SI 1999 Nos 220 and 2219) Name changed to National Institute for Health and Clinical Excellence.|
|Commission for Health Improvement ||NHS in England and Wales||Nov 1999||24.5m (2001-2002)||To help improve the quality of patient care by assisting the NHS in addressing unacceptable variations and to ensure a consistently high standard of patient care||Undertakes clinical governance reviews of all NHS organisations every 4 years; monitors implementation of guidelines from NICE, national service frameworks, etc; investigates major system failures within the NHS||A non-departmental public body established by the Health Act 1999. Subsequently the Healthcare Commission.|
|Modernisation Agency |
abolished in 2005 after the Arms Length Bodies review
|NHS in England||Apr 2001||54.6m (2001-2002)||To help the NHS bring about improvements in services for patients and contribute to national planning and performance improvement strategies||Encompasses existing national patient action team; primary care development team; collaboratives programme; leadership centre; beacon programme; and clinical governance support unit||Part of the Department of Health and abolished.|
|National Patient Safety Agency (www.npsa.org.uk)||NHS in England||Jul 2001||15m (2002-2003)||To collect and analyse information on adverse events in the NHS, assimilate safety information from elsewhere, learn lessons and feed back to the NHS, produce solutions, set national goals and establish mechanisms to track progress||Will establish and operate a new, mandatory national system for reporting adverse events and "near misses," and provide national leadership and guidance on patient safety and adverse events||A special health authority set up by statutory instrument (SI 2001 No 1743)|
|National Clinical Assessment Authority, subsequently merged into NPSA||NHS in England ||Apr 2001||10.1m (2002-2003)||To provide a support service to health authorities and hospital and community trusts who are faced with concerns over the performance of an individual doctor||Deals with concerns about doctors in difficulty by providing advice, taking referrals and carrying out targeted assessments where necessary||A special health authority set up by statutory instrument (SI 2000 No 2961). Merged in 2005 with the National Patient Safety Authority.|
Government proposals attempted to do two things, not necessarily compatible. First the 'person' approach, looking for individual errors; second a system approach looking at the entire system and introducing risk management, memory aids, and the reporting of problems to ensure their rectification. The regulatory bodies equally might follow either a sanction driven approach, or might attempt to stimulate development on the assumption that most bodies were essentially well-meaning, and would improve their performance given the chance.
National Clinical Assessment Authority (NCAA),
The NHS Plan of July 2000 established a National Clinical Assessment Authority (NCAA.) in April 2001, separate from the Department of Health, as a Special Health Authority and proposed a supervisory body to oversee professional regulatory bodies. NCAA operated on a confidential basis, bringing expert support and advice to situations where doctors' performance was being questioned. Cases could be referred to NCAA by an employer or by the doctor personally. If a problem could not be resolved locally, NCAA would undertake its own assessment, report on the action that might be taken and monitor what then happened. The roles were
NCAA assesses the contribution of individual doctors to the local service by addressing individual performance issues;
The GMC investigates serious misconduct, health or performance issues of individual doctors which may call into question the doctor's fitness to remain on the medical register.
CHI assesses clinical governance in all NHS organisations, and will review systems in health authorities and trusts for identifying and handling poor performance. CHI also investigates when there are serious system failures;
In 2005 the NCAA became part of the National Patient Safety Agency.
National Patient Safety Agency
Building a safer NHS for patients (2001) put an emphasis on reporting adverse events and risk reduction. The independent National Patient Safety Agency (NPSA) was established in July 2001, a 'mandatory system for logging all failures, mistakes, errors and near-misses across the health service' to feed lessons learned back into practice, and work alongside the Commission for Health Improvement, later the Healthcare Commission, and the Clinical Governance Support Team. In 2005 the Agency expanded to incorporate the National Clinical Assessment Service and the National Research Ethics Service. It also took over the funding of three Confidential Enquiries into: Suicide and Homicide, (hosted by the psychiatry division of Manchester University Medical School, Maternal and Child Health, (hosted by the Royal College of Obstetricians and Gynaecologists) and Patient Outcome and Death (a charity and limited company representing Royal Colleges).
When the NHS was established its clinical standards were those of individual clinicians and their professional organizations. If the emerging NHS had tried to challenge the traditional freedom of clinicians, the medical profession would have walked away. Attitudes changed. Medical practice based on evidence, rather than on anecdote and opinion, gained credence. Studies during the 1990s showed that the results of clinical research were poorly incorporated into routine care and that inappropriate variations in the standards of clinical practice abounded. As part of the 1998 Comprehensive Spending Review officials were asked to look at ways of improving efficiency and effectiveness in the NHS. The report proposed a systematic and national approach to the appraisal and management of new technologies. The White Paper, The New NHS (December 1997), announced the establishment of a new National Institute for Clinical Excellence to give guidance on drugs and other technologies. NICE profoundly changed the way that England and Wales evaluated health interventions, for the better. Established in April 1991 it brought together a number of organisations that worked on quality.
Its initial functions were
appraising new technologies, including drugs, and from 2003 to assess whether interventional procedures used for diagnosis or treatment were safe enough and worked well enough for routine use in the NHS.
deciding which should be encouraged in the NHS, and which should be held back.
producing or approving clinical guidelines (for example on GP referral to hospital)
identifying ways of improving the quality of care, and encouraging quality improvement
*funding the four confidential enquiries into maternal deaths, stillbirths and deaths in infancy, perioperative deaths, and suicides and homicides by people with mental illness.
[*These studies were later transferred for funding to the National Patient Safety Agency. Two were amalgamated into CEMACH in 2003 – the Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) and the Confidential Enquiry into Maternal Deaths (CEMD). The study into Peri-Operative Deaths continued within NCPOD, and the National Confidential Inquiry (NCI) into Suicide and Homicide by People with Mental Illness operated under the aegis of Manchester University.]
NICE was established as a Special Health Authority accountable to the Department of Health, at the controversial intersection of quality, innovation, access, reduction of practice variations and cost, with a remit to operate in an open way and to deal with clinical and cost uncertainties. Initially a small organisation chaired by Sir Michael Rawlins, within two years, often by contracting work out, it had issued 22 reports. By April 2005 the number had risen to 86, often important to specific but small groups of patients. NICE did not accept or reject health care technologies on cost effectiveness grounds alone, although this was a major factor, and operated to a set of principles. However above £30,000/quality adjusted life year (QALY) the case for supporting the technology had to be increasingly strong - draft guidance rejecting drugs for kidney cancer was issued on this ground (2008). Some criticised the threshold as too low, excluding some treatments; others that it was too high, with the result that the health service had to economise on forms of care that were possibly more worthwhile, but had not been mandated by NICE.
Steadily NICE's credibility grew, it came in some part to replace the National Service Frameworks and it became a major feature of the landscape of clinical medicine. Its guidelines were increasingly welcomed, and its work began to achieve international recognition. Internationally, NICE was unusual in having a formal appeals process. In 2004 a review of arms' length bodies recommended that NICE should take over the the public health functions of the Health Development Agency. From 1 April 2005 it became the National Institute for Health and Clinical Excellence (still known as NICE), an independent organisation responsible for providing national guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector.
Regularly government would suggest new groups of drugs and procedures for assessment, usually of new procedures, rather than existing patterns of treatment. The reports fell into several main categories: ( Bosanquet N, Health Service Journal, 19 June 2003, p 30-1)
Cancer treatment and chemotherapy
Surgery, laparoscopic and orthopaedic
Lifestyle drugs, smoking and weight reduction
Central nervous system and mental illness including Alzheimer
Long-term conditions, rheumatoid arthritis and renal disease.
In September 2006 NICE was asked to launch a new programme to help the NHS identify interventions that are not effective, to help the NHS make better use of its resources by reducing spending on ineffective treatments, that did not improve patient care or represent good value for money. Technology appraisals would be undertaken where clinical evidence suggested that current practice is no longer appropriate or effective and does not improve patient care. For example, a clinical guideline could be developed on how to manage sore throats in children. Antibiotics are known to be largely ineffective, for example they will not work if it is a viral infection. NHS could then invest in drugs and approaches to care that make a positive difference to patients’ lives
An early aim was to end ‘postcode prescribing’ where treatment was determined by local decision and place of residence. In October 2001 government decided that the NHS should be compelled to implement the recommendations. NICE decisions were made without consideration of budgetary constraint. Zyban and other anti-smoking devices were likely to cost an additional £50 million/year and a drug to treat hepatitis C £18 million. Courses of in-vitro fertilisation, free for women between 23-39, also had major cost consequences. Most recommendations suggested routine use of technologies, or accepted them with major or minor restrictions. In 2002 the NICE estimated that its guidance could increase costs to the NHS in England and Wales by about £575 million, and in 2007 by £1.6 billion. Prescribing costs in general practice rose at 10% per year or more, substantially as a result of NICE recommendations. Its guidance was in theory mandatory for the NHS so sometimes the choice was to cut services or fund the recommendations and the treatments that Trusts had to cut might have a higher QUALY than those NICE approved and which became mandatory.
Controversy was never far from the surface. NICE early ran into dispute over the flu drug Relenza and beta interferon for multiple sclerosis. In 2006 Pfizer and another company took court action over its decision to restrict access to dementia drugs to those at a moderate, not an early stage, seeking a judicial review of how the NICE reached its conclusions. The Court supported the process by which NICE came to its conclusion. NICE was responsible for delayed use of some new drugs; it did not approve atypical anti-psychotics until 2002, ten years after they had entered clinical practice. It probably increased the dissemination of some technologies judged cost-effective, e.g. taxanes, but there was less compliance with other recommendations, for example new drugs for arthritis and schizophrenia. It was less successful in discouraging the use of drugs thought not to be cost effective. Neither was it clear that when changes had occurred, it was the result of the guidance rather than manufacturers' marketing efforts. While denying that it was rationing health care, others contended that prioritization inevitably meant this. In the absence of detailed knowledge of individual patients only general guidance could be given - while it was individual patients that received or did not receive treatment. NICE inevitably had to consider treatments one at a time and not necessarily the whole range of alternatives available.
The method by which its appraisals were conducted was criticised, as by the House of Commons health select committee in January 2002. The Committee's report called for a move away from isolated technological appraisals towards broader guidance, and more willingness to work with others. NICE asked the WHO Regional office for Europe to conduct a review of the technology appraisal programme which was largely supportive, although commenting on the difficulty in reconciling openness of decision-making and the use of commercially confidential material provided by the pharmaceutical industry.
Initially the Chairman said it was not the Institute's role to veto drugs that, though expensive, had clinical benefit. Progressively cost/benefit entered the equation, 'whether a drug was effective use of NHS resources' and cost-benefit criteria were used. This led to increased criticism of its decisions. For example a drug to help smokers give up was approved, when some cancer chemotherapy drugs were not. However NICE did not try to work within a budget for NHS drugs - affordability to the NHS was a matter for government. NICE had criteria other than cost and cost-effectiveness, including encouragement of innovation and the broad clinical priorities of the NHS. It had to make scientific judgments on what was good or bad, and social value judgments on what was good for society, in which it was assisted by a Citizens Council.
Scotland, with its greater health funding per capita, made drugs available more rapidly. NICE also appeared to take its time in making assessments, and was criticised for its delays and decisions on Tarceva (lung cancer), Velcade (multiple myeloma), Alzheimer's drugs, Alimta (mesothelioma) and Gliadel (brain tumours). NICE was itself under financial constraints; its budget was reduced in 2005 and one of the three committees undertaking assessments was scrapped. This increased the time it took to approve drugs, for example new ones used in breast and colon cancer. While doctors could prescribe drugs licensed by the Medicines and Healthcare Products Regulatory Authority (MHRA), in practice it was rare to get NHS funding in advance of a NICE recommendation.
NICE exists to give health professionals advice on providing their NHS patients with the highest clinical standards of care
It undertakes its economic assessments using a cost utility approach (cost per quality adjusted life year)
Decisions about cost effectiveness are made on a case by case basis
Judgment is needed to balance the tensions between efficiency and equity
Rawlins M & Culyer A J BMJ 2004; 329: 224-7
In January 2008 the House of Commons Health Select Committee published its second report into NICE, six years after its first. The committee questioned the financial threshold used by NICE, suggested that appraisals should appear at the time of drug launch, not long afterwards, and was concerned about the quality of data used, much of which was derived from the drug industry.
Until the establishment of the Commission for Health Improvement (CHI), independent inspection of NHS hospitals was largely unknown, unlike the situation in the USA where there was a lengthy tradition and substantial experience. CHI was established in April 2000 to undertake a rolling programme of provider and service reviews. Kenneth Robinson had established the Hospital (later Health) Advisory Service in the sixties in the wake of scandals in long term care but it had neither the scope nor size of CHI. CHI was immediately asked to investigate problems in two trusts in Cumbria and the Carmarthenshire in Wales. The hard hitting reports established its position as a trouble-shooter and the classic ingredients, a whistleblower, a culture of secrecy and previous internal enquiries that had failed to bring about sufficient action. There was a tension between the role imposed by government as a watchdog with a punitive function reviewing every Trust, and the concept of a catalyst promoting continuous quality improvement. The staff and budget of CHI increased fast. By 2002 as many as nine reports might be published in a single week. CHI attempted to assess the processes of care and the way the organization operated, but assessing the quality and outcome of care was harder. The role of CHI was diagnostic. The follow-up of recommendations was for others, and it had no power to enforce its recommendations.
CHI was not independent of the Department of Health. Professor Ian Kennedy's report on the problems of paediatric heart surgery at Bristol later recommended that it should be and Government accepted this proposal. The NHS Reform and Healthcare Professions Act (2002) tried to rationalize inspection, gave CHI a wider role and greater independence, and the responsibility for the private health sector through the National Care Standards Commission, initially a separate organization. It required the commission to publish information on performance and from 2003 made CHI responsible for the star ratings system (previously calculated by the Department of Health) comparatively free from government intervention. The star rating system and the number of hospitals in each band was, however, highly subjective. Drawing on its experience of visits, in 2003 CHI published a report, Getting Better? a report on the NHS, identifying such problems as infection control, too great a concentration on waiting lists, and a lack of doctors in management positions.
CHI relied heavily on the professional expertise of its teams, rather than explicit standards. It had been directed to study "clinical governance" and this largely focused on process issues rather than patient care per se. The reviews led to much trust activity in the years before and after; then rather less. The follow up was for others, regional offices or strategic health authorities, so the feedback loop was not complete.
In April 2002, the government announced plans for a new Commission for Healthcare Audit and Inspection (CHAI) with greater powers, to subsume the Commission for Health Improvement, the value-for money-responsibilities of the Audit Commission and those of the National Care Standards Commission (concerned with licensing private health care and only in operation for three weeks). "I" now stood for inspection, rather than improvement. CHAI would have four roles, setting standards, audit and inspection of performance, clinical governance and finance, improvement (alongside the Modernisation Agency itself now living on borrowed time) and enforcement, working with strategic health authorities.
It seemed natural that the chairman should be Professor Sir Ian Kennedy, the author of the Bristol report. It was rebranded as the Healthcare Commission. The new regulator would inspect all health care providers – public and private – against "uniform, clear and comprehensive standards". and there was a clean break between the old and the new organisations. Peter Homa, the chief executive, resigned as the new chairman rethought the way the organisation would function. The Healthcare Commission, reporting in July 2004, said that the 'inverse care law' of Julian Tudor Hart (Lancet 1971; 1:405-12) still held sway. Those most needing care were least likely to receive it. An ambitious undertaking for so young an organisation, the report profiled several issues, such as the care of ethnic minorities, children, and the elderly.
The Commission wished to rationalise the overlap between organisations responsible for healthcare inspection to provide a more coordinated approach to visits and requests for information. Sir Ian wished to make visits more targeted and more proportionate. The Healthcare Commission published the star ratings in 2004 for hospitals, primary care and mental health care trusts. Sir Ian wished to move from inspection, an expensive and not necessarily reliable tool, to regulation based upon data - information derived from a multitude of sources. He wanted the information to come from trusts themselves. This would be supplemented by visits, sometimes as a result of the information received, but others random in nature. A new system based on "core standards" was introduced, using seven topics, safety, clinical and cost effectiveness, governance, patient focus, accessible and responsive care, the care environment and amenities, and public health. Trusts assessed and self-certified how far they met these standards, and the separate and defined elements of each. Kennedy regretted that it had not been possible to assess pathways of care and the outcomes achieved, to design a system that was prospective rather than retrospective (to identify problems as they were arising) or to incorporate patient experiences adequately.
The first new annual "health check" ratings appeared in October 2006 and annually thereafter. They painted a mixed picture of the quality of services in the NHS. The score for quality covered areas that mattered to patients, including safety, cleanliness and effectiveness.
Sir Ian had disputes with government and in November 2006 the Department consulted on a proposal to merge three organisations, the Healthcare Commission, the Commissions for Social Care Inspection and the Mental Health Act Commission) into the Care Quality Commission (CQC) Legislation created the new regulator "to ensure clean and safe services, and high quality care" with the power to instigate a statutory warning notice demanding improvements, a formal caution, a temporary suspension of mandatory registration, conditions restricting what can be provided or criminal prosecution. Baroness Young (Barbara Young) was appointed Chair.
In 2008 the organisation of audit, previously undertaken by the Commission, was awarded to a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and the Long Term Conditions Alliance to be known as the Healthcare Quality Improvement Partnership. It would create a National Clinical Audit Advisory Group (NCAAG) to provide advice and guidance on the programme of work,
Changing clinical practice
Since the start of the NHS clinical innovators, leaders of the medical profession, government and NHS management had tried to spread good practice and ensure that everyone had access to high quality and up to date care. Government had often established a professional sub-group of the Standing Medical Advisory Committee and commended its proposals. In the seventies both the Conservatives and Labour had issued a range of proposals to improve clinical services, for example Better Services for the Mentally Handicapped (1971)..SMAC and SNMAC were abolished in 2005. A new mechanism evolved to produce national strategies and National Service Frameworks (NSFs) which "set national standards and defined service models for a specific service or care group, put in place programmes to support implementation and established performance measures against which progress within an agreed timescale will be measured".
NSFs were issued in 1999 for mental health and for coronary heart disease in March 2000. More followed. As the number grew, they moved away from centrally driven targets towards the identification of good practice. Experienced and senior clinicians were appointed to central positions of responsibility. The Chief Medical Officer had previously chosen consultant advisers and the medical staff of the Department of Health had developed close links with them. But as the Department's Medical Division shrank, Health Directors, or "tsars" were appointed to drive clinical policies in cancer, heart disease, mental health, older people's services, primary care, children, emergency access and patients' issues. These National Clinical Directors came to influence clinical policies and in 2006/2007 were asked to publish a series of papers, the "Clinical Case for Change" as part of Lord Darzi's programme.
Advances in the management of serious acute conditions influenced the pattern of the hospital service. If the best treatment for a heart attack was early coronary angioplasty (common in the USA for ten years), patients needed direct admission to a unit capable of performing this. Similarly, a specialist stroke unit with scanning facilities and clot-busting drugs 24/7 might reduce ultimate dependency. Such units could not be provided in every DGH - they might need a population of a million. Reconfiguration of hospital services was given impetus by the reports from Prof.Sir Ara Darzii, the National Advisor on Surgery. His report on the future of planned surgery, 'Saws and Scalpels to Lasers and Robots - Advances in Surgery', said that 80% of all surgery should be done locally with the remaining 20% of the more complex cases at specialist centres with access to the highly skilled surgeons and the most up to date technology. This might include complex cancer surgery, surgery of blood vessels, transplantation, removal of brain tumours and open heart surgery
Increasingly health services dealt with chronic diseases. Improving their management and reducing the many admissions for which such diseases were responsible became a high priority for government and led to an examination of the methods adopted by US managed care organisations. Routines developed to handle acute illnesses were ill suited to chronic diseases. Two new approaches were tried in the UK, disease management and the chronic care model.
"Disease management", a concept from the USA, was provided by large companies unrelated to doctors' practices, paid by health insurers. They used sophisticated information systems to identify patients with chronic diseases and establish close communication with them, educating them and their families on self-care, tracking their progress and intervening if problems seemed likely to arise. The pharmaceutical industry was interested in diseases requiring long term medication. In theory systematic, integrated evidence-based care of chronic high cost diseases such as asthma, rheumatoid arthritis and diabetes might be more effective. However, the management of specific diseases by a separate organisation risked the fragmentation of care, as patients with multiple unrelated pathology might be directed to specialised units. The chronic care model, in contrast, was based within the doctors' practices, reorganised to create informed patients with self-management skills, and developing multidisciplinary teams to monitor patients at risk. (Casalino JAMA.2005; 293: 485-488.)
Factors affecting premature death.
Health is influenced by genetics, social circumstances, environmental exposures and behavioural patterns. Medical care has as relatively minor role in reducing early deaths. The single greatest opportunity to improve health and reduce premature deaths lies in personal behaviour. Obesity and physical inactivity combined are the top two behavioural causes or premature death. (We Can Do Better — Improving the Health of the American People, Steven A. Schroeder, NEJM 2007, 357; 1221-1228 ) It was here, and on smoking, that effort was concentrated. Department of Health economists had difficulty in assessing the balance between spending on health promotion and health care services. There was some resistance to rigorous application of cost-effectiveness frameworks to favoured interventions. Nevertheless a range of preventive programs that seemed cost effective included universal 'flu vaccination for the over 65s, statin therapy for middle-aged people with coronary heart disease or who were at high risk, screening for Chlamydia infection, nicotine replacement and increased support for counselling for smokers wishing to stop.
On election in 1997 Labour had promised a new strategy to break the cycle of ill health due to poverty and deprivation. A mind-numbing series of reports appeared, lengthy, repetitive and because of the compromises necessary to avoid encroaching on private liberty, were more radical than some wished, and less prescriptive than others would have them.
The Acheson Inquiry (1998)
Saving Lives - our healthier nation (1999)
Tackling Health Inequalities - A programme for action (2003)
Securing Good Health for the Whole Population (2004)
Choosing Health (2004)
Labour commissioned an inquiry into inequalities in health in 1997, conducted by Sir Donald Acheson, an unusual choice as he had been CMO when The Health of the Nation was prepared under the previous administration. The inquiry team, composed of scientists but no economist, based their recommendations on published evidence. Because of evidence that the poor generally lived shorter unhealthy lives, the key recommendations involved a wholesale redistribution of wealth. The difference between the mortality rates of Social classes IV and I for stroke, heart disease, accidents and suicide were, if anything, widening. Unlike the recommendations of the Black Report (1980), Acheson’s 1998 recommendations were not costed. Sir Donald wanted to see the package implemented as a whole. ‘The inquiry had not looked at cost effectiveness’, he said, ‘affordability is not a matter for scientists but politicians…’ Some recommendations were vague, for example the need to take ‘measures to prevent suicide among young people’ or ‘policies to reduce fear of crime and violence’. Sir Donald had asked an evaluation group to look at the quality of the evidence it used to reach its conclusions and support its recommendations. For most there proved to be no high quality controlled studies showing that the recommendations would improve health - there were few randomised-controlled trials available – but hard evidence of effectiveness has seldom underpinned changes in health policy. Indeed at least in the US education was a powerful predictor of mortality, far more than income inequality (BMJ 2002;324: 1-2)
This reviewed the 1992 Health of the Nation initiative and found that it had failed to change spending priorities and made no significant impact on health authorities, trusts or GPs. In 1999 Labour published a revised programme as a Green Paper, Our Healthier Nation, then a White Paper, Saving Lives - our healthier nation. This aimed to improve the health of everyone, particularly the worst off, taking into account the social, economic and environmental factors affecting health. It reduced the number of health improvement targets to four and re-iterated the contributions to health of social, economic and environmental factors, and the individual decisions taken by individuals and their families. The document expressed aspirations and tended to say what government could do - and not what it would do. The role of the health visitors would be strengthened, and educational programmes would be introduced, for example sessions at school to help children to avoid accidents. The new policy was not substantially different from the old one, though the goal was now to improve the health of the worst off in particular.
In July 2003 Tackling Health Inequalities - A Programme for Action set out a three-year plan on health inequalities. It aimed to meet the 2010 national health inequalities target on life expectancy (by geographical area) and infant mortality (by social class) and was organised around four themes, supporting families, mothers and children to break the inter-generational cycle of health; engaging communities and individuals to ensure relevance, responsiveness and sustainability; preventing illness and providing effective treatment and care; and dealing with the long term underlying causes of health inequalities.
In his first report to the Treasury, largely concerned with financial matters, Derek Wanless had provided 3 different scenarios based on different levels of involvement of the public in relation to their health. Economic analysts within the Department of Health had a substantial input to these scenarios. In April 2003 he was asked to provide an update on the challenges involved, focusing on prevention and the wider determinants of health. Two issues emerged again, regulation versus patient education, and local versus national projects. In December 2003 he issued a report on population health trends and his final document, Securing Good Health for the Whole Population, appeared in February 2004. Wanless thought the costs of the health service would be massively less if there was "full engagement" - i.e. energetic and effective action by all concerned, including individual people. Wanless drew attention to the problems of smoking, lack of activity and obesity, while failing to make clear what the costs would be incurred if individuals avoided life-style induced illnesses, and died later of something else instead.
Key points included
Individuals are primarily responsible for their own health and lifestyles, but lack of information and the social context in which they live may lead to people failing to achieve the substantial improvement in health possible. These failures must in part be addressed by government
There had been much written, often covering similar ground and apparently sound, but rigorous implementation of identified solutions had often been lacking.
There is generally little evidence about the cost effectiveness of public health policies in part caused in part by lack of research funding.
This has led to the introduction of a wide range of initiatives, often with unclear objectives and little quantification of outcomes
That led to a consultation document and a further White Paper, Choosing Health.. Increasingly the role of the individual was emphasized in the making of healthy lifestyle choices.
Published in November 2004, the principles were informed choice (with the protection of those too young to choose, and ways of ensuring that one person's choice did not harm others), tailoring proposals to the reality of individual lives, and working together. Among a myriad of actions to make the NHS a health promoting organisation, Choosing Health proposed
action to increase the number of smoke-free workplaces
Curbs on the promotion of unhealthy foods to children
Clear, unambiguous labelling of the nutritional content of food
better provision of information to the public, e.g. a 'Health Direct'
NHS Health Trainers to provide advice to individuals on how to improve their lifestyle
The Health Development Agency
The Health Development Agency, established in 2000 as a special health authority, was the successor to the Health Education Council (1969-1987) and the Health Education Authority (1987-2000) It aimed to develop the evidence base to improve health and reduce health inequalities. It worked in partnership with professionals and practitioners across a range of sectors to translate that evidence into practice. It too succumbed as a result of the Department of Health's 2004 review of "arms length bodies", and its functions were transferred to NICE on 1 April 2005. Speaking in Nottingham on Public Health on 26th July 2006, the Prime Minister, Tony Blair, said that the role of government was to enable and help people to act with responsibility. Referring to the problem of obesity, smoking levels, drinking habits and diabetes, he pointed out that "these individual actions lead to collective costs."
Organisation of public health
Repeated changes in the organisational structure created problems for public health as the boundaries seldom matched those of local authorities. Until 2001 most public health doctors worked on the “purchaser” or “commissioner” side and a few as epidemiologists in hospital trusts. Each Authority had a Director of Public Health sometimes with other roles such as Director of Health Strategy and usually with support from other consultants and trainees. April 2002 completed the move to Primary Care Trusts, increasing the problems of public health as a discipline. Primary Care Trusts were essentially built upon general practitioner registered populations rather than a defined geographical area, and the large number of PCTs, each of comparatively small size, posed problems for public health. Later, an attempt was made to align many PCTs with local authority boundaries.
As regions were abolished and regional outposts were integrated into the Department of Health, Regional Directors of Public Health became civil servants. "Observatories" were created to report on the problems at regional level by the analysis of statistical data. In parallel non-medical staff concerned with public health, e.g. health visitors, health educators and environmental officers, became eligible for membership of the Faculty of Public Health and the government decided that the post of Director of Public Health did not require a medical qualification. Public health was changing and ceased to be largely a discipline for doctors who had received additional training, and came to incorporate non-medical disciplines that had always made a substantial contribution to the subject, such as epidemiologists, economists and statisticians amongst others. Simultaneously, medical management positions that previously had often gone to those with public health skills, were increasing occupied by clinicians.
9 Regional Public Health Groups were ultimately formed to match the strategic health authorities and were part of the Department of Health, co-located in each of England’s nine Government Offices. They worked alongside public health colleagues in NHS, local authorities and other agencies to improve and protect their local population. The Association of Pubic Health Observatories drew together public health intelligence from across the UK and Eire. It provided the NHS with expertise in fields such as alcohol and drug misuse, and diseases such as stroke, cancer and sexual health. It produced health profiles for every local authority in England.
An increasing number of expensive but clinically effective drugs, sometimes "life-style" in nature, were introduced. Prozac, HRT and Viagra might improve qualities of life to which medicine had previously paid less attention. In January 2001 NICE approved three new drugs for the treatment of mild or moderate Alzheimer's disease. A new anti-obesity drug, Xenical (Orlisstat) , offered the possibility of reducing fat absorption; NICE agreed in 2001 that it could be prescribed when patients were motivated to lose weight, obesity was significant and was posing a threat to health. Two other anti-obesity drugs, silbutramine and rimonabant also appeared, later to be withdrawn on safety grounds. In 2002 NICE recommended the use of bupropion (Zyban) and nicotine replacement therapy (NRT) for smokers who wished to quit.
Expensive yet effective drugs increasingly appeared for common conditions, for cancer, coronary artery disease and stroke. Statins represented the largest drug cost to the NHS (£1.1 billion in 2004) though the cost of simvastatin fell greatly when out of patent. Herceptin achieved a major reduction in the recurrence rate of an aggressive form of breast cancer in those with the HER-2 gene - but cost £20,000/year. Adults with diabetes of the insulin resistant type stood to benefit from a new class of drugs, the thiazolidinediones. Organ transplantation became more reliable with the development of new immune-suppressors. The treatment of benign prostatic hyperplasia, a common condition, was improved by combination therapy with doxazosin and finasteride which reduced the risk of acute urinary retention and the need for surgery.
A new group of drugs derived from monoclonal antibodies began to appear. Infliximab (1998), an artificial antibody, was introduced for autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylits and psoriasis. It worked by blocking tumour necrosis factor alpha (TNFα). TNFα is a chemical messenger (cytokine) and a key part of the autoimmune reaction. Infliximab blocks the action of TNFα by preventing it from binding to its receptor in the cell.
The examination of drugs for safety and efficacy in the UK had a history back to the thalidomide disaster in the 1960s. Within the EC the European Medicines Evaluation Agency brought together the resources of European Community members and was based in London. In April 2003 the Medicines Control Agency (MCA) was merged with the Medical Devices Agency (MDA) as the Medicines and Healthcare Products Regulatory Agency, (MHRA), a role similar to that of the FDA in the USA.
Some drugs proved risky, either before or after public release. In 2006 at the clinical trial stage, the testing of a monoclonal antibody TGN1412 at Northwick Park Hospital led to multi-organ failure simultaneously in 6 young men; all survived but some suffered permanent injury. While reporting systems made it possible to spot increased numbers of rare events, such as liver failure, a raised incidence of a common problem, for example heart attacks, was harder to discover. A new anti-depressive, Paroxetine (Seroxat) seemed to be associated with a raised incidence of suicidal thoughts and suicide. Cox-2 inhibitors were introduced in 1999 for the the treatment of arthritis in the hope that gastro-intestinal side effects would be less common. They received massive publicity, often direct to consumer and combined sales exceeded $5 billion annually. After 5 years evidence emerged of higher risk of heart attacks and strokeapparently an effect of all drugs in that class. In September 2004 Merck withdrew rofecoxib (Vioxx ) from the market. The belief that the Company had not drawn attention to early indications of problems led to Court actions and substantial awards. Pfizer also withdrew Celebrex (celecoxib), there being well established alternatives for the treatment of all the approved indications for their use. (Drazen J M, NEJM 17 March 2005)
The prescription of a medication in a manner different from that approved was legal and common, often in the absence of adequate supporting data. Off-label uses had not been formally evaluated and evidence provided for one clinical situation might not apply to others. It usually entailed use for unapproved clinical indications or in unapproved subpopulations (e.g. paroxetine [Paxil] for depression in children) from a presumed drug class effect, extension to milder forms of an approved indication, extension to related conditions or extension to conditions whose symptoms overlap with those of an approved indication. The pharmaceutical industry wanted to enlarge its markets to ensure future profits and sustain drug development. The public wanted drugs that were safe, evidence-based, and affordable; but also wanted the newest therapies and physicians wanted the autonomy to prescribe drugs for individuals regardless of the state of approval.
Ask your doctor about.....
Many patients consulted their doctors after hearing of drugs on TV or in the papers. Europe differed from the USA in its approach to Direct to Consumer Advertising (DTCA) of prescription drugs for governments inevitably wished to control drug budgets, while in 1997 the US Food and Drug Administration (FDA) further relaxed controls. DTCA was a powerful tool, designed to create demand and maximise profits by encouraging patient demand. Bob Dole, a former US vice-presidential nominee, appeared in the US on a TV commercial for erectile dysfunction - paid for by Pfizer. Some drugs had become household names, Viagra, Prozac for depression, Claritin for allergies, Rogaine for baldness and Matrix for migraine. DTCA was often inaccurate; from 1997 to 2001, the FDA in the USA issued 94 notices of violations, mostly because benefits of the drug were hyped and risks minimised. In 1999 drug companies began ‘public awareness campaigns’ in England. These had little to do with health education, for the material and the advertisements were not about inexpensive diuretics, immunisation or cervical smears, but unsightly rashes and cures for baldness. In 2001 the European Commission proposed changes in EU law to allow DTCA for AIDS/HIV, diabetes, and asthma for a 5-year period, a proposal categorically rejected by MEPs the following year. New Zealand reviewed DTCA and concluded that the benefits did not outweigh the harms; similar views were held in Canada and Australia. Internet increased pressure on doctors to prescribe the drugs publicised and industry regarded it as part of their DTCA campaign aimed at people actively searching for information.
More drugs were cleared for over the counter (OTC) sale by a pharmacist, as was simvastatin 2004. Little time was lost in advertising it to the public once it ceased to be a prescription drug. Candidates for OTC were usually drugs for non-chronic conditions that patients could easily self-diagnose with a low potential for harm from widespread availability. Three factors motivated OTC, the patient self-help movement, the desire to minimise costs to the public purse, and the belief by the company that this was profitable.
The National Screening Committee, established in 1996 on a UK basis, developed protocols for screening. In 1998 it identified almost 300 screening programmes, many at a research stage and nearly 100 in practice. Only four met stringent criteria for both quality and evidence of effectiveness, breast and cervical screening, and neonatal blood spot screening for phenyl-ketonuria and hypothyroidism. There was a growing body of evidence that screening could harm people, particularly because of false-positive and false-negative results. Breast cancer screening might save lives, but many women had breast surgery that in the event proved unnecessary. To Wilson’s earlier criteria (see paragraph on screening in Chapter 2) was added a new one, that there should be evidence from high quality randomised controlled trials that programmes were effective in reducing mortality or morbidity. In 2003 it was agreed to work towards a national screening programme for bowel cancer, the second most common cancer in men and women and testing of stools for blood was introduced in the over sixties in 2007. Further trials would be undertaken for an alternative method common in the USA, flexible sigmoidoscopy.
"Multi-phasic screening" as a form of health check, had been popularized in the USA in the sixties. Now a new form of "screening" emerged there and was subsequently introduced into the UK, whole body spiral CAT and MRI scanning. Mobile units might offer cardiac, thoracic or abdominal scans. Other organisations provided Doppler ultrasound investigations to the worried well. There were, of course, some positive findings - for example young men with an operable but clinically silent cancer. Such procedures might take only a few minutes and cost £200 each, not an impracticable sum, though the marketing literature seldom spelt out what could be expected in terms of false positives and false negatives, the images often being reported by unnamed clinicians in other countries.
Imaging technology was increasingly central to accurate diagnosis but was costly. The promise of digital radiographic systems was fulfilled as hospitals were reequipped with systems allowing images to be rotated, enlarged and manipulated. The filmless hospital was commonplace by the end of the decade. The Department of Health’s Picture Archiving and Communications System (PACS) increasingly enabled images to be stored and mailed electronically rather than printed on film and filed manually.
Computed tomography was developing rapidly. In the late eighties the rotation of the x ray source was combined with continuous movements of the table on which the patient was placed. Because the tube was rotating while the subject moved smoothly through the scanner, the x ray beam described a spiral pathway. This meant more rapid scans, closer spaced cuts, and a scan within a single breath-hold, giving three-dimensional images. For example, the colon could be viewed in exquisite detail. Multi-slice scanners were introduced with not one row of detectors, but up to eight. Image acquisition was faster and a larger area could be covered.
Magnetic Resonance Imaging became a rapid imaging tool for the whole body. Widely useful, particularly for neurological and cardiac disease, its ability to reveal skeletal spread of cancers, sometimes when no primary tumour had been found, radiation risks were avoided. Positron Emission Tomography (PET) had a similar and increasing range of uses. In 2000, Nutt and Townsend working first in Geneva and later in Pittsburgh, combined computerized tomography scanners (CAT) with positron emission tomography. The result was a single machine that could simultaneously image anatomical structure, for example cancer and metabolic processes, reducing patient discomfort. Conformational radiotherapy, which enabled accurate dosage to be given to precisely the required field even if it was irregular in shape, enabled higher doses to be given with less tissue damage and, hopefully, better outcomes. "Intensity modulated radiotherapy" enabled different doses to be administered to different parts of a tumour. Electron beam imaging was also under development.
Progressive development of imaging systems aided the development of minimal access surgery. Image-guided surgery used imaging systems during a surgical procedure to assist its performance. Magnetic resonance imaging was the best technique, but it had not been practical because the machines had been fully enclosed. The first truly open scanner was installed in Boston in 1994, but in 1999 one was installed at St. Mary's Paddington. Surgeons had full access to any part of the patient's body, while it was scanned. Endoscopic views could be combined with MRI images, and important structures could be identified and safeguarded during surgery.
Following the 9/11 attack on the Twin Towers, and an episode in the USA in 2001 when anthrax was sent through the mail (with many cases of skin infection and several deaths from pulmonary anthrax), the possibility of similar attacks in the UK arose. The NHS and the emergency services were primed to plan and organise for bioterrorist emergences. The US government placed a major contract for ciprofloxacin, an appropriate antibiotic. Concern that smallpox might be used by terrorists led the US and the UK government to order supplies of vaccine and to issue contingency plans for on the containment of local outbreaks and mass vaccination.
European health ministers planned to strengthen the EU's communicable diseases network to cover bioterrorist attacks as well as the threat posed by world-wide mobility of people, infections, food and products. Avian influenza, in 2004/5, led to world-wide warnings of disaster and the stockpiling of anti-virals and vaccines.
Getting Ahead of the Curve
The Chief Medical Officer of the Department of Health launched a strategy in January 2002, Getting Ahead of the Curve, to improve the system of preventing, investigating and controlling the threat of infectious diseases threats. A new Health Protection Agency (HPA) would combine the existing functions of the Public Health Laboratory Service, the National Radiological Protection Board, the Centre for Applied Microbiology and Research, and the National Focus for Chemical Incidents). There would be a national panel to assess the threat from new and emerging infectious diseases. Local PHLS laboratories would be taken over by the NHS, the HPA having local health protection services, working with the NHS and local authorities. The PHLS opposed the strategy but in August 2002 Sir William Stewart, formerly of the Microbiological Research Authority, was appointed to chair the Health Protection Agency in April 2003. 42 Local Health Protection Teams were formed with access to expert advice on chemical and radiological issues, health emergency planning, and communications
Drug resistance and anti-bacterials
Staphylococcus resistance had been a problem in the 1950s-1960s. In the eighties infection by methicillin resistant Staphylococcus aureus (MRSA) began to increase once more. The Standing Medical Advisory Committee (SMAC) reported on the threat in 1998 - The Path of Least Resistance. SMAC believed that up to 75% of antibiotic use was of questionable value yet society demanded easy answers and there was increasing use of broad-spectrum antibiotics. By 2000 roughly a third of strains isolated in hospitals were resistant. Some now showed resistance to the only remaining antibiotic, vancomycin. The number of patients from whom MRSA had been isolated had multiplied more than ten fold over ten years. The National Audit Office reported in 1999/2000 that dirty hands and unsanitary conditions in hospitals caused 5,000 deaths a year and over 100,000 inpatients became seriously ill with infections, costing the NHS £1 billion a year. A follow-up report in 2004 showed only patchy progress. Voluntary surveillance of hospital-acquired infection had long been undertaken; government made it mandatory in April 2001 and launched initiatives to attempt to improve hospital hygiene and lower infection rates. By 2006 Clostridium difficile was rivalling MRSA as a cause of hospital acquired infection and death in hospital, and the Healthcare Commission publicised large outbreaks at the Maidstone Tunbridge Wells Trust, whose chief executive resigned.
Until the 1980s a steady stream of new antibacterials had become available. The 1980s saw little new investment in them, but the continuing emergence of resistant strains established the need and three approaches were followed, the modification of existing agents, genomic approaches and vaccine development. Agents such as the fluoroquinolones, active against anaerobes and streptococci, began to appear. In January 2001 Zyvox, (Linezolid), a synthetic antibiotic of the oxazolidinone class used for the treatment of serious infections caused by multi-resistant organisms including MRSA, was approved for hospital use. With a multiplicity of antibiotics, and ever increasing microbial resistance, accurate information on antibiotics and their proper use became essential. A free peer-reviewed database was provided on the Internet by Johns Hopkins, Baltimore.
Annual notifications of tuberculosis in England were steady at roughly 6,000 although the number in London was rising steadily. Around seven out of every ten people with TB came from an ethnic minority group, and two-thirds of people with TB were born abroad. Six percent were multi-drug resistant. Tuberculosis was an increasing global problem because of the breakdown in health services in parts of the developing world, the spread of HIV infection and the emergence of multi-drug resistant tuberculosis (resistance to two key first line drugs, rifampicin and isoniazid.) Extensively drug resistant tuberculosis (XDR) where there was resistance to at least three of the six classes of second-line agents was almost untreatable and the first British case (in a Somali) was admitted to a Scottish hospital in 2008. In 2001 an outbreak in a Leicester school, though contained, demonstrated the need to maintain an effective tuberculosis services and to be aware of the global problems presented by the disease. Bovine tuberculosis remained a hazard and there were pressures to cull the badger population.
Britain's biggest outbreak of Legionnaire's disease occurred in July and August 2002 in Barrow-in-Furness, when a cloud of infected steam from an inadequately maintained air-conditioning unit passed over the town centre. There were 7 deaths and a total of 179 cases.
In February 2003 an unusual form of pneumonia was recognised, severe acute respiratory syndrome (SARS). It was responsible for the first pandemic of the 21st century. Initially of unknown origin, it was soon found to be due to a new coronavirus. Within months after its emergence in Guangdong Province in mainland China, it had affected more than 8000 patients and caused 774 deaths in 26 countries on five continents. It illustrated the potential of air travel and globalization for the dissemination of a new infectious disease and the need for a coordinated global response to contain such disease threats.
Food born infection continued to cause concern. A survey of 70 general practices produced an estimate of 9 million cases annually, most of which were never seen by a GP. Campylobacter was the most common bacterial isolate, but in the majority of cases, none of the main food poisoning organisms was identified. Milk born coliform infection in Cumbria received national attention. In 2002 Norwalk-like virus gastroenteritis affected a number of large cruise ships.
Until 2002 the UK had the luxury of being free from rabies. That year the first case of indigenously acquired rabies occurred in over 100 years. A naturalist and bat handler died from European bat rabies, since when infection has been verified in bats in various parts of England. People bitten or scratched by a bat now had a small risk of developing. rabies.
AIDS and sexually transmitted diseases
Internationally AIDS deaths reached record levels. In 2007 it was estimated that 33 million people were living with AIDS/HIV and that 25 million had died. In the west, the introduction of highly active antiretroviral therapy transformed the prognosis, dramatically reducing infections and mortality. However in the USA while infections contracted homosexually had been stable from 1992-1996, and the death rate was falling, the rate of new infections doubled over the next four years. Because of drug therapy more people were healthy and people were less scared of unprotected sex. A tendency to complacency in the western world contrasted with the tragedies elsewhere. Of roughly 40 million cases, two thirds were in Africa, one fifth in Asia and China increasingly figured. In Thailand AIDS first affected homosexuals, then in turn drug users, prostitutes, their clients, the wives and girlfriends of the clients, and then the children of those women.
In 1999, it became policy in England to offer HIV testing to all pregnant women. It was in the inner cities, with their multi-racial populations, that the incidence of maternal infection was at its highest. In 2000 heterosexual sex became the leading cause of new infections in England. Since the epidemic began in the early 1980s, by 2007 about 18,000 deaths were known to have occurred. in the UK. In a tragedy that attracted little attention over 1,000 haemophiliacs contracted HIV from therapy, of whom 600 died. In 2007 there were an estimated 77,400 persons of all ages living with HIV in the UK, perhaps a third of whom were unaware of their infection. An estimated 7,734 were newly diagnosed with HIV in 2007; a third at a point after the point at which treatment had become desirable.
Two fifths of newly diagnosed persons probably acquired their infection in the UK, of whom approximately two thirds were men who had sex with men. Sixty percent of new cases were in London and a fifth of these were in Lambeth, Southwark and Lewisham, more than half of these in ethnic minority populations. The patients might be on student visas, seeking asylum, or less commonly seeking treatment not available in their own countries. Increasingly HIV was drug resistant, 27% of new cases in 2000, compared with 14% in 1994. (Adler M, BMJ 2003, 327: 62-3) There were only two approaches to the epidemic, preventing new HIV infections and anti-retroviral treatment for those needing it. In established HIV infection treatment included a combination of three potent anti-viral drugs, possibly four. In 2007 three new agents were developed for the management of drug resistant virus, two new classes of anti-HIV drugs - entry inhibitors and integrase inhibitors - and a second generation of non-nucleoside reverse transcriptase inhibitors (NNRTIs). There was new hope for patients in "deep salvage" who were resistant to currently available drugs. For the third world, new low cost drug regimes, administering zidovudine in pregnancy, offered a chance of reducing the infection of the fetus by the mother by some 80%; more intensive treatment from 28 weeks of pregnancy was even more successful. But though drug companies might offer special deals, funds were hard to find in the third world and "dismal" was a charitable way of describing the treatment-coverage rates in many countries. The problem was compounded by the unwillingness of some fundamentalist churches to talk about condom use.
Other sexually transmitted diseases
Cases of gonorrhoea in England and Wales rose from 16,470 in 1999 to 18,710 in 2007, with a peak of 25,000 in the middle of this period.. Over 40% of the cases were in London. Until 1998, the number of cases of infectious syphilis remained stable among both sexes in England, but then rose rapidly to 2,437 in 2008. Outbreaks were often localised, and might have different characteristics, for example predominantly among men sleeping with men, or commercial sex work and crack cocaine use. (See Excel worksheet for detailed figures)
Cases of chlamydia had been rising since 1993, partly as a result of improving awareness and diagnosis -. from 56991 in 1999 to 121986 in 2007. The highest incidence per 100,000 was in black ethnic groups. Chlamydia became the most common sexually transmitted infection seen in clinics While it could later lead to pelvic inflammatory disease it frequently passed undiagnosed, and the numbers might have been far higher. Following pilot trials in which approximately 1 in 10 women using sexual health services were found to be infected, a national chlamydia screening programme for women aged 16-24 began in 2003, coordinated by the Health Protection Agency and a programme of immunisation against human papilloma virus began.
The Labour government established a judicial review of the handling of BSE, chaired by Lord Phillips, which reported in October 2000. Twenty eight Ministers, civil servants and scientists were criticized in the Report. A culture of inter-departmental dispute between the Ministry of Agriculture and the Department of Health, and unnecessary secrecy, was exposed. The public assurances of safety, given at the most senior level, had been flawed at the time they were given. The then Chief Veterinary Officer Keith Meldrum and the Chief Medical Officer, Sir Donald Acheson, were accused of glossing over potential health risks. ‘Safe’ seemed to mean different things to the public and to government officials. A government compensation scheme was introduced.
There were continuing cases of new variant Creutzfeldt-Jakob disease (vCJD), 10 in 1996, 10 in 1997, 18 in 1998, 15 in 1999, 28 in 2000 and by November 2007 a total of 166 confirmed and probable cases throughout the UK with 162 deaths had been reported. The numbers were beginning to decline. Though infection in cattle was most marked in the UK, it was also reported in France and Germany, and human vCJD was found in France.
Molecular strain typing and transmission studies confirmed that vCJD and cattle BSE were caused by the same prion strain. A cluster of five cases in a single small village, Queniborough, provided useful information. All patients had lived in the village between 1980 and 1991, and died between 1998 and 2000, providing some indication of the incubation period in their cases.
To begin with nobody knew if vCJD was transmitted by blood products but in 1998 it was decided not to use UK blood plasma, and instead to import this from the US. Whole blood was also treated to remove white blood cells. Of those known to have vCJD at least nine had been blood donors so there was a small risk of infection from transfused blood. In December 2003 a case of vCJD was reported in a patient who had previously received blood from a donor incubating the disease and two more followed.. In April 2004 people who had received blood transfusions were stopped from being blood donors. Blood donated by a small number of people who went on to develop vCJD was traced. Some had received direct one to one transfusion of whole blood and they were contacted and told about the risk that the might face. Plasma from the same donors used to manufacture products such as clotting agents was traced and recipients contacted. Some 6,000 people were involved.
Better methods of identification of infection in its earlier stages made population screening to determine the incidence of infection easier. A study of 12,500 specimens of tonsils and appendix showed 3 cases of the prion responsible for vCJD, suggesting that perhaps three thousand people carried the infection. Guidelines in 2001suggested that disposable surgical instruments should be used in operations such as appendicectomy and tonsillectomy but after operative difficulties followed their use they were withdrawn. (The issue of disposable instruments also arose in relation to sporadic Creutzfeld-Jacob disease, which regrettably killed notable surgeons including Donald Matson in Boston).
Compensation became available to people who had been infected with Hepatitis C from blood transfusions and developed liver cirrhosis, after the hazard was recognised but before the introduction of routine screening in April 1991 - lump sum payments of £20,000. John Reid extended this to cover a wider range of people infected as a result of being given blood products by the NHS. In October 2001 compensation was also offered to victims of vCJD and their families.
With professional committees advising the Department, Dr David Salisbury oversaw the programme for 20 years or more and was key to its success. In 2000-01 about 94.5% of children had been immunised against diphtheria, tetanus and polio by their second birthday, and about 94% of 2 year olds had been immunised against Haemophilus influenzae b, 94% against pertussis and 87% against measles, mumps and rubella (MMR). Over the previous ten years meningitis as a result of meningococcal infection had steadily increased. More cases were associated with septicaemia and more children and teenagers were dying. A newly emergent strain, meningococcal group C, was responsible for much of the increase and, in 1998/9, a new vaccine for this strain was introduced into the routine childhood programme and in 2002 for everybody under the age of 25. In 2001 there were 79 confirmed cases of meningitis C and three deaths compared with 551 cases and 47 deaths in 1999 before the vaccine was introduced. Routine infant immunisation against Haemophilus influenzae, introduced in 1992, also continued to prove successful. In 2001
a campaign to immunise travellers on the annual Hajj Muslim pilgrimage to Mecca, estimated at 50,000, dramatically cut the number of cases from 45 cases in 2000 to just 6 with no deaths. A specific vaccine incorporating the W135 strain prevalent in Saudi Arabia was used.
A paper by Andrew Wakefield and colleagues from the Royal Free Hospital, published in The Lancet (Lancet 1998, 351. 637-41 - retracted), suggested a linkage between the combined vaccine and some cases of autism. Though the scientific limitations of the paper were immediately apparent, the media took up the scare story and rates for Measles, Mumps and Rubella immunisation fell. Neither studies suggesting that the vaccine was safe nor government campaigns alleviated anxieties. There was a fall in uptake from 91% to below 80%. Outbreaks of measles followed, with 740 cases in 2006 and 971 in 2007 and the first deaths since 1992. In 2004 a Sunday Times journalist, Brian Deer, published an investigation into the paper, uncovering the possibility of research fraud, unethical treatment of children, and Wakefield’s conflict of interest from involvement in a law suit against manufacturers. The GMC launched
an investigation which resulted in Wakefield being struck off. The Lancet retracted the paper in 2010 and subsequently Deer unearthed clear evidence of falsification. Clinical records could not be fully reconciled with descriptions, diagnoses or case findings published in the journal.
Late in the day, the media changed sides and supported immunisation. Children had suffered, and energy and money had been diverted from efforts to understand the real causes of autism.
Other anxieties were raised about the mercury content of some vaccines. In 2002 a vaccine against chickenpox became available, but where it would fit in to the normal programme of vaccination was not decided.
In August 2004 the routine programme for children was modified, and a single vaccine against five diseases was introduced., diphtheria (D), tetanus (T), pertussis (a new acellular whooping cough vaccine),
and because of the risk, one in a million, of live vaccine reverting back to the
wild type, inactivated polio vaccine replaced live oral vaccine), plus Hib – (haemophilus influenzae type b).
In 2006 a vaccine for pneumococcus was introduced into the childhood programme.
The 2008 schedule for children (source DH website)
When to immunise
Diseases protected against
Two months old
Diphtheria, tetanus, pertussis (whooping
cough), polio and Haemophilus influenzae type b (Hib)
+ Pneumococcal conjugate vaccine, (PCV)
Three months old
Diphtheria, tetanus, pertussis, polio and
Haemophilus influenzae type b (Hib)
Four months old
Diphtheria, tetanus, pertussis, polio and
Haemophilus influenzae type b (Hib)
+ MenC + PCV
Around 12 months
Haemophilus influenza type b (Hib)
Around 13 months old
Measles, mumps and rubella
Three years and
four months or
Diphtheria, tetanus, pertussis and polio
Measles, mumps and rubella
DTaP/IPV or dTaP/IPV
Thirteen to eighteen
Diphtheria, tetanus, polio
Complementary, or alternative, medicine remained in public demand. The common factor seemed to be the time and patience of practitioners, commodities in short supply in the NHS. The Prince of Wales, like many of the Royal family, was a longstanding advocate for these therapies, or at least for research into their effectiveness. In November 2000 the House of Lords Select Committee on Science and Technology, chaired by Lord Walton, reported that there was scant evidence that alternative remedies worked. Yet the public spent £1.6 billion annually and 50,000 practitioners were treating some 5 million patients. Only for osteopathy, chiropractic and acupuncture was there limited evidence of efficacy. The report commended some aspects of herbal medicine as a large number of effective drugs are of herbal origin, but there was no convincing evidence to support homeopathy which stuck out as being on more than a placebo. Complementary measures such as the use of massage and aromatherapy gave some comfort to patients with terminal illnesses, even though this had no effect upon the progress of the disease. The subcommittee was particularly concerned about dangerous and inaccurate information that appeared in some media articles and on internet. Better regulation of practitioners, and control of misleading product labelling, were needed. In December 2001 the Department of Health expressed a willingness to consider the provision of some forms of complementary medicine within the NHS, subject to evidence of its effectiveness. Almost certainly such evidence would be a long time coming. How, in any case, could one regulate and examine people in an ever changing and expanding number of alleged disciplines, most of which had the scientific background of snake-oil salesmen? In 2004 the Department of Health provided £900,000 to The Prince of Wales’s Foundation for Integrated Health to support its work in developing "robust systems of regulation for the main complementary healthcare professions" . The foundation published a guide online to help people understand the main alternative therapies available. The guide avoided the obvious question, "does it work?" In 2006 the Prince of Wales addressed the WHO, urging delegates to embrace alternative therapies in the fight against serious disease. Leading doctors spoke out against his campaign, and a group wrote to the chief executives of all acute and primary care trusts, urging them to stop paying for unproven or disproved alternative medicine at the expense of more conventional treatments.(HSJ 25 May 2006)
Genetics offered the possibility of early identification of people likely to become ill, perhaps from vascular disease and diabetes, because some disorders are preceded by a prolonged presymptomatic period. This opened the possibility of preventing disease, instead of diagnosing it at a later stage. Genetics also provided an insight into the cause of many diseases at a molecular level, understanding its mechanism. rather than just describing it. Diseases previously thought of as one could be separated into categories with a different origin - and therefore treatment. A computer algorithm designed to seek out those breast tumours that had the most similar genetic profiles and cluster them together, revealed that 98 cancers fell into two main groups that could be recognised on the basis of the activity of 70 genes. A woman with a “poor” 70-gene signature would be 15 times more likely to suffer a recurrence within five years than a woman who had a “good” genetic signature and who might possibly be spared aggressive chemotherapy with all its side effects. The possibility existed of developing smart drugs with an appropriate therapeutic action. Genetics provided the pharmaceutical industry with a wealth of new targets against which to design drugs; suddenly the industry went from famine to feast and trials of gene therapy in a number of single gene diseases were underway.
The Human Genetics Commission (HGC) was created in 1999 to provide the Government with advice on genetics and the wider social and ethical issues involved in the use of genetic data in insurance. The Commission's concerns that the results of genetic tests might be used by insurance companies to the detriment of the population were examined by the Department of Health's Genetics and Insurance Committee (GAIC). In October 2000 the committee agreed that to allow insurers in the UK to use genetic test results for assessing the risk of Huntington's disease. The Gene Therapy Advisory Committee (GTAC) was also established to advise on the ethical acceptability of proposals for gene therapy research on humans and on developments in gene therapy research.
Academic centres evolved into regional centres serving populations of 2 - 6 million with "hub and spoke" systems to clinics in district hospitals. They provided access to the latest developments, clinical diagnosis, laboratory (DNA and chromosomal) diagnosis, genetic counselling and the care of extended families long term. In 2001 Alan Milburn allocated £30 million to genetic services and in 2003 the White Paper Our inheritance, our future - realising the potential of genetics in the NHS painted a vision of a future health service offering personalised care based upon a person's genetic profile. Awareness that demand for services might exceed resources led to the establishment by the Department of Health of the Genetics Commissioning Advisory Group, to develop ways to evaluate and set priorities for genetic technologies within the NHS. Two 'National Reference Laboratories' to help the NHS keep abreast of new genetic testing methods and discoveries, were formed in Manchester and Salisbury in 2002.
The lengthy hunt for the structure of the human genome accelerated as commercial interests united with the international programme led by the American National Institutes of Health. A draft structure for the entire genome was announced in June 2000 and the virtually complete mapping of the human genome was completed in April 2003.
The development of pre-implantation genetic diagnosis (PGD) could ensure that a newly conceived embryo was not a carrier of some genetically determined diseases. In 2004, the Human Fertilisation and Embryology Authority (HFEA) agreed to the use of PGD for assessing the risk of familial adenomatous polyposis. By 2006, in the USA, with a credit card and a few clicks of their computer mouse, consumers could organise a test for the BRCA1 or BRCA2 gene mutation or any of hundreds of other diagnostic assays, with or without involving their physician. Direct-to-consumer marketing of genetic testing and other laboratory services had arrived.
Advances in surgery have partly depended on the steady advance of anaesthesia. Better drugs and better equipment have improved the speed of recovery and made the surgeon's task easier. BMJ 1999;319:557-560 Since 1948 the simple Boyle's machine carrying cylinders of nitrous oxide, oxygen and often cyclopropane, with its lever controlled vaporisers for ether, had been replaced by more complex equipment with calibrated vaporisers coupled to central gas supplies. Chloroform and ether were superseded by halothane, enflurane and sevoflurane. Intravenous barbiturates such as thiopentone have given way to short action drugs such as propofol (1986) with a significantly lower incidence of nausea and vomiting, and post operative drowsiness. Endotracheal intubation was largely replaced by the laryngeal mask airway. Neuromuscular blockade with curare or suxamethonium made possible light levels of anaesthesia and rapid recovery. Local and regional anaesthetic techniques improved with the introduction of more reliable drugs. Monitoring of inspired and expired gasses is easily available and blood oxygen levels were routinely monitored.
Better anaesthesia, minimally invasive techniques, optimal pain control and aggressive postoperative rehabilitation, were reducing the patients' responses to stress, shortening the recovery time. As a result earlier discharge was possible and fast track surgical units extended the longstanding achievements of day surgery. Operations such as splenectomy, vaginal hysterectomy and mastectomy were becoming possible on a day or 24 hour stay basis. Purpose-designed fast-track surgical units were appearing and these were seen as one way to reduce lengthy waiting lists for treatment. Minimally invasive surgery was facilitated by improvements in miniature video cameras producing good images so the operator and the assistant could work together. Virtual reality simulators became available for training. Laparoscopic cholecystectomy was becoming the technique of choice.
New surgical procedures, unlike new drugs that were subjected to clinical trial before licensing, might be developed anywhere in the world and introduced by a surgeon locally without much in the way of formality. Indeed, many operations - for example those on the heart - would never have been developed if the high mortality among the earlier cases had been considered as it would have been for a drug. Operative procedures were now considered by the National Institute for Clinical Excellence (NICE). Twenty years previously minimal access surgery had been hailed as a major advance, saving the patient pain and reducing the length of admission. Subsequent reassessment revealed the complication rate of such operations while the techniques of open operations were improving, as in the case of inguinal hernia. NICE reviewed minimal access surgery for hernia which accounted for 100,000 cases each year. It recommended in January 2001 that people with first time inguinal hernias should have ordinary (open) surgery rather than a minimal access procedure. For the repair of hernias that reoccurred or were on both sides minimal access surgery should be considered, a totally extraperitoneal procedure, which did not involve opening the peritoneum, was preferable. The open procedure was, in general, cheaper. Such centrally formulated guidelines were increasingly affecting the decisions of surgeons.
Virtual reality/robotic surgery
Developed in the eighties and nineties, virtual reality and robotics were coming to fruition. The United States Department of Defence had developed telepresence surgery to meet battlefield demands and an increasing number of systems became available, Aesop and Zeus. The da Vinci® Surgical System evolved from these efforts. A main ambition was to apply it to heart surgery; but in the event the primary use became radical excision of the prostate, sparing the nerves on which urination and potency depended. This proved a profitable use and the number of centres providing robotic surgery in the USA mushroomed. In 1999 Intuitive Surgical introduced the da Vinci system, the first commercial equipment, increasingly applied to many conditions. The surgeon sits at a computer console, views a three-dimensional virtual operative field, and performs the operation by controlling robotic arms that hold the stereoscopic video telescope and surgical instruments that simulate hand motions with seven degrees of freedom. Instruments permitted smaller incisions and tremor free operating. The three-dimensional imaging and hand like motions of the system facilitated advanced minimally invasive thoracic, cardiac, and abdominal procedures. "Master-slave" robotic procedures were also used for minimally invasive coronary artery bypass grafting and laparoscopic surgery. Neurosurgeons also were using image guided surgery and augmented reality
The next generation of instruments was likely to use the surgeon's eye movements to link instruments to the area being handled, improving visualisation, flexibility of instruments and their sensation.
Military medicine and trauma
War is an efficient schoolmaster, said a US surgeon general. The conflicts in Iraq and Afghanistan led to major advances in trauma care. Injured soldiers obtained a level of care of which the normal NHS patient could only dream. A military wing at the NHS hospital Selly Oak, Birmingham, took injuries but consultant care was now available in the frontline. - "we are projecting the emergency department forward into the helicopter." An engineered process from early transfusion at the beginning of the chain, to the weekly clinical audit sessions in Birmingham, led to better survival, including many with the gravest injuries who at any other time in history would have died.
Improved understanding of the way in which the body responded to major trauma and severe multiple injuries led to the introduction of new methods of managing them. Sometimes it appeared best to intervene less in the immediate phase after injury. Rapid restoration of fluid volume and blood pressure might lead to further catastrophic bleeding; hypothermia could sometimes protect from brain and tissue damage. New drugs were introduced to reduce the likelihood of multiple organ failure in the weeks after injury. Increasing numbers of gunshot injuries in London and other big cities, often related to illegal drugs, sent trauma surgeons in search of the training available in countries with longer experience in this field.
Emergency care had to become more sophisticated. Changes in general practice out of hour arrangements and the increasing role of NHS Direct made it important to review accident and emergency departments and they became first in line for reconfiguration as the pattern of hospital organisation was seen to require changes. The early doubts about helicopter ambulance services had now been stilled and most areas had a scheme, often funded on a voluntary basis. Professor Sir George Alberti, National Director for Emergency Access (2002), and previously President of the Royal College of Physicians, oversaw a review of Accident and Emergency Services. Sir George had been on the Modernisation Board, and was involved in service reviews in outer southeast London, and Stoke on Trent. A target was established and achieved for the percentage of patients seen within 4 hours and systems were reviewed to try to reduce the time taken by each stage of a patient's visit. For example "see and treat" was encouraged, a senior doctor or emergency nurse practitioner being the first to review each arrival.
Urgent care, as opposed to emergency care, involved patients who needed an operation within a day or two, though not necessarily immediately. The higher mortality among people operated on at night and weekends by junior staff led to a new approach, consultant assessment day or night, and a decision about whether surgery was better delayed until normal working hours.
Trauma and orthopaedics
Trauma and orthopaedics looked set for advance as a result of new materials, computer aided manufacturing technology and molecular biology. The improvement of imaging had a substantial impact on orthopaedic practice. Musculo-skeletal imaging, for example of the knee joint, made greater accuracy possible in the assessment of suspected cartilage and ligament injuries, often substantially altering treatment.
Roughly 50,000 hip arthroplasties were performed annually, mainly for osteoarthritis. Younger patients, leading an active life, were likely to wear out the replacement hip, and NICE suggested that they should be considered for a metal-on-metal resurfacing arthroplasty, in which the femoral head and the joint were both fitted with new metal wearing surfaces. In the USA minimally invasive hip arthroplasty was introduced, using a 3" incision and specially lit instruments, reducing pain, the time spent in hospital, and the speed of recovery. While in the seventies and early eighties knee replacement was widely considered a poor operation, by the nineties the basic principals of successful surgery had evolved. The joint would be re-surfaced, reproducing the normal anatomy with a low friction joint, the remaining ligaments providing stability. Some 35.000 operations were now performed per year, with about a 90% success at ten years.
Femoral fractures in children had traditionally been treated with traction and hospital stays of 4-12 weeks. A new technique, flexible nailing of the femur, developed in Switzerland, allowed early mobilisation. Flexible nails produced from new metal alloys were small enough to fit the intramedullary canal in children but were also able to maintain their shape after contouring and were strong enough to provide stable fixation. They were inserted through a 5 mm skin incision. The length of time spent in hospital was reduced allowing earlier weight bearing, movement, and return to school, in addition to fewer complications. The nails were removed after the fracture had healed.
Many injuries, including sporting injuries, damaged articular cartilage which had poor potential for repair. Damage might lead to arthritis many years after injury. Transplantation of hyaline cartilage had been used for a number of years, but there are few sites where donor articular cartilage could be harvested without damaging the joint. So only small defects can be treated with this method. However, a new patented technique, autologous chondrocyte transplantation, allowed small amounts of hyaline cartilage to be harvested, the chondrocytes extracted and the cell population increased in tissue culture. The number of cells increases by about 15 times over four weeks. These cells could then be reimplanted beneath a periosteal patch which is sutured over the articular defect.
Cosmetic surgery was a growth industry and in some circles an obsession. Both in the UK and the US the demand was growing rapidly. In 2001, over 13,400 patients were registered as having had a breast implant. The most common reason was cosmetic augmentation (77%). The NHS was not providing much of a service in this field and therefore little training for young surgeons. The private sector mushroomed. Professionally, who should be regarded as qualified and competent to carry out plastic surgery, for some were clearly lacking appropriate skills? In 2005 the Healthcare Commission, with the support of the Department of Health, took action to regulate and monitor those providing such services. The use of botulinum toxin (botox) to reduce wrinkles was popular. In the US it was approved by the Food and Drugs Administration for the removal of wrinkles and Botox parties were commonplace. In the UK Boots planned to provide facilities in some of its larger stores. Collagen fillers were widely used and sugar molecule injections looked set to become the next hot cosmetic item.
Around 25% of adults in England are now considered obese, with a BMI of 30 or greater. Obesity is a global problem and based on surgical techniques originating in the 1950s, 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) developed considerably, and increased in popularity in recent years worldwide..In 2002 NICE published guidelines recommending surgery. From 2000-2008 it increased exponentially in England. Gastric banding and gastric bypass were the commonest procedures, the mortality being about 0.8%. Increasingly laparoscopic procedures were used. The results were best when it was concentrated into specialist units. It was effective in leading to weight reduction in most people and reduced the risk of obesity related illnesses.
Diagnosis was increasingly aided by developments in imaging and non-invasive techniques. Magnetic resonance imaging could assess heart function, mass and volume, and detect heart infarction. Ultrasound could assess heart function. Contrast media, in association with MRI, could demonstrate infarcts. Ultra fast CT scanning for coronary artery calcium might indicate an increased risk of a heart attack. There was a clearer understanding of the pathology of coronary arterial plaques. Better blood tests such as the measurement of plasma myeloperoxidase made it easier to predict risk of myocardial infarction.
A National Service Framework for Coronary Heart Disease was introduced in 2000 and outlined good practice, smoking cessation clinics, rapid access to chest pain clinics, rapid thrombolytic treatment, shorter delays for assessment and treatment, more effective use of aspirin, beta blockers and statins after a heart attack and more coronary artery surgery. Guidelines for preventing disease, for example by blood pressure reduction, were refined. Death from ruptured aortic aneurysm, some 6000 per year, was shown to be reducible by ultrasound population screening. Estimation of cardiovascular risk became the starting point of therapy, using risk tables covering age, sex, blood pressure, smoking and cholesterol status, and conditions such as diabetes. It was recognised that unstable and acute coronary disease could be due to a vulnerable plaque, which might not tightly narrow a coronary artery but could be affected by various risk factors. Acute coronary syndrome, which could proceed to a heart attack, might be treated by early administration of a glycoprotein inhibitor. There was often dramatic improvement from the use of anti-platelet and thrombolytic agents in the treatment of coronary disease Action could be taken to reduce the risk of clot formation associated with common cardiovascular disorders such as atrial fibrillation and heart failure, various cancers and after orthopaedic surgery. . Wald & Law suggested that heart disease and stroke could be reduced substantially by giving, on a population wide basis, e.g. to those over 55 years, a "polypill" that would reduce low density lipoprotein, cholesterol, platelet function and blood pressure. Possible constituents might be aspirin, a statin, a ß blocker, a thiazide, an ACE inhibitor, an angiotensin II receptor antagonist and folic acid. Other analyses suggested that long term low dose aspirin could reduce the incidence of cancer.
The prognosis of congestive heart failure was improved by the use of ACE inhibitors. Guidelines suggested that high blood pressure, a major contributor to heart disease and stroke, was best treated with a combination of drugs. A new class of drug, vasopeptidase inhibitors, were shown to be at least if not more effective in the treatment of high blood pressure, cardiovascular and ischaemic heart disease, than the existing ACE inhibitors. The evidence of benefit to patients with high blood cholesterol levels and atherosclerotic disease from the use of cholesterol lowering drugs, e.g.statins, had been clear since the mid 1990s. Yet although they were easy to take, effective and comparatively free from side effects, they remained under-used. Less than a third of patients who had a history of coronary artery disease or stroke received lipid lowering treatment. In 2003 some statins were made available over the counter.
Manual defibrillators had long been available but required training, e.g. interpretation of electrocardiograms, restricting prompt treatment. In adults the commonest primary arrhythmia at the onset of cardiac arrest is ventricular fibrillation or pulseless ventricular tachycardia. Survival is crucially dependent on minimising the delay before providing a counter shock. Ambulances seldom respond rapidly enough to provide defibrillation within the desirable eight minutes. This led to ways of automating defibrillation so they could be used by those untrained. (Liddle R et al. BMJ 2003;327:1216-1218) Automated external defibrillators (AEDs) that talked the attendant through the process began to make their appearance in public places. They proved highly effective in public settings where there were designated rescuers (e.g. flight attendants or security guards) or a large number of bystanders were immediately available. Used within first two minutes after collapse they improved outcome over traditional methods. In 2002 AEDs went on public sale in the USA, with FDA approval, for about $2500. In 2004 they became available without prescription and in the UK a range
Coronary artery surgery
Early in the decade in some areas of the USA ambulances were routed past hospitals towards cardiac centres equipped to perform surgery and angioplasty 24 hours a day. By 2006 this became routine in many British centres as well. The two main procedures for opening up blocked coronary arteries, balloon angioplasty and open heart surgery were rivals. Coronary artery bypass grafting (CABG) was more invasive, requiring lengthy rehabilitation. However new techniques allowed bypass grafting on the heart while beating, reducing the morbidity associated with the pump and induced cardiac arrest.
Percutaneous coronary angioplasty (PTCA) usually required one or two days in hospital, and patients could expect to be back at work within a week. Primary angioplasty could be used in the early stages of a heart attack and seemed to improve patient outcome. First undertaken in 1977, the procedure was now regularly undertaken throughout the country. Restenosis initially occurred in over 30% of patients but with advances in stent design and improved techniques for implanting them the rates came down to 10% - 20%. This is comparable to the 10% of vein grafts that are lost in the year after bypass grafting. Newer stents were made of metal coated with a cytostatic agent such as sirolimus or paclitaxel. These agents were released slowly and locally to reduce proliferation of smooth muscle and might reduce arterial restenosis. Grech ED, BMJ2003; 326:1080-2. As the decade ended the long term advantages of the two procedures remained a matter of debate but the demand for cardiac surgery was shrinking. However the NHS was increasingly organised to provide angioplasty as an emergency procedure round the clock. In 2006 in London 6 centres were nominated across the capital to which ambulances went directly, the paramedics having identified the patient as having had a heart attack.
Artificial heart systems had been developed in the early 1980s and had been used in the US and Europe, though only occasionally in the UK. As well as total heart replacements with a high stroke volume, left ventricular assist devices (LVADs) with small electrically powered pumps, provided a lesser stroke volume and pulsating blood flow that could be used to support the patient's own heart and give it time to recover. The larger total replacements were used as a bridge before heart transplantation,
Some drugs used to treat disturbances of heart rhythm could themselves have dangerous effects. Implantable cardiac defibrillators were used to treat ventricular arrhythmia; automatic cardioverter defibrillators could be life-saving and promising new developments took place in pacing technology. Particularly in younger patients this improved substantially as did the introduction of catheter ablation, the accurate destruction of an area of the heart responsible for the disturbance of rhythm, through a catheter within the heart. Multiple leads could be inserted to synchronize contractions of the different chambers of the heart and improve heart output.
Deep vein thrombosis, for long recognised as a hazard of bed rest, came to public attention following the death of a young passenger flying from Australia. Studies showed that perhaps one in a hundred passengers flying long haul developed thrombosis, asymptomatic. Lancet 2003; 362: 2039-44 It seemed associated with lengthy flights, alcohol consumption and failure to move about the cabin.
The results from organ transplantation steadily improved with advances in immunosuppressive therapy. From the early 1980s onwards drugs such as cyclosporin and tacrolimus had made modern transplantation care possible. Mycophenolate mofetil (MMF) reduced the risk of acute rejection and monoclonal antibodies were also increasingly used. In 1969 less than half those transplanted survived a year. Now 95% had a functional kidney after a year and most would probably work for 20 years.
Some 3,000 new cases needed a transplant annually, and some 3,000 were transplanted. However there were 8,000 on the waiting list and roughly three people died daily waiting for transplantation. Some centres began to retrieve organs from non-heart beating donors as well as conventional brain dead donors. In the USA patients were increasingly urged to look for a live donor among their friends and
relatives where a kidney or part of the liver might be given. Transplant survival was better and the wait for transplantation shorter. As a result of the increased use of seat belts and the better treatment of subarachnoid haemorrhage and strokes the number of organs available for transplantation fell throughout the decade. Donors had to be "fit but dead" and most potential donors were to be found in critical care units - perhaps only 2,500 people a year were suitable. In 1999 the BMA voted in favour of an ‘opt-out’ system so that the organs of those dying were automatically available unless there was a written statement to the contrary. Transplant surgeons, however, preferred the existing 'opt-in’ approach, fearing public reaction to a more radical policy. Under pressure, in 2006 Ministers established the UK-wide Organ Donation Taskforce, chaired by Elisabeth Buggins, to identify barriers to organ donation and make recommendations. Reporting in 2008, Organs for Transplants, the Taskforce looked at the pathway from potential donor death to transplantation and the obstructions. Its recommendations aimed to make an unusual procedure usual, and to encourage location action to solve a national problem. It sought a National Donation Organisation within NHS Blood & Transplant.(NHSBT) which was established as a Special Health Authority in October 2005.. It suggested appointing 100 additional transplant coordinators to increase donation, removing financial disincentives from hospitals whose own patients would not in fact benefit, Trust Donation Committees to encourage local action, and pursuing the possibility of an opt-out system . However the arguments against this, consent could never truly be "presumed", its legality under human rights legislation, the difficulty of ensuring everyone knew that an opt-out right existed, and the absence of evidence that countries with an opt-out system did better, led to this approach being discouraged. Live donor transplants provided some organs, but the risks to the donor were not insignificant, particularly in the case of the liver.
Heart transplantation survival rates improved over the decade especially in the first year after the transplant. About 88 percent of patients survive the first year after transplant surgery, and 72 percent survive for 5 years. The 10-year survival rate is close to 50 percent, and 16 percent of heart transplant patients survive 20 years. Yet since 1995 there had been a significant fall in the number of patients receiving new hearts, lungs, or heart and lungs through transplantation. In 2000 265 patients in the UK were treated and there were six heart and lung transplant centres in England (Birmingham, Cambridge, London, Manchester, Newcastle and Sheffield). The need to ensure that centres undertook enough operations to maintain expertise was appreciated, and a National Specialist Commissioning Advisory Group took on responsibilities for commissioning heart and lung transplants for both adult and children.
The techniques necessary for the re-attachment of limbs had already been developed and in 1998 the first hand transplant was carried out in France, a second – more successful – was undertaken the following year in the USA. The first face transplant was also undertaken in France in 2005.
Stem cell transplantation was revolutionizing the outcome of a range of malignant and non malignant blood disorders, including immunological diseases. Stem cells could be obtained from blood, bone marrow and umbilical cord blood. Cord blood banks were established in London, Bristol, Belfast and Newcastle to collect, preserve and type blood products, and to test for viral contamination.
Many new drugs were being introduced for epilepsy, not all of which appeared to be better tolerated or more effective. For temporal lobe epilepsy, surgery emerged as the most effective treatment. Costly drugs, which only had a slight effect on diseases otherwise difficult to treat, were a particular problem for neurologists, for example the interferons in multiple sclerosis and drugs in dementia.
Some rare neurological diseases had long been known to have a genetic cause; now gene mutations were discovered that increased the risk of developing a common one, Alzheimer’s disease. As in other fields of medicine, there was hope that the identification of causal factors at a molecular level would open the way to treatment that would influence the course of the disease. As brain cells did not appear to regenerate, it would be important to develop an early diagnostic system, so that treatment, when available, could begin as soon as possible. The newer systems of imaging, for example positron emission tomography (PET), sometimes gave indications of how a neurological disease was developing, and how brain function was affected. National strategy, however, was mainly aimed at earlier diagnosis.
Advances in neurosurgery were driven by technology. Frameless stereotaxy linked information from CAT or MRI scans, through computer linkages to sensors that could ‘know’ where the skull was. Magnetic resonance imaging could be used to display blood vessels including the carotid arteries. Stereotaxic systems helped the surgeon to navigate safely through high-risk areas of the skull and brain, knowing exactly where the surgical instruments were. Interventional magnetic resonance imaging provided another possibility, with enough space within the scanner for the patient to move and for some neurosurgical procedures to be carried out
Stroke is one of the commonest causes of admission. The outlook was improved by very early thrombolytic therapy if intracranial bleeding could be ruled out by an immediate CAT scan. The outcome in the UK was poorer than most European countries, where rapid assessment by specialised centres was more common. Most district general hospitals did not have a 24 hour on call neurological and scanning service. A National Stroke Strategy, stressing the need for immediate admission of those with strokes or transient ischaemic attacks (TIA) to a unit that could provide brain imaging on arrival, 24 hours a day, was published in 2007. People had to recognise early signs of a stroke which needed to be treated as a medical emergency. The development of stroke care networks and redesign of services across networks to ensure appropriate urgent care became a priority - some SHAs for example Oxford, Newcastle and London responded rapidly.
Progress in ophthalmology was steady. Foldable intraoccular lenses could be inserted through a small self-sealing incision. Better drugs became available for local treatment of glaucoma and endoscopic laser techniques also helped in its treatment.
A new treatment became available for age-related macular degeneration, a common cause of blindness. This involved monoclonal antibodies, anti-VEGF therapies (vascular endothelial growth factor), a sub-family of growth factors. These included bevacizumab (Avastin), antibody derivatives such as ranibizumab (Lucentis), or orally-available small molecules that inhibit the tyrosine kinases stimulated by VEGF : sunitinib (Sutent), sorafenib (Nexavar), axitinib, and pazopanib. NICE reviewed the evidence for their efficacy and agreed that they should be used.
World-wide, the occurrence of cancer steadily increased - populations were often older and other causes of mortality were being attacked. Many cancers were related to diet, but precisely to what dietary habits in different countries was unclear. Infections, for example Hepatitis B and Helicobacter, were also responsible. Genetic factors were being discovered. Some families had a very high incidence of particular cancers and specific gene faults could be identified. Survival from cancer in the UK was lower than in many European countries and the USA. The United Kingdom used chemotherapy less, access to diagnostic services and staffing levels were poorer, there were fewer oncologists and 40% of cancer patients never saw one. A major problem was undetected spread at the time of first treatment and the difficulty of reducing the delay from referral or diagnosis to first treatment, particularly in radiotherapy. Government, through a National Cancer Plan (NSF) (2000) aimed to improve coverage, staffing levels and service organisation.
Cancer networks were established and effort went into re-engineering the clinical pathways. Government pledged that patients with suspected cancer would be seen within two weeks of referral by a GP. However reports from the National Confidential Enquiry into Perioperative Deaths (November 2001), the Commission for Health Improvement and the Audit Commission found that standards of care were variable and too few patients, particularly when admitted as an emergency, saw a cancer specialist. The report by Calman & Hine was in many places far from implementation. In 2007 a new plan, the NHS Cancer Reform Strategy, was launched. Key elements included focus on prevention, spending more on radiotherapy equipment, faster treatment, extended screening, fast-track drug approval and extended services for the increasing numbers of people surviving cancer.
Slow improvement was taking place, particularly for cancer of the breast, colorectal cancer, non-Hodgkin's lymphoma and leukaemias. For men in early middle age the prevalence of smoking had halved between 1950 and 1990 and the death rate for lung cancer at ages 35-54 fell even more rapidly. However women and older men who were smokers in 1990 had higher rates than in 1950. In 2000, the deaths of women from cancer of the lung exceeded those from cancer of the breast for the first time. The survival of women diagnosed with breast cancer was improving and the age band for breast screening was increased. Deaths in England and Wales fell 21 percent between 1990-1998 because of screening, earlier diagnosis, better treatment, including the addition of chemotherapy and hormonal treatment, e.g. Tamoxifen. It was hard to separate the effects of screening and adjuvant chemotherapy as both had been introduced at the same time. The diagnosis of cancer of the breast was an area in which errors were regularly made.
Surgical treatment for cancer improved and was increasingly conservative, retaining organs and structures where possible. Radiotherapy centres were increasingly well equipped and tomographic treatment machines gave a more accurate dosage. Linear Accelerators and "multi-leaf" collimators allowed radiation doses to be delivered to the precise shape of the tumour and helped to reduce the volume of treatment irradiated, sparing normal tissue around the cancer. Precision therapy greatly increased staffing requirement and there was a shortage of radiographers. A new advance in radiotherapy, CHART - Continuous Hyperfractionated Accelerated Radiotherapy (CHART) was introduced. Radiotherapy was given for 12 successive days, including weekends, 3 times each day, with a 6-hour gap between treatments. The total dose was higher, and there might be side effects, but in lung cancer treatment the "cure" rate seemed better. Further ahead was the possibility of charged particle beam therapy consisting of protons or carbon ions produced in a synchrotron or cyclotron, the first facility being at Clatterbridge (Wirral). Bone marrow transplantation remained central for some cancers, and the cure rate of acute leukemia in children improved.
Pharmaceutical research moved from the search for new cytotoxics to drugs acting on defined molecular mechanisms. There was an explosion of information about the molecular biology of cancer, but the dramatic successes achieved in some rarer cancers were not repeated in the commoner ones, breast, lung or colon. Controlled trials improved the results of chemotherapy as new agents were introduced, as for example in colorectal cancer and cancer of the breast (anastrozole and letrozole). In hormone-dependent breast cancer, five years of postoperative tamoxifen therapy prolonged disease-free and overall survival. The aromatase inhibitor exemestane, by suppressing estrogen production, was found to improve the outcome after two or three years tamoxifen therapy.
Some of the newer drugs were used mainly to extend the survival of people with terminal cancer. Cure remained uncommon but survival might be lengthened. Karol Sikora, from Imperial College, predicted that within 20 years cancer would be considered a chronic disease to be controlled, such as diabetes and asthma. The new treatments would be more selective, les toxic and given for long periods, perhaps life long. The NHS would have difficulty in paying for everything available. When their effectiveness became apparent they might be used earlier, as in the case of paclitaxel (Taxol) in ovarian cancer, one of the earlier drugs to be assessed by NICE and recommended as standard initial therapy. Oxaliplatin (trade name Eloxatin) & irinotecan (trade name Campto) were approved for metatstatic colorectal cancer. Three drugs for small cell lung cancer were also approved, gemcitabine, paclitarel and vinorelbine.
Monoclonal antibodies, after many years, began to live up to some of the expectations. There was rituximab (Mabthera) for low-grade non-Hodgkin lymphoma. The antibody attached to the B-cell surface receptor, present in most cases. Another was trastuzumab (Herceptin), that targeted a protein on the surface of fast-growing cancer cells, and was accepted for advanced breast cancer in 2002. Given much earlier to people with aggressive breast cancer carrying the HER-2 gene it achieved a major reduction in recurrence rate. There were many more monoclonals in the pipeline, each active against a receptor on a malignant cell surface. It was a growth area with high costs. Another group of drugs active against cancer were anti-angiogeneis drugs, which keep tumours from developing good blood supplies.
The development of a vaccine against infections with human papilloma virus (HPV), which though often benign could lead to cervical and anogenital cancer, opened the possibility of preventing a substantial number of cases. In 2006 the vaccine received its European licence and a programme of vaccination, starting with young girls aged 13 started in September 08 with a massive nationwide campaign.
The 6th Report of the Confidential Enquiry into Maternal Deaths (CEMD) in the UK was published in 2004. Maternal death is a rare event, 391 being reported from 2000-2002. The main causes of death remained the same as ever, thrombo-embolism,
haemorrhage and anaesthesia. However sepsis was staging a come-back, and
the largest cause of death overall was psychiatric, generally depression.
In addition it was clear that women in families affected by unemployment, who
lived in deprived areas, or from minority ethnic groups were at substantially
higher risk of death than others. The titles of the reports changed to reflect
the rarity of maternal death and the linkage of the health of the mother and the
child. CEMD and the Confidential Enquiry into Stillbirths and Infant Deaths
(CESID) merged to form the Confidential Enquiry into Maternal and Child Health
in April 2003. From 2006 it became a four yearly report, providing an overview of the numbers and causes of maternal death in the United Kingdom.
The 7th Report of the Confidential Enquiry into Maternal and Child Health in 2007, (deaths between 2002-2005) showed that over 20 years there had been little improvement in the figures. Something over half of the deaths directly or indirectly associated with childbirth occurred in women who were overweight or very obese, mothers who were older and often from disadvantaged communities including immigrants and asylum seekers. Some of the avoidable deaths were the result of doctors failing to manage medical conditions effectively that were outside their normal expertise, for example heart disease. Black African women, including asylum seekers and newly arrived refugees had a mortality rate nearly six times higher than white women. To a lesser extent, black Caribbean and middle eastern women also had a significantly higher mortality rate.
The nature of antenatal care - and making it more sensitive to the parents' desires - was the subject of several reports, starting with Changing Childbirth in 1993 with a vision of midwifery-led, woman-centred care in which women could choose where to give birth. There were plenty of pilots but no systematic change. In 2007 came Maternity Matters, which set out the wider choice framework for maternity services, including a guarantee (within safety limits) of choice over where to give birth, how to give birth and what pain relief to use. There was little fundamental change. A supplementary document to the Lord Darzi's London report (2007) also looked at obstetric services nationally, and the place of home delivery, midwife led units (either stand-alone or co-located with a hospital unit) and hospital obstetric units.
The pattern of antenatal consultations and care had remained much the same for half a century since the time when its importance was first appreciated. In 2003 (further revised in 2008) NICE recommended evidence based changes and suggested that care should begin earlier, around eight weeks to give women more time to make decisions about screening and to plan the kind of antenatal care that they would like. Ultrasonography should be carried out at 10-13 weeks, to increase the accuracy of pregnancy staging. Healthy women pregnant for the first time should typically be offered 10 appointments, and 7 in subsequent pregnancies. All women should be offered screening for fetal Down's disease during their pregnancy. During delivery continual monitoring of the fetus became near universal. Defensive obstetrics was important for hospitals needed evidence of good care in case of future legal actions. To safeguard the health of the baby, networks of neonatal units were established so that women in labour could be transferred when desirable to a unit providing the most intensive neonatal care.
There was an ever increasing demand for fertility treatment, often in women who had delayed pregnancy until their mid-thirties. Births from successful IVF steadily increased. In 2007 36,000 women received treatment and there were more than 11,500 births from IVF or intra-cytoplasmic sperm injection (some multiple births). NHS resources being limited, most of this was undertaken in the private sector at personal cost. More than one embryo was often implanted to increase the success rate and the number of multiple births in older women increased rapidly. Many babies were of low weight, and delivered early, increasing NHS costs. The pressure on the NHS to make fertility treatment part of mainstream NHS services was successful - NICE recommended that three cycles of treatment should be available to women age 23-29 years of age. (HFEA figures)
The abortion rate has been rising since records began. It stood at 14.8 per 1,000 women in 1988, but 18.2 per 1,000.in 2007. The rate for under 16s was 4.2 and for under 18s it was 18.9. The highest abortion rate was seen among 19-year-olds with 36 per 1,000 women. By 2007 almost 200,000 terminations were being performed annually. From January 2001 the "morning after" pill became available over the pharmacist's counter rather than solely through medical channels. A third of abortions was carried out on women who had already had one. In 2008 parliament reviewed the 24 week limit for termination, and left it unchanged.
Clinical genetics was increasingly applied to diagnosis and treatment. Pre-implantation genetic diagnosis developed apace. For example the ability to screen, in vitro, for the inherited Fanconi syndrome enabled a clinical tour de force - the selection of one among a number of embryos for implantation that was not only unaffected by the disease, but which led to the delivery of a baby whose cells could be used to treat an elder and sick sibling. The Human Fertilisation and Embryology Authority (HFEA) decided to allow selection of an embryo so that a baby could become a donor for a brother seriously ill - the so-called saviour sibling. Similarly women in families predisposed to cancer of the breast could be assessed so that only embryos free from the significant gene were implanted. International travel made it possible for those with the money to evade national legal controls on embryo sex selection.
Improvements in imaging, endoscopy and drug treatment all contributed to steady advance in gynaecology. Fibreoptic endoscopes enabled the replacement of some major operations by minimally invasive procedures. Ectopic pregnancy could be diagnosed early by ultrasonics and treated by laparoscopic surgery. New approaches to the treatment of heavy menstrual loss were developed, for example endoscopic ablation of the endometrium by laser. Simpler methods of treating endometrial polyps were also possible. Better understanding of the risk and frequency of incontinence after delivery, and the technique of the repair of tears, offered more hope to women suffering such embarrassment. The development of a vaccine against the most common forms of human papilloma virus offered the prospect of a radical reduction in the number of cases of cervical cancer.
Concern about injuries to the pelvic floor was among the reasons for rising Caesarian section rates. While a Caesar carried its own risks, neither doctors nor patients resisted the pressures to do everything possible to ensure a good outcome for the baby. To try to produce good evidence about the incidence and advantages of section, the Royal College of Obstetricians and Gynaecologists undertook a large-scale survey; the section rate was 22% and many obstetricians believed this to be too high.
Problems with reading cervical cytology slides emerged from time to time. Even in units recognised to be of high quality the inherent difficulty in reading test results led to audits that showed repeated failures to identify abnormal smears.
Despite decades of accumulated observational evidence, the balance of risks and benefits for hormone replacement therapy (HRT) in healthy postmenopausal women remained uncertain. A US trial of a combined oestrogen/progesterone preparation was stopped in May 2002 after an average 5.2-year follow-up among healthy postmenopausal US women, because risks (for example invasive breast cancer, heart disease and stroke) exceeded benefits, e.g. a reduction in fractures. (JAMA. 2002;288:321-333). Over 2 million women were reported to be taking HRT in Britain and an MRC trial of long duration oestrogen after menopause had been underway since 1996. It was decided in November 2002 to bring this trial to an end as well. The results of the "Million Women Study" (Lancet 2003; 362: 419-27) confirmed the increased incidence and death from breast cancer, particularly for oestrogen-progestagen combinations, leading to calls for its prescription to cease. HRT might be responsible for an additional 5,000 cases of breast cancer in that country annually. BMJ 2003;327:767. In 2006 it was reported from the USA that the number of cases of breast cancer was falling since many women had stopped taking HRT following the publication of the evidence of a linkage It became increasingly clear that for many years the pharmaceutical industry had quietly encouraged the use of their products by providing financial support to meetings that were essentially PR, and organisations encouraging the use of HRT, some of which had apparently been established by groups of oestrogen product manufacturers.
The quality of services for children had been a concern over the years (Platt 1958, Court 1976). A Children's Task Force was established in 2000, and Professor Al Aynsley-Green was appointed national director for children's services to lead the development of a national service framework to improve the 'fragmented and poorly coordinated' services that children might receive (2004). His framework reiterated principles of care expounded since Platt. Children were different, needed to be looked after by people who understand their particular needs, and should have services designed specifically for them. Accessible and age appropriate services were needed, earlier diagnosis and intervention, and a smoother transition from child to adult services. There must be someone at senior managerial level in every NHS organisation who took responsibility for ensuring that children's voices were heard. Existing policies could improve without any major investment of money. All newborn babies should have access to the most appropriate care where and when they needed it and there should be regional networks of care to minimise the need for transfer. However in 2007 the Healthcare Commission reported that a substantial number of hospital trusts still could not provide round the clock life support care for children, and called for re-configuration of paediatric services to make this practicable.
The increasing ability to diagnose fetal defects by antenatal ultrasonic scans, and the emergence of feto-maternal medicine as a specialty, meant more work for paediatric surgeons. Spina bifida, kidney and bladder diseases might be diagnosed before birth. Surgery immediately after birth could be planned, and where the defect might result in the death of the fetus or neonate, fetal surgery was sometimes possible, sometimes endoscopically.
Organ transplantation in children presented difficulties not found to the same extent in adults. Drugs used to suppress immune reactions might affect growth. Nevertheless advances in medical knowledge and surgical technique extended the range of indications and improved both survival and the quality of life. The outlook of children dying of liver, kidney or heart failure was revolutionised. It became possible to transplant kidneys at younger ages with a good chance of success. Liver transplantation was extended to the neonatal age group. Congenital heart disease and cardiomyopathy could be treated by heart transplantation. Paediatric transplantation was a victim of its own success. Improved survival led to increased referrals and waiting lists.
Although the elderly were now usually admitted to acute wards, the care they received was still sometimes poor.. The Health Advisory Service (HAS) examined the care of elderly people in acute wards in 16 general hospitals throughout England. The fabric and design of the wards was often poor, equipment might be lacking, ward routine might be inflexible and patients might not be helped to eat or drink. The HAS preferred specialised facilities for the elderly rather than those integrated with other facilities. This was strange as most acute admissions now were of the elderly. It asked for national standards, that older people should be helped to eat and drink, should lie in a clean, dry bed, and be treated with respect. In March 2001 the Standing Nursing and Midwifery Advisory Committee's Report "Caring for Older People : A Nursing Priority" was published. The report said
"There is a great deal of evidence to support the conclusion that the care that older people receive often fails to meet their most basic needs for food, fluid, rest, activity and elimination and the psychological and mental health needs of older people are often entirely neglected in acute health care settings. The nursing care of older patients is mainly deficient in terms of fundamental skills, such as communication and helping a patient to maintain their nutritional status, skin integrity and continence."
In March 2001 the Government published a National Service Framework for Older People as a ten-year programme setting national standards covering "age discrimination", person centred care, hospital care, specialised stroke services, falls, mental health and the promotion of an active healthy life.
To geriatricians the most worrying feature was its proposals for developments in intermediate care. Geriatricians recalled that in the 1960s there were many intermediate care beds outside acute hospitals, into which "bed blocking" old people were transferred in the hope that somehow they would disappear from the system. Geriatricians spent their lives getting such beds closed and to provide the specialist rehabilitative care needed to get people safely and expeditiously home. Specialist geriatric rehabilitation units are crucial elements of comprehensive acute hospital services but are expensive. They might now have to fight to prevent their beds being downgraded to intermediate care.
Labour, in opposition, had accused the Conservative Government of forcing thousands of pensioners to sell their homes to pay for long term care. The Royal Commission on Long-Term Care for the Elderly (1999) proposed making all nursing and personal care, including help with washing and dressing, free to all needing it. Labour was now cool towards this solution, with its immense costs. Personal care would not be free in England. The Scottish parliament decided that it would be. Nursing care, would be free. A compromise had to be made between idealistic aspirations and what could be afforded within budget. The problem was at least as great for the social services that were often responsible for the costs after discharge. Private residential and nursing homes began to close because payments did not cover the cost of providing a staff intensive service, and the cost of meeting (quite properly) newly introduced standards of accommodation. Hospital trusts reported that it was difficult to admit emergencies as it was difficult to discharge older patients requiring care.
Alzheimer's disease was among the conditions in which genetic problems were sought though specific genetic defects represented less than 10% of the total of cases. In the great majority of cases there was no evidence of a specific gene being involved, though genes seemed related to the production of amyloid protein within the brain. Aberrant processing of amyloid precursor protein, leading to increased production and aggregation of amyloid peptide in the brain, seemed central to the pathogenesis of Alzheimer's disease. This in turn suggested types of treatment that might in future be developed. Three drugs, cholinesterase inhibitors, for treating mild or moderate Alzheimer's disease were approved for use in the NHS by NICE in January 2001.
A National Director of Mental Health, Professor Louis Appleby, (the 'mental health czar') was appointed in 2000. He said that key areas of the National Service Framework would include:
phasing out mixed-sex psychiatric accommodation
the elimination of out of area acute admissions as soon as possible
24 hour access to mental health services for patients and carers
new training for psychiatrists in 'cultural awareness'
a drive to encourage more nurse consultants in the mental health area, particularly to work with people with mental ill-health and drug and alcohol problems.
A new vision was emerging in the mental health services. Two big ideas were that patients with mental illness should be treated in the community, and that young people with early psychosis should receive timely and comprehensive intervention at the outset. The National Service Framework for Mental Health (September 1999) followed pledges in the NHS Plan and increasingly money flowed into mental health services. Over several decades large mental health hospitals had been closing, to be replaced by community psychiatric teams, generally with too few staff yet with wide responsibilities for cases of many different types. This 'generic' approach where teams were responsible for all the problems in their community often proved inadequate. Increasingly teams with particular skills and smaller case loads were formed to provide specialised services, for example crisis and early intervention services (to reduce the need for admission), personality disorder and prison in-reach. Crisis Resolution Home Treatment (CRHT) teams helped people through short-term mental health crises by providing intensive treatment and support outside hospital, ideally at home. Made up chiefly of mental health nurses, with additional input from consultant psychiatrists, social workers, occupational therapists and psychologists, they could denude the community health teams who were left to handle large case loads of people whose problems did not fall into specific categories. Muijen M, HSJ 2003, 9 Oct, 18-19. The National Audit Office reported in December 2007 that the introduction of CRHT teams was associated with reduced pressure on beds, and the teams were successfully reaching service users who would otherwise probably have needed admission. CRHT teams were also supporting the earlier discharge of people from inpatient treatment – for example in around 40 per cent of the discharges in the NAO sample.
Organisational change had a substantial impact on psychiatry and community care. Changing organisations and changing boundaries of, for example, the Mental Health Trusts, made the development of team work with social work services difficult. As patients were discharged into the community, some old mental hospitals such as Friern Barnet (North London), St Francis (Haywards Heath), Oakwood (Maidstone) and The Royal Holloway (Virginia Water) were converted into high quality living accommodation for the well-to-do. Developers appreciated the amazing assets these former institutions possessed. Yet care in the community as a policy only produced new problems. SANE, a voluntary mental health charity primarily concerned with schizophrenia, believed that while it worked for some people, it let down many others. A social experiment meant true liberation for many people who, with the new drugs, were well able to live outside hospital, but for others it had meant fighting for mental and physical survival alone in flats and bed sits, or with their families who broke down under the strain. There was a famine of community psychiatric nurses, and there needed to be enough hospital places, places of asylum in the true sense of the word.
Government accepted that there had been too many failures of the policy and promised £1 billion and a review of the Mental Health Act 1983. Government strategy, Modernising Mental Health Services, had two essential elements
increased investment to provide more beds, outreach facilities and 24 hour access and new treatments.
increased control of patients to ensure compliance with treatment in the community, and a new form of revisable detention for those with a severe personality disorder.
In December 2000 a White Paper, Reforming the Mental Health Act aimed to deal with public concern about care in the community that had led to the release of hundreds of patients some of whom did not receive care, becoming a risk to themselves and others. Such releases had contributed to 1000 suicides and 40 murders a year. A draft Mental Health Bill, published in June 2002 attracted criticism over the proposals for compulsory detention and treatment of people with dangerous severe personality disorders and the withdrawal of the Bill, with the promise of new legislation published in November 2006. Finally a new Mental Health Act was passed in 2007 which allowed people with serious personality disorders to be detained, even if they had committed no crime, if a danger to themselves or others. It also allowed compulsory treatment in the community under certain circumstances.
The 1999 NSF proposed targets including a 20% reduction of suicides. A strategy to reduce suicides among high risk groups, promote mental well-being in the general population and to research suicide and suicide prevention was published in September 2002, measures to include the improvement of the prescribing of antidepressants and analgesics, and partnerships to identify and improve safety at suicide ‘hot spots’ such as railway bridges.
New and 'atypical' antipsychotics were introduced, e.g. amisulpride, olanzapine, quetiapine, risperidone and zotepinethat, said to produce fewer extrapyramidal side effects and to reduce the suicide rates compared with drugs such as chlorpromazine, . They were many times more expensive but there was public and professional pressure for their widespread use. It was 20 years before careful examination of the clinical trial evidence showed major flaws, for example comparing the new drugs with haloperidol, a drug known to have many serious side effects. Marketing and publicity had overtaken science. Though the evidence for their cost-effectiveness of these "second generation drugs" was equivocal, in June 2002 NICE approved their use both for patients with side-effects from the traditional drugs, and as a first treatment. The extent to which street drugs such as crack cocaine were often taken by patients with recognised psychiatric problems was an increasing hazard. There was also hope that the new drugs in the pipe-line would modify the disease, rather than merely treat the symptoms. Perhaps, caught early, schizophrenia would go into full remission, or the progression of Alzheimer’s disease might be alleviated.
Hospitals for those with learning disabilities had been the centre of scandals in the 1960s/70s. They still hit the headlines from time to time. In 2007 the Health Care Commission found that Orchard Hill Hospital in Sutton and Merton was 'in a time warp' and delivery care at an unacceptable level, describing "some of the environments in which people lived as impoverished and completely unsatisfactory. Staff were not properly trained or supported to provide an acceptable level of care, and inadequate levels of staff meant that people were often left day in day out with little to occupy their time. There were failures in management and leadership at all levels, from managers to the trust’s board" The Commission decided to inspect some 200 similar institutions, recalling Richard Crossman's establishment of the Hospital Advisory Service in 1970.
Major changes were taking place in primary care. The pattern of practice was altering reflected in a new contract partly based on quality and outcomes. Where could people best be treated?
In the community? There was an increasing load of treatable chronic disease &
the issues of obesity and health promotion - plus the desire of doctors to work
more normal hours.
For overseas readers who may not know much about UK primary health care
Everyone registers with a general practice in which each of the doctors probably have about 1,800 patients and holds lifetime records of patients. There are two types of contract in UK general practice: GMS and PMS. Roughly 70% of GPs are independent practitioners and have a GMS contract and 30% have a Personal Medical Services contract and are generally salaried. GPs traditionally owned their own premises and they work with nurses, health visitors, midwives, secretarial and computer support. However the NHS and other organisations increasingly provide premises. GPs are responsible for health promotion, care of acute disease, and long-term care of chronic illness, referring to hospital when necessary. GPs undertake 3 years vocational training before entry to practice. Until recently they were responsible for 24 hour care. Responsibility for out of hours care has now passed to primary care trusts.
The pattern of practice
The classic pattern of primary care,
the "RCGP model" with continuity of care, was breaking down and other countries
identified the same issues. JAMA 2008, 299: 13; 1595-6. Increasingly advice to patients was given by A & E, ambulance services, paramedics, emergency care practitioners, walk-in centres and NHS Direct. GPs had little or no control over other professions who were expanding their roles. A service without continuity as a feature might meet the needs of people with acute and minor problems. It was not the best way of coordinating multiple complex chronic illnesses. Government and the medical profession seemed to collude to undermine co-ordinated care. The old pattern of lifelong continuous service was increasingly replaced by doctors, sometimes salaried, who came and went. GPs preferred a Monday to Friday day time service. Cox J, Br J Gen Pract 2006, 56, 83-4 The 2006/7 UK General Practice Workload Survey showed that GPs were seeing fewer patients (perhaps 90/week) but were spending more time with each patient, 11.7 minutes. More consultations were with nurses, a rise from 21% to 34% between 1995 and 2006. More consultations were by phone, and visits were fewer partly because of the use of out of hours services. (Trends in Consultation Rates in General Practice 1995 to 2006 www.ic.nhs.uk)
Practices had more staff - the average practice about 24 many of which were non-clinical. Anticipatory health care, along the lines suggested by Julian Tudor Hart, was increasing and being institutionalized. For the first time GPs were working
for organisations based in the community, with a focus on management, support and leadership - primary care trusts (PCTs).
The community nurse caring for chronic disease, the out-of-hours rebellion by GPs who wished for more control over their lives, the desire of younger and part time GPs for a salaried service, modern information technology and new types of contract were destroying the traditional pattern of practice and the gatekeeper role with it. Only half the population thought his mattered; many were happy to see any doctor as long as it was convenient.
A White Paper,
Building on the Best (2003), implied that the GP as the as the sole, centre-point of continuity of care, was on the way out; commuters might have a GP near their work as well as near their home.
Quite apart from pharmacists and nurses, there were now three competitive provider models. Government became eager to ensure that new practices were opened where they were needed, and that if possible these should not be along traditional lines, but use
newer contractual patterns such as "Alternative Provider Medical Services
To try to achieve better access and reduce the flow of patients to A and E
Departments, new points of access were devised.
Government, initially against professional opposition, piloted walk-in centres in stations and shopping malls. Some were located near major hospitals. Thirty six were announced in 1999 and by 2004 87 were in operation or planned for example
at main line railway stations. Private sector organisations such as Care UK obtained contracts to run some of these.
, nurse-led minor injuries clinics and triage points, tended to see patients of working age during the working day, often when people were away from their normal GP, at work or on holiday. They offered simple advice and treatment for minor health problems using computer-based decision support software. The most common reasons for attendance were minor viral illnesses, unprotected sexual intercourse (emergency contraception) and minor injuries. Four out of five people could be handled without onward referral. They did not greatly affect the workload of local GPs, but if there was a nearby local minor injuries unit, that would receive more patients. Opening hours were wide, (usually 7 am to 10 pm every day)
The average consultation length was 14 minutes..
Salisbury C et al. BMJ 2002; 324: 399-402; Grant C, Nicholas, R, Moore L, Salisbury C, BMJ 2002;324:1556
A new pharmacists' contract in 2004 added another source for care, for it encouraged pharmacists to expand their role into chronic disease management, supervision of repeat prescriptions, smoking cessation and other appropriate services. A White Paper (Pharmacy in England, Building on strengths - delivering the future) in 2008 heralded further development in the role of pharmacists, in part to undertake simple forms of care that might otherwise occupy family doctors.
GP led Health Centres
Primary Care Trusts were instructed to develop new centres to provide better access. GP led health centres opened from 8 a.m. to 8 p.m. seven days a week, providing access to GPs or nurses to anyone who turned up, whether registered or not, but also registering patients like a normal practice. Increasingly they were developed and adopted many different names, health access centre, medical centre or even polyclinic.
Department of Health negotiators had at times bearded the BMA's GP negotiators about accessibility of family doctors compared with banks such as First Direct. In 1997 the head of operational research in the Department of Health asked "what would an NHS look like that was radically reconfigured so that demand could be handled by direct means" such the telephone, TV and Internet. The subsequent establishment of NHS Direct in March 1998 was part of a rapidly developing mosaic of first points-of-contact for health care. High on Labour's priorities, this 24-hour telephone triage system, operated by nurses, advised callers on the most appropriate form of care. Sophisticated computer-based software helped the nurses, reducing the possibility of dangerous errors. T
he scheme became nation wide in November 2000. Call centres might be based with ambulance services, which had much of the necessary infrastructure.
NHS Direct responded to consumerism and technology, doing what cash machines had done for banking, to offer a more accessible, convenient and interactive gateway. The commonest reasons for calls were rashes, abdominal pain, dental, tooth and jaw pain, and medicines advice. The telephone service was supplemented in December 1999 by NHS Direct Online. It also provided information about clinical conditions. The website attracted people who were seeking information about problems often on an anonymous basis while the phone lines attracted those with an immediate problem. The numbers of callers steadily increased. The website was expanded to incorporate a health encyclopaedia about common conditions.
Surveys showed substantial user satisfaction although
only 64 per cent of callers managed to speak to a nurse within five minutes & one in five callers had to wait more than 30 minutes for a nurse to call them back. It was no cheaper than GP consultations and many patients were referred. There was no evidence about whether NHS Direct made more or fewer mistakes than a GP would have done. A National Audit Office Report stated that on the e
vidence NHS Direct was operating safely, and advice to callers erred on the side of caution; there were 29 adverse event cases in three years, fewer than one for every 220,000 calls. NHS Direct undertook continuous evaluation and audited 1% of calls.
overnment aimed to make NHS Direct a single access point for out of hours care, integrating and controlling practice by, for example, making direct bookings for patients at the surgery and providing a point of entry for 999 calls of low importance, out-of-hours calls to GPs, information about emergency dental and pharmaceutical services and handling low priority ambulance calls. I
plans for further expansion were announce
Additional functions were added, for example patient reporting of adverse drug reactions. In April 2004 NHS Direct was established as a Special Health Authority. By the end of the decade the service was answering 25,000 calls a day at 35 call centres and employing 3,000 people.
NHS Estates, a central government agency, continued to support the design and development of GP premises.
As part of the NHS Plan government introduced a new way to fund premises, the local improvement finance programme (LIFT) in which primary care providers would collaborate with private investors to build facilities. Most were owned by the private developer, but some were developed with public money and money from the GPs if they wished. The schemes might provide space for health related and appropriate retail services, and seemed particularly suitable for urban and deprived areas where GPs were reluctant to invest their own capital.
In 2002 a total of 42 such centres were announced and the first such a centre (Manor Park), costing £4.9 million, was opened in November 2004 in Newham. It contained three general practices, health visitors, accommodation for dentists in the future, a pharmacy, a cardiology clinic, X-ray, pathology and optometry services, and a healthy living café.
Particularly in areas where there was a shortage of GPs, government began to look to the private providers.
In May 2006 Care (UK) opened primary care facilities in Barking and Dagenham, family doctor services being provided to the NHS by the private sector. Government influenced the procurement process in under-doctored areas, making it easier for larger organisations to put forward proposals.
In 2005 the Department of Health consulted on the possibility of a "medical care practitioner" - physician's assistant - perhaps on the lines of the North American model. Such practitioners might
- Obtain full medical histories and perform appropriate physical examination;
- Diagnose, manage (including prescribing) and treat illness within their competence;
- Request diagnostic tests and interpret the results;
- Provide patient education and preventative healthcare advice regarding medication, common problems and disease management issues; and
- Decide on appropriate referral to, and liaison with, other professionals.
There was agreement that such practitioners would be useful particularly in primary care and in 2008 the Universities of Wolverhampton, Birmingham and Warwick with Coventry launched the first course to physicians assistants.
There was the possible introduction from the USA of Retail Health Clinics - the 'doc in a box'. The organising principles were taken straight from the fast food industry, convenient locations (e.g. Wal-Mart), long opening hours, limited menu and low prices. Some dozen or more companies, owning and running some 200 clinics each, provided nurse practitioners working from guidelines who for a fixed charge dealt with anything that a mid-level practitioner could do. Anything requiring judgment was referred. The average costs were substantially lower than in a physician's office or emergency room, and patients liked the accessibility, low costs and walk-in availability.
GPs with Special Interests (GPwSI)
Partly driven by the problems of GP recruitment, the BMA's Health Policy and Economic Research Unit proposed i
n February 2002 that the existing medical workforce might be better utilized by greater use of nurses (themselves in short supply). A new pattern might be needed in general practice. Nurses were becoming increasingly important in the provision of primary health care. Government considered that "community matrons" might would remove
the need for the patient to attend the GP surgery or outpatients or stay in an acute bed unnecessarily. More efficient use of doctors time might allow them to devote more time to tasks which require their advanced levels of clinical training and specialization.
Research suggested that the introduction of nurse practitioners in the surgery did not significantly change the workload of the doctor. Full nurse-substitution would require a pattern of nurse training that included the complex problems of the diagnosis of ill-defined and newly presenting problems. Both
general practitioners and government were coming to view the role of primary care differently. The NHS Plan (2000) could be read as implying that much that the GP did could be done by nurses, and GPs might become intermediate level specialists as the BMA Unit's report suggested. General Practitioners and Nurse Practitioners were increasingly specialising in particular aspects of clinical management, education or research. Nocon A & Leese B, BJGP 2004, 54, 50-56. GPs were taking on tasks previously more commonly the responsibility of secondary care, providing such services for patients outside their own practice, and being paid specifically for them. This development was viewed with approval by the Royal College of General Practitioners (RCGP).
Led by the Modernisation Agency, there was a move to accrediting GPwSIs, particularly if they could provide a service that could avoid hospital referral. PCTs began to contract for services. By 2003 there were more than 1250 of GPwSIs in specialties such as dermatology, ENT and cardiology. Often they worked in fields where there was a long waiting list to see a consultant. The additional equipment needed by GPwSIs was extensive and expensive, costing anything from £10-40,000, and the cost-effectiveness was open to question. Rapid access to hospital facilities for complex investigation was also necessary. Several models were developed, fully independent from secondary care, services with close hospital support, services with consultant triage, or fully based in the hospital. A measure of specialisation appealed to some GPs. It was clear, however, that such services were an addition to, rather than substitution for secondary care. GPwSIs represented a new way to configure services, and one that management could influence.
Traditionally the work of
most doctors included evening visits to the home and an occasional night disturbed by an emergency call. Continuity of care had been a core value. Since the introduction of deputising services in the 1960s, and later GP cooperatives, GPs had increasingly devolved care to them,
90% of GPs fulfilling their out-of-hours responsibilities in this way. With increasing demand for 24 hour access and changes in the medical workforce - over half the entrants being women - this was inevitable. Since 1948 the GP's contract had provided for 24 hour patient care and pay had been on that basis.
In 2000 John Denham, the Health Minister, said that out-of-hours primary care would in time move from the GP to NHS Direct, and the members for the BMA English GP Committee voted to end their legal responsibility to be on call 24 hours a day, forcing a review of this principle. For 30 years government had found the 24 hour commitment convenient and economical but a new
contract in 2003 gave GPs the right to opt out.
From December 2004, GPs could transfer their out-of-hours responsibilities to an "accredited organised provider of out-of-hours services", subject to the approval of their PCT. Ninety percent did so. PCTs were responsible for coordinating provision and accrediting providers of out-of-hours services. The cost rapidly escalated, putting pressure on the budget for primary care. In 2005 the cost in England was £392 million, 22% higher than predicted. Some PCTs had to fly doctors in from Europe to provide a service. The private sector saw the possibility of handling the administration, triage, call handling and providing cars and drivers for duty doctors. Among a variety of arrangements, PCTs increasingly looked at Ambulance Trusts for assistance, and alongside paramedics Emergency Care Practitioners emerged as people who might make a first assessment of a patient making an emergency call. There was income to be raised by the provision of an ECP service. Some Ambulance Trusts organised lengthy and comprehensive training courses; others did not. Concern about a deterioration in out of hours services became a political issue. Gordon Brown, incoming as Prime Minister, made it a priority agianst initial GP opposition to get them to provide more services for a longer part of the day, for example in the evenings. An Interim Report from Lord Darzi set a target of half of all practices to offer out-of-hours services - with a clear instruction for PCTs to find someone who will if GPs would not.
There was a rise in emergency admissions and a move of other professionals to fill the gap GPs were vacating.
A White Paper (Our Health, Our Care, Our Say) was published in January 2006 by Patricia Hewitt, Secretary of State. It had a strong emphasis on life style and health promotion and restated policies that previously existed (e.g. more pay for GPs in deprived areas), shifting expenditure from hospitals to the community and preventative services, bringing some specialties from the hospital nearer to people, e.g. dermatology, ENT, orthopaedics and gynaecology, and an expert patient programme.
n 2007 the Royal College of General Practitioners (RCGP) published a roadmap on the Future of General Practice that analysed the environment in which GPs were operating now that they were no longer the main entry point to the NHS or working in a single model of practice organisation. It suggested that GPs should become 'federated' into larger groups to provide a wider range of services such as scans and x-rays to cover most health problems in the population, including mental health, closer to patients’ homes. Hospitals should be reserved for acute illness, specialised investigations and major surgery.
The Department of Health published Our vision for primary and community care,
along with Darzi's report in July 2008.
with an emphasis on prevention and a vascular risk assessment programme for those between 40-74 years, focussing on outcomes in the Quality and Outcomes Framework, and increasing choice for patients.
The move to larger units was accelerated by the reintroduction of the idea of polyclinics, either very large centres or by a hub and spoke pattern with central facilities used by local practices. Lord Darzi, reporting in 2007 on health services in London, had suggested polyclinics, providing walk in services as well as those for registered patients, with specialist and investigative support. He proposed 100 new practices in areas with poor provision delivered by a wider range of providers, some perhaps in the private sector. There was a highly politicised and polarised row. The King's Fund tried to clarify issues in a report Under One Roof, concluding that shutting down smaller practices and a single model, with a highly centralised one, would not be suitable for all areas. A poll conducted for The Times revealed contrasting views of doctors and patients. Almost half patients thought polyclinics would improve the standard of care and access, and that seeing the same doctor on each visit or in an emergency did not greatly matter. GPs opposed them and argued for continuity of care, an aspiration that in practice could never be fully delivered. (The Times 23 February 2008) One private provider, United Health, obtained the contract to run three practices in North London. Sainsbury's and Asda piloted the provision of surgery space to local doctors in stores in the evening. GP organisations feared that the strengths of British general practice were being undermined by officials lacking in understanding of primary health care; in the wake of the final Darzi report in July 2008
From 1948 until 1997 all GPs worked under a single contract for services, nationally negotiated and set out in "The Red Book".
The NHS (Primary Care) Act 1997 was passed shortly before Labour came to power and allowed health authorities to commission primary care services from GPs and others within the NHS in new ways. A new style contract for personal medical services was often with a group or practice
, instead of with individual GPs and were for a defined package of services.
Contracts were local, rather than national, with a firm linkage to quality; and services could be tailored to the needs of specific groups, such as the unemployed. It became possible to test alternative systems for delivering primary and community care schemes and to try our new mixes of skill. There was a realisation that the standard contract did not meet the needs of all communities equally well; and in addition that there was a case for more competition in primary health care.
In 2003 the Health and Social Care (Community Health and Standards) Act allowed Primary Care Trusts to commission care from "anyone capable of securing the delivery of those services" It established four contracts
General Medical Services (the traditional GMS contract as revised between trusts and practices not individuals)
Personal Medical Services (PMS see below)
Primary Care Trust Medical Services (PCTMS) in which PCTs provided services themselves, directly employing staff
Alternative Provider Medical Services (APMS) in which the PCT contracted with an individual or an organisation, e.g. independent sector organisations such as United Health Europe or Care UK, the voluntary sector, other PCTs, Trusts or even a parallel contract with GMS or PMS practices.
The legal basis of practice had changed, and commercial law was now involved in contracts, not public law alone. The monopoly of individual GPs as contractors was broken. Pollock A et al. BMJ 2007;335:475-477 (8 September). Alan Johnson, Secretary of State, felt that existing practices had no God given right to particular populations. Personal Medical Services contracts became popular. Services were unbundled and, instead of a single individual providing everything (in theory), additional or enhanced services such as screening or the care of chronic conditions could be provided by different systems. Commercial firms, and some groupings of general practitioners took advantage of these opportunities. Boots entered the market by offering to provide premises for primary care teams in their stores – in 400 there was excess space that could be converted. GPs obtained a 5-10 year lease in accommodation newly converted with their needs in mind in areas where this was difficult to find in, for example, in Birmingham city centre.
This new type of contract (begun under the Conservatives and expanded under Labour) was based upon ideas discussed between the Department of Health and the NHS GPs' negotiating body in the early 1990s. Flexible salaried contracts established by management locally might meet the needs of inner cities better, and overcome a problem of the traditional contract that made short term employment impossible.
PMS were piloted and became a mainstream option before evaluation was completed.
GPs seemed willing to trade income for better conditions, freedom from out of hours working, from administrative responsibilities and an ability to work part time. Salaried options appealed to the doctors early in their career, those approaching retirement and to women, but the hope that they would help deprived areas was not always realised. Often it was in the affluent areas that salaried doctors were to be found.
Some PMS schemes delivered traditional primary care; others provided community services as well, and in a few "nurse-led" practices a nurse might be the first point of contact. There was a progressive shift towards a PMS/salaried service, often with salaried GPs working alongside 'independent contractor' GPs.
In a succession of waves, the numbers of GPs involved increased steadily and
in 2003 it was decided to ensure that pay increases matched those of doctors on standard contracts. From March 2004 it became a permanent alternative to the general medical services contract and b
y 2005 40% of GPs worked under PMS contracts.
Fixed 1-3 year contracts and a salary of perhaps £55,000 for a ten session week, made the prospect appealing. Indeed when a new contract was later introduced, PMS payments were ratcheted up and the contract was very appealing to the doctors indeed.B
oth the profession and government wanted changes to the contract to reflect emerging patterns of practice.
GPs wanted to reduce the scope of their responsibility to a core of essential services (so that additional work would be separately priced), to remove the obligation to provide 24 hour cover, and to be able to choose their pattern of work. Government wanted teamwork, better access for patients and an emphasis on quality of care as in previous negotiations. The rewards should be for the quality and range of services, rather than speed in seeing patients.
Postgraduate education and clinical audit would become mandatory. Many of the changes were only possible because of the increasing use of computers in the recording of practice activity. In June 2001 GPs voted to resign if it was not possible to achieve a reduction in paperwork, directives and workload. Alan Milburn handed over the perennially hot-potato of negotiation to the NHS Confederation
losing the expertise of his own team. The new
negotiators did badly and ended by paying vastly more money for somewhat less work. In April 2002 new proposals were sent for consultation immediately after the announcement of more money for the NHS.
The list of patients would practice-based, not individual, opening the possibility of salaried posts and part-time working. Payment would be based on the numbers of patients, the services offered, the quality to which they were delivered, and the needs of patients taking account of their age, sex, deprivation and morbidity
All GPs would provide essential core services, the care and management of those who are ill or think they are ill, and the general management of the terminally ill. Most would boost their income substantially by offering additional services, including vaccination, cervical screening, antenatal care and the management of chronic conditions. If they opted out an alternative provider would be sought. There would also be enhanced additional clinical services, some of which would be needed everywhere, others might be specific to a particular area. A proportion of a practice's payment would come from a quality element of the contract, which might include clinical quality standards (process), organisational standards (structure) and patient experience. There would also be an annual "achievement" payment. Practices would be given money for infrastructure expenditure such as additional premises, staff or information technology. GPs would be allowed to opt out of the obligation to provide cover outside a five day week, Primary Care Trusts assuming the responsibility
There would be new skill-mix initiatives (i.e. nurses performing some of the roles previously undertaken by doctors), and acceleration and expansion of the roles of other health care professionals, such as pharmacists, in primary care.
There would be a progressive programme of "demand management" focused on information and education to enable the public to care for themselves and use the NHS appropriately.
GPs had asked for a radical new contract, to drop 24 hour responsibility and to be rewarded for delivering high quality care.
The contract was based on targets - some 147 performance indicators.
Government announced increased resources for primary care of some
30% over three years. It used to be said that half a dozen people, three in the BMA and three in the Department, fully understood how GPs were paid; now nobody could grasp .the new contract, more complex said the BMJ, than the Minotaur's labyrinth. The new contract
used a complex formula based on weighted list-sizes which produced odd effects
At a conference of local medical committees in May 2003 the GPs instructed negotiators to renegotiate key points with the Government. Ultimately by four to one GPs accepted the contract and in September 2003 the detailed terms were agreed. Implementation took full effect from 1 April 2004.
The Quality and Outcomes Framework (QOF)
QOF became far more important than most had thought and a revolutionary change. Concern about the quality of public services, the move to evidence based medicine and a culture of public accountability led to targets for practices, the achievement of which would determine a substantial part of GP earnings. Of 147 targets introduced in 2004, 76 were clinical and 10 involved long term conditions. As a result, most practices improved the quality and range of services they provided to which some 20% of the primary care budget was tied This resulted in significant increases in GP income and investment in terms of additional GPs and nurses and gave
Primary Care Trusts and Government a financial headache, compounded by the agreement that doctors with PMS contracts should have similar increases and that there should be a protected minimum practice income guarantee.
The contract was estimated to have cost £300 million more than had been expected for the average net salary rose from 2003/5 to 2004/5 by over 30%, to more than £100,000. The National Audit Office reported on the effect of the new contracts. The additional money, far more than had been planned, had achieved at least in part some (but not all) of the anticipated benefits. It had not helped deprived areas much and there were doubts about productivity.
The organisational framework
Family doctors, for years administered by bodies established solely with them in mind, were now managed within a broader framework. After NHS reorganisation in 1974 they were within the remit of Area Health Authorities, but AHAs remained at arms-length. However the amalgamation of Family Health Services Authorities into Health Authorities (1996) altered the situation. Because primary care determined the work of the hospital services, health authorities, primary care groups and primary care trusts (PCTs) saw the need for involvement. For the first time since 1948 general practice/primary care, and community care, were brought into a single organisation with a unified budget managing family doctors, running community nursing and setting the contracts for hospital services. PCTs became planners and funders. PCTs were a long way from simple administrators of GPs.
The rise and fall of fundholding
In the early 1990s, the Conservatives tried to contain increasing demand and rising costs by the purchaser-provider split and the introduction of GP fund holding. Hospital contracts were placed in two ways, by fund holders for their patients and district authorities for the rest. Though voluntary, the number of fund holders was spectacular; by 1998 about 55% of the English population were covered by some kind of fund holding arrangement. Fund holders were energetic and academic evaluations suggested that they cut elective admissions and waiting times. They drove service reform and led doctors to consider management issues.
Pros and Cons of Fundholding
Source: Ray Robinson, HSJ, 3 July 2003, 18-19
Small scale organisations, combining financial and clinical decision making, were able to harness the enthusiasm of GPs eager to develop their practices
Many commissioners and contractors increased transaction costs.
Fundholders achieved shorter waiting times for their patients and reduced unnecessary hospital referrals, while health authorities proved unwieldy , slow to move and constrained by threats to local stability.
Evidence of a two tier access to health care between patients of fundholders and patients of non-fundholders.
GPs who opposed fund holding but wanted to help shape secondary care teamed up to advise health authorities through "locality commissioning", a model more to Labour's liking. Labour determined that fundholding would end in April 1999 and GPs were brought together within Primary Care Groups (PCGs) to commission all secondary care except mental health services. In England around 500 PCGs, each covering populations of around 100,000, took over from nearly 4000 health authorities, fund holders, and locality commissioning groups, later encouraged to become Primary Care Trusts (PCTs). From April 1999 all GPs in England and Wales worked within PCGs/PCTs that commissioned or purchased secondary care for their populations with limited annual prescribing budgets and ring-fenced funds for providing general medical services and developing primary care.
Primary Care Groups were not definable in neat geographic terms, the areas being decided by the homes of those on the list of participating GPs. GPs lost influence in organisations that were becoming mini-health authorities, and whose Chief Executives had often worked for the previous health authorities. PCTs increasingly concerned themselves with the complexities of secondary care and their vision of the future was not solely that of their GPs. The wide responsibilities stretched PCT management. Recruitment of top calibre staff was difficult and mergers were considered to ease the difficulty, or sharing back-office functions such as payroll, or partial or full merger of management teams covering more than one PCT.
PCTs began to flex their muscles. Stronger practice management, the modernisation of premises and concentration into larger centres with better diagnostic facilities and outpatient services, and a move towards nurses as the first point of contact particularly out of hours, were on the agenda. PCTs increasingly influenced the way GPs worked. The Bradford PCT, a leader, worked towards "demand management" and "the best use of hospital services". GP specialists began the triage and treatment of urological conditions, dermatological conditions, "uncomplicated" neurological referrals, musculoskeletal problems, diabetics, and minor surgery for example vasectomy and 'minor eye surgery'. PCTs, responsible for implementing the new GP contract could employ GPs with special interests to achieve their goals. They might encourage the adoption of PMS contracts, which allowed the Trust greater management powers. It also made it possible to plan the devolution of commissioning to practice level.
Fundholding was abolished by the incoming Labour government in 1999. Primary Care Trusts were considered risk averse, bureaucratic and ineffective commissioners leading government to give GPs notional budgets under practice based commissioning. PbC received a widespread welcome though there would be no personal financial advantages for doctors. The use of national tariffs reduced the possibility of hospitals offering "bargain basement" services. GP practices would have incentives to provide x-rays, tests and outpatient consultations within their practice or to commission these services from another provider. Savings from managing referrals more efficiently would be reinvested into patient care.
It became policy that PbC should be universal but the effects were patchy with GPs slow to get involved. It was described by a primary care tsar as " a corpse not fit for resuscitation."
thought the growth in the number of doctors was not great enough to provide the level of service Government wanted.
he number of doctors completing vocational training had been dropping and practices found it more difficult to recruit new colleagues. Earlier, general practice was the first career choice of 40-50% of newly qualified doctors but it was now 20-25%. GPs wished to retire earlier and the loss of a cohort of older GPs, many of Asian origin who had entered practice in the 1960s and 1970s often in unattractive areas, was imminent. Increasing the number of GPs was affected by the fact that most entrants to practice were now women frequently wishing to work part time;
some of the popularity of general practice was the perception of a better life/work balance.
Yet numerically the GP work force was steadily increasing. In England in 1998 there were 28,251 GPs excluding registrars and those retraining. (NHS Information Centre) In 2007 there were 33,364. The massive increase in pay certainly helped.
Vocational training to general practice was progressively developed to fit in to the framework of Modernising Medical Careers and the in 2007 the Membership of the Royal College of General Practitioners was developed into a necessary requirement for entry into NHS general practice.
Since 1948 the Medical Practices Committee had worked effectively for an equitable distribution of GPs, attempting to see that inner cities were reasonably served. In April 2002 this committee was abolished under the Health and Social Care Act (2001). Henceforth Primary Care Trusts would manage recruitment within national guidance. PCTs were divided into groups, according to their number of GPs expressed in terms of weighted population. All would be encouraged to recruit, although some should aim for larger increases than others, and all would have to do so within their financial allocations. Given the shortage of GP entrants, it was probable that more attractive areas would have better luck.
During the decade there were major changes in the hospital service. Workload increased but waiting times for outpatient appointments and for admission fell later in the decade. Systems to assess the quality of services were introduced, staffing was increased substantially, and although the number of beds fell steadily, hospital building increased mainly under public-private partnerships. Reconfiguration of services began.
Hospital development had been been based upon planning and an assessment of local health needs. The development of the 'market' in the 1990s led to a decline in this approach, replaced by business planning, financially driven, short term and institutionally based. However as new policies, such as quality, clinical networks, patient choice and changes in financial flow were developed, this became inadequate; significant analysis and forward planning was increasingly needed. Financial stringency made reconfiguration of an area's services important.
For overseas readers who may not know much about the structure of the NHS
The NHS inherited multiple hospitals, often small and in a bad state of repair, from local authorities and not-for-profit charities in 1948. Over a period of years hospitals were closed, rebuilt and merged with the aim of providing a single district general hospital in each area, supporting local general practitioners and being supported by university and specialist hospitals. In general such hospitals are 500-800 beds in size, operate to 90% capacity or more, and save in city centres have little competition. There have been steady trends to increased throughput, and with sub-specialization the number of consultants has steadily grown. The organisational framework within which the hospitals operate has repeatedly changed.
Hospital episode statistics - England - 1998/2007 Source Health & Social Care information centre web site
Ordinary admissions (1000s)
Day cases (1000s)
Hospitals remained under increasing pressures. New technology was costly and the demand and volume increased as better and less traumatic forms of care became available. Each month acute hospitals saw over a million new patients in acute specialties, and a further million attended A and E departments. The reduction in the GPs' gate keeper role, particularly out of hours, was a factor in the rising demand.
In 1998, at a time of scandalously long waiting lists, the Government established a National Beds Inquiry chaired by the Chief Economic Adviser of the Department of Health, Clive Smee. Reporting in 2000 it showed that the number of staffed hospital beds in England had peaked in 1960 at a quarter of a million, and then fallen steadily to 147,000 Elective admissions had remained static, but emergency ones had risen steadily to 60% of the total. Those over 65 years of age were major and increasing users of the service. York University's evidence to the study concluded that about 20% of the days older people spent in hospital would probably have been deemed inappropriate if other, intermediate, facilities had been available.
The inquiry outlined three options, an increase in the number of acute beds, an increase in health services in the community, or the provision of ‘intermediate care’ services, to prevent avoidable admissions and make discharge home easier. Intermediate care had problems. Management in search of money to keep acute hospitals running had often closed the natural centres for such care, the GP hospitals and community hospitals. There was little evidence that such facilities could deliver effective outcomes in a cost-effective manner; the 'hospital at home' schemes had not done so. Neither had anyone explained how, if intermediate facilities were to be funded from money taken from the existing acute hospitals, those would keep within budget, increase their throughput and improve the quality of their own services.
A year later in 2001, after the Blair Breakfast with Frost, it was decided to raise NHS growth by over twice the rate of past trends. The long term bed forecasts of the inquiry were obsolete. Capacity was seen as a restraint to the reduction of waiting lists and Alan Milburn accepted that more beds were needed. Bed closure to keep within budget ceased to be encouraged and new PFI projects no longer had to reduce bed numbers. Authorities were asked to produce plans for increasing their capacity. Staffing shortages in almost all staff groups were a major restriction in the hospital service. The NHS Confederation, representing NHS authorities and trusts in England, published a briefing in 2006 which provided a good analysis of the factors affecting bed numbers and the changing pattern of hospital care, Why we need fewer beds.
Hospital bed numbers in England, (Source NHS Confederation report and DH statistics)
Labour’s manifesto had promised to reduce the waiting lists inherited from the Conservatives by 100,000. Successive governments had grappled in vain with the problem but against all predictions Labour made great progress. There were three distinct phases in government policy. From 1997-2000 government focussed on waiting lists rather than waiting times and slightly increased funding. From 2001-2004 funding increased dramatically and Alan Milburn chose to focus was on waiting time targets and performance management. Then from 2005-2007 government expanded supply, increased patient choice and introduced competition. Initially waiting lists increased rather than falling. Some trusts paid huge sums to tempt doctors to work out-of-hours to reduce lists. Over the next few years a bad winter might create problems, but slowly matters improved. Sometimes figures were falsified and the Audit Commission highlighted trusts where there had been deliberate misreporting of waiting lists as did the National Audit Office. As waiting times fell, targets were tightened. from 12 to 6 months and then to18 weeks from referral to treatment for elective care, measuring the time from GP referral to the completion of treatment. By March 2008 something like nine out of ten elective patients were treated within this time span. The improvement did not reduce social equity in terms of those treated.
Since1948 district general hospitals had been the building block of the hospital service, accepted by Powell's Hospital Plan (1962) and the Bonham-Carter Report (1969). Reconfiguration was now needed because of
Increasing sub-specialisation and the recognition that outcomes were often better where work was concentrated, for example trauma, heart attacks and stroke. National Service Frameworks supported the idea of centralising some services and establishing clinical networks, elective treatment centres and niche services focussing on a single procedures might achieve effectiveness and efficiency
The reduced working hours of medical staff had made it difficult to staff smaller hospitals out of hours
Closer alignment of research, education and services within academic health science centres to ensure that scientific advances were translated into better care
More care might be delivered by GPs in community based centres
These ideas, and publications such the King's Fund's Rethinking the District General Hospital, were absorbed widely within NHS management and subsumed into the reports from the National Directors of Clinical Services and Lord Darzi.
A report of a joint working party of the BMA, Royal College of Physicians (RCP) and Royal College of Surgeons suggested that a single general hospital now should serve populations of not less 500,000. (Provision of Acute Hospital Services, London, RCS 1998) Such hospitals should relate to a tertiary service provided for around a million and would contain independent departments of super-specialty care. The Senate of Surgery of Great Britain similarly believed it was essential to reconfigure and centralize trauma services for severe injuries and the Academy of Medical Royal Colleges (the umbrella body of 20 UK Colleges and Faculties) looked at acute services, specialty by specialty in a working party report in 2007. Emergency medicine required reorganisation for fewer physicians could practice general internal medicine effectively - many sub-specialists lacked competence in common medical causes of admission. Medical assessment units and medical admission units were now usual. The Royal College of Physicians suggested that a new specialty should form - physicians whose prime responsibility would be to manage the acute medicine service, lead multidisciplinary teams and support colleagues in A&E departments, in high dependency units and on general wards.
The Department of Health looked at reconfiguration in 2002 and in 2003 published Keeping the NHS Local, guidance soon withdrawn as the pendulum was swinging in the opposite direction. There were often objections to proposed changes of service. In 2003 the Independent Review Panel was set up to advise the Secretary of State for Health on contested reconfigurations in England and to give advice about proposals formally referred to the Secretary of State for decision. Its establishment derived from the NHS Plan (2000). Legislation gave councils with social care responsibilities the power to scrutinise matters relating to the health of local people by local authority health overview and scrutiny committees (HOSC). The panel, that reviewed 19 cases in the next ten years, sometimes supported the proposals, but often found that their basis was doubtful or they had not been presented effectively to local people.
Re-configuration was also influenced by clinical networks. Cancer and neonatal paediatric care networks involved cross referrals from local units to more specialised ones. Another model developed in ophthalmology in London where Moorfields NHS Foundation Trust, developed multiple peripheral centres providing outpatient services and some surgical and inpatient care as well. Locally based staff were Moorfield's staff and by 2007 Moorfields was providing the ophthalmological services for St Georges', Barts and the Royal London, Homerton, Watford, Barking, Mayday Croydon, Northwick Park and Ealing. Moorfields had found a way of increasing the hospital's population base, necessary for its survival and its research and education, and providing a good clinical service to hospitals that would probably not have been able to provide it themselves. Moorfields linked with University College London, through the Institute of Ophthalmology, and to City University as its academic partners. The Royal Marsden, similarly, opened a satellite unit at Kingston.
Treatment Centres were established to help meet waiting time targets by increasing capacity, introducing competition, forcing efficiency and increasing patient choice. Some were NHS but independent sector centres were also built and opened (ISTCs). They aimed to offer fast, pre-booked day and short-stay surgery and diagnostic procedures for which there were often long waiting times, such as ophthalmology and orthopaedics. In 2001 plans were announced to build 26 centres in England at new and existing hospitals financed by PFI or public funds. The Prime Minister announced that 250,000 consultant episodes, some 8% of the total, would take place in the private sector. The first wave of ISTCs were guaranteed volumes of patients and payment some 15% above NHS tariff costs to recognise the start-up costs. In October 2004 a second wave doubled the prospective case load to 500,000. The contribution of the private sector was small, but its existence made it easier for hospital management to improve hospital working practices and reduce waiting times.
Many trusts felt that they could provide additional capacity themselves. They resented attractive contracts to the private sector when some NHS centres, including the pioneering one at the Central Middlesex Hospital, were working at far below capacity. Reporting in 2005, the Department of Health said that 29 centres, NHS and private, were in operation and 100,000 patients had already been treated. There were however concerns about the effect on the training of young surgeons in the UK and about the quality of the surgery being performed. Assessment of the policy and of the centres was virtually impossible because of poor routine data collection systems and the insistence that data was 'commercial in confidence'. There seemed to be a policy decision not to undertake an evaluation. The Parliamentary Health Select Committee reported ambivalently on the ISTCs in 2006, and the government defended the programme in its response. The gloss was going off the idea. Seven of the second wave of ITCs were cancelled and others were delayed. Some contracts were cancelled, compensation being paid.
Hospital designs changed dramatically with more emphasis on aesthetics and adaptability. National standard designs were out and projects were generally one-offs. Single bed rooms, standard elsewhere in the world, might combat cross infection and MRSA. Information technology and remote diagnostics would also affect design. However economies meant that bricks and roofs were often of cheaper materials.
Until 1991 all major capital expenditure in the NHS had been funded by central government. The NHS did not have to pay interest or repay capital, so in effect new equipment and buildings came "free." But for twenty years there had been a squeeze on capital expenditure and hospital building stock was recognised to be in a poor state. The Private Finance Initiative was always a trade off, for the money was more expensive than central funds would have been, but as that money was unavailable hospitals could be built that would otherwise never have existed. A substantial rise of investment in hospitals began.
Under the Conservatives from 1992 hospital development was based on reliance on private finance, the Private Finance Initiative, (PFI). A good idea, it became increasingly costly and cumbersome. Labour developed this policy, later referred to as public-private partnership. Major schemes were typically "DBFO" - a private consortium designed the facilities to NHS requirements, built them, financed the capital cost and operated their facilities. The NHS paid an annual fee to cover the capital cost, maintenance of the hospital and any non-clinical services provided over the 25-35 year life of the contract, after which it would be handed over in good state. As contracts could include staffing and clinical services unions opposed schemes in which private companies could set their own terms and conditions of service.
PFI became "the only game in town". The number of schemes under PFI was overwhelming. Government argued that PFI would result in better hospital designs, the private partner taking on the risk of construction cost and time over-runs, and more efficient maintenance. (Guy's Hospital Phase 3 rose in cost by over 300% and was three years late.) Critics, such as Allyson Pollock, believed it was locking the NHS in to expensive 30-year contracts. PFI more than doubled the cost of capital as a percentage of trusts' annual operating income. (BMJ 2002;324:1205-1209). A select committee of the House of Commons reported in 2002 that PFI was being blamed for ills not directly related to it, whereas the many benefits ascribed to it had yet to be proved; and recommended that more capital was found from central sources for major schemes so that PFI projects could be compared with conventionally procured ones.
An "outline business case" was prepared for central approval. A detailed statement of content and who should bear the financial risks was submitted. There was usually a reduction of beds to curtail acute sector in favour of care in the community and cut costs. Private finance was more expensive than public borrowing and services might be designed to fit pre-determined financial allocations. Around 2000, was it accepted that reducing beds in the acute sector had gone too far and a reduction in capacity was no longer seen as a virtue.
Between May 1997 and March 2002 64 major PFI hospital developments were approved with a total capital value of more than £7.5 billion and 11 were completed and operational by early 2002 including Carlisle, Dartford & Gravesham, South Buckinghamshire, Greenwich, North Durham, Calderdale, South Manchester, and Norfolk & Norwich, Hereford and schemes at Worcester and Barnet & Chase Farm. For a few schemes, e.g. Sheffield, government pledged public funds. By 2006 24 PFI schemes were complete and operational, with a total capital spend of £2.1 billion. Another 14 schemes were approved, to a value of £3 billion. In preparation were other schemes worth another £12.1 billion, at various stage of negotiation including cancer and cardiology the Bart’s and the London and the University Hospital Birmingham schemes. With an annual spend of some £3 billion, the construction now under way was, in real terms, the largest programme that the NHS had seen. (List of schemes to 2007)
The downside was that the cost could be 20-30% more than money lent by the exchequer, and closure of PFI units would incur high compensation payments. Future hospital planning was hog-tied as there were surprisingly high costs in altering a hospital. The National Audit Office, examining the Dartford and Gravesham Hospital in 1997, found that the savings were less than had been calculated. PFI appeared to be less open to outside scrutiny, sometimes led to developments that might be smaller than clinically required and to create a substantial future revenue burden. Relatively modest expansions were hanging round the neck of Trusts. Some were so costly to run that they risked permanent deficit, and savings could be made only but cutting services at older hospitals that were cheaper. Decisions on closures were likely to be made on economic grounds, rather than on patient need and care.
In southeast London the PFI schemes at Queen Elizabeth Hospital Trust in Woolwich, Bromley and Lewisham imposed an immense burden; the QE was in effect bankrupt because of the annual payments to be made. A major reconfiguration project in South-East London known as “A Picture of Health” started in 2005, lasting 6 years.
In 2006 Government established a rapid review lest this situation became commonplace, in particular of the Barts/Royal London scheme which would pre-empt a substantial proportion of revenue, jeopardizing patient care in those hospitals and others further a field, but agreed that this should proceed. A further 6 schemes were examined, sometimes trimmed, and approved as they were considered to be financially sustainable over the long-term.
While the Conservatives favoured competition, Labour used central control, targets, clinical guidelines (NICE), inspection and hit squads, and rating systems. The Department of Health developed global measures of hospital performance. The first system from 2000-1 gave zero, one, two, or three stars. Indicators such as inpatient and outpatient waiting times, cleanliness and financial results, were pulled together in a formula that relied on the data available and not the effectiveness of clinical care. In adult critical care there was no relationship between outcomes and star ratings. The system was not aimed to assist patient choice but to target hospitals with poor management, or select hospitals that could be trusted with a greater financial or management freedom. Three star trusts would have greater freedom to manage their own affairs. Those with no stars were at risk of central task forces, to 'work with them'.
The league tables were odd. Some prestigious hospitals were found to be unsatisfactory, though many of those failing had major problems to face, rebuilding, hospital mergers or the implementation of major new information systems. Others had adopted many forms of good practice without it showing in the assessment. Star ratings were dependent on data the trusts themselves had supplied and some was fallacious. All zero star hospitals were in the southeast where people were healthier, but it was more difficult to recruit quality staff on national pay scales than in the north. The Audit Commission in reviewing progress towards the NHS Plan (Achieving the NHS Plan) in June 2003 found little correlation between star ratings and management, financial stability or clinical outcome. Similarly published results from Dr Forster, an independent healthcare assessment organization, showed that standardized hospital mortality showed no correlation with the number of stars awarded to hospital trusts. (The Times, May 12, 2003, p 4) The no-star Dartford and Gravesham was given new management, as were three other no-star trusts, but this idea (known as franchising) was gently dropped, to be revived again in 2008 when a "tough new performance regime" was promised. In general competent NHS managers, rather than taking on a failing hospital, preferred to maintain their own hospitals.
The star system was dropped in favour of systems developed by the Healthcare Commission to examine different facets of performance.
Many of the proposals in the NHS Plan were designed to improve hospital care.
More hospital building
More doctors and more nurses. Staffing was a constraint on development of the NHS. Workforce Development Confederations were established in 2001, commissioning training programmes and managing contracts. Coterminous with Strategic Health Authorities, they were integrated with them in 2003. A strategy for HR More staff working differently, was issued in July 2002.
Improved hospital cleanliness
Hospital food, long a subject of criticism. A report by the Nuffield Trust (1999) had shown that much food was wasted because it was served at rigid times, was unattractive, and patients who needed help with feeding often did not receive it. A team of professional chefs was recruited and produced a book of "Chef's Recipes". The cost of the recipes being high, hospitals delayed their introduction. Some patients preferred their traditional cottage pie to celebrity cuisine.
The aim that by 2003-4 two-thirds of outpatient appointments and elective admissions would be pre-booked, and no longer subject to waiting lists.
The Modernisation Agency, established in the wake of the NHS Plan, distilled its recommendations for the improvement of hospital systems into ten "high impact" changes.
1. Treat day surgery as the norm for elective surgery
2. Improve access to key diagnostic tests
3 Manage variation in patient discharge
4 Manage variation in patient admission
5 Avoid unnecessary follow-ups
6 Increase reliability of performing interventions: a care bundle
7 Apply a systematic approach to care for people with long-term conditions
8 Improve patient access by reducing number of queues
9 Optimise patient flow using process templates
10 Redesign and extend roles
Source: Health Service Journal supplement 9 September 2004
Cross border health care
A ruling by the European Court of Justice in 2001 that medical care in hospital was subject to European law on the free movement of services, and that prior authorization was an obstacle to free movement of patients, raised important issues. The Court ruled that patients had the right to seek treatment aboard if they faced undue delay led to the possibility of health authorities placing patients in pain who had already waited months for knee and hip joints with European hospitals, where rapid and effective treatment was available. The legal background for overseas treatment was strengthened when, in 2003, a High Court judge, Mr. Justice Munby ruled that "if treatment in this country under the NHS is unduly delayed, then an NHS patient is entitled as a matter of European law to travel to another member state, there to be treated on terms requiring the NHS to reimburse the cost of that treatment. lan Milburn agreed to allow overseas treatment if after clinical assessment the patient wanted it and the primary care trust could meet the cost from its budget. The Department of Health coordinated pilot areas for authorities wishing to buy packages of operations from continental hospitals. In January 2002 the first group of nine patients left for Lille, and accommodation a world away from crowded NHS wards. Evaluation by the Health Economics Consortium at York described the experience of the first 190 patients as "very positive". Once the trial was over few further patients were sent. The priority both for the Department and for health authorities was expansion of capacity at home.
The European Commission published proposals for how citizens of the European Union should obtain health care in other member states in 2008. The commission's proposals had three main strands; values (universality, access to good quality care, equity, and solidarity) and principles (quality, safety, care based on evidence and ethics, patient involvement, redress, and privacy and confidentiality), second, aspects of cross border care not already covered by existing legislation, such as that covering people who fall ill while temporarily abroad. Key elements relate to people who choose to go abroad to obtain care. Third, mechanisms to foster European collaboration on health services, such as shared facilities in border areas, common methods of technology assessment, and centres of excellence for rare conditions. BMJ 2008;337:a610 Lengthy debates by member states seemed inevitable.
In 1997 Frank Dobson commissioned Sir Lesley Turnberg and a panel to undertake a strategic review of health services in the capital. Turnberg said that London no longer could be considered over bedded compared with the rest of England. London had made radical efforts to reduce the number of "surplus" beds. but now not merely elective surgery but emergency admissions were jeopardized. The problems of inner city primary care remained.
The panel considered a number of capital developments within five sector plan already adopted by the University for medical schools, approving the development proposed for the University College London hospitals, and modifying the proposals for St Bartholomew's Hospital and The Royal London. A £422 million private finance initiative to unite the University College London Hospitals on a single site came to fruition with its opening in 2005. In 2001 UCLH purchased the old National Heart Hospital, now converted into a state-of-the-art private heart unit. Planning for the redevelopment of the Royal London Hospital made progress. Attempts were made to improve primary health care. There had been high hopes for the London Initiative Zone, established in 1993 to introduce innovative approaches to problems and develop cost-effective care outside hospital. A review five years later showed a mixed picture. London still had fewer young GPs, more single-handed practices and larger lists. Although primary care in the capital was improving, it was not doing so more rapidly than elsewhere in the country. The initiative was terminated.
Organisational change in London
There have been two main patterns for London's health service planning - the "starfish" with a radial organisation reflecting the transport links and the "doughnut" with the elite hospitals, the cream, in the middle. Bevan had chosen the starfish and London had been divided into four radial health regional hospital boards. The arguments for such a pattern were now weaker. A London region had been proposed in the Tomlinson Report (1992). In June 1998, the Secretary of State, Frank Dobson, decided that from 1 April 1999 London would become a single NHS region (a doughnut). This would give greater cohesion and coterminosity with government departments and local agencies, including local authorities. Change would have ripple effects on the surrounding areas. A new boundary at the western side of Bedfordshire would separate an Eastern region from a large ‘L’ shaped South-eastern region. Covering 7 million people, the London region had 100,000 employees and a budget of £7 billion. However, the University decision to go for five radial strategic health authorities and the decision to abolish first regions and then Departmental regional offices returned the starfish to favour. Five radial strategic health authorities were established within London in 2002 - but in 2006 the five SHAs were amalgamated into a single NHS London. Changes in organisational structure made centralised planning difficult and the establishment of Foundation Hospital Trusts increased the power of some hospitals to determine their own future.
Ten years after the Turnberg report, David Nicholson, then chief executive of the London SHA, commissioned Professor Sir Ara Darzi, to review the health services in London. His first report in March 2007, The case for change, outlined reasons for change, for example health inequalities, failure to meet patients' expectations and value for money. The follow-up, A Framework for Action, was published in July 2007, just after the author had been appointed by Gordon Brown as a junior health minister and ennobled so he could act for Labour in the House of Lords.
The report was the product of many hands. Technical groups had looked at the nature of the London population the trends and likely health problems in London in the future. Clinical groups had considered the care pathways best suited to differing groups of patients. A changed pattern of health service organisation was proposed. London primary care would be provided by 150 polyclinics, handling much care previously undertaken in hospitals. The number of major acute hospitals would be cut by more than a half, and there might be some 12 specialist hospitals and 8-16 major acute hospitals. Trauma, accidents and emergency surgery would be reorganised. Supporting papers dealt with the clinical problems of other specialties including maternity, long term, mental illness and terminal care. Patients with emergencies would be admitted to the hospital best suited to their needs.
Brilliant in conception, clinical in slant, but a recipe for turbulence according to the Guardian, it was a blueprint for radically different NHS, not unlike the 1920 Dawson report. Some conclusions flowed directly from the evidence. Others were less well founded, for example there was no evidence that polyclinics were the answer for every locality, reducing ease of access even were they affordable. Neither was it clear how far this top-down concept fitted with patient choice, the freedom of foundation trusts, practice based commissioning or payment by results. Darzi had no knowledge of general practice. There was a naive belief that polyclinics could be created and money saved by transferring perhaps half hospital care into them. Other reports followed.
more healthcare should be provided at home
new facilities – polyclinics – should be
developed that can offer a far greater range
of services than currently offered in GP
practices, whilst being more accessible and
less medicalised than hospitals
local hospitals should provide the majority of
most high-throughput surgery should be
provided in elective centres
MAJOR ACUTE HOSPITALS
some hospitals should be designated as major
acute hospitals, handling the most complex
existing specialist hospitals should be valued
and other hospitals should be encouraged to
ACADEMIC HEALTH SCIENCE CENTRES
Academic Health Science Centres should be
developed in London to be centres of clinical
and research excellence.
The sixth decade of the NHS, 1998-2007, saw revolutionary changes in medical education, staffing and the roles of doctors.
The establishment of new and expansion of established medical schools
A major increase in the number of medical students
Exponential growth in medical knowledge with reshaping of the undergraduate syllabus
Attempts were to improve postgraduate education and with a new pattern, Modernising Medical Careers
New contracts with hospital consultants and general practitioners aiming to improve productivity and quality but major errors in negotiation led to massively increased bills and sometimes to a poorer service
During the decade the numbers of students starting medical studies rose by two-thirds. Doctors number some 100,000 out of more than a million workers in the NHS, government is responsible for the costs of medical education and is also the main employer of doctors. The 1968 Royal Commission on Medical Education (Todd) recommended a doubling of medical school intake to 4,230 by 1980, numbers not achieved until 1992. Planning was often based upon pessimistic assumptions about growth in health expenditure rather than changes in the size of the population or the services needed. Treasury insistence on limiting expenditure and professional concerns about medical unemployment went virtually unchallenged. Small increases were suggested by the Medical Manpower Standing Advisory Committee from 1991 onwards but then policy altered.
In the late 1990s it was decided to reduce the huge dependency of the NHS on foreign trained graduates by expanding medical school places by 40%. Plans to improve the capacity and quality of the NHS were crucially dependent upon professional staff,s and it was clear that there were too few. A major expansion of training facilities was set in hand. ( Smee C, Speaking Truth to Power, Nuffield Trust 2005). In view of the increasing workload and the working life of doctors (30 years for a man and 22 for a woman) the third report of Medical Workforce Standing Advisory Committee in 1997 (a subtle change in name reflecting the women's entry) proposed that the UK should aim for self-sufficiency. Planning the medical workforce. Third report, London: Department of Health, 1997 . The annual student intake should be increased by 1,129 above the 1996 figure of 4,820, in the most cost-effective way as soon as possible. Though the Advisory Committee was subsequently abolished, when Labour announced additional money for the NHS in July 1998 some was for the expansion of medical (and nursing) education. This enlarged intake coincided with a resource reduction from university sources for medical schools, particularly as the money from research grants fell. The Schools felt that they were being expected to train more students at the same time as they were having to make medical school staff redundant. The problems of academic medicine were highlighted in the CMO's annual report on The State of the Public Health for 2004.
The NHS Plan (2000) promised a further increase of 1,000 in medical school places to nearly 7,500. The Joint Implementation Group, (joint between the Higher Education Funding Council for England (HEFCE) and the Department of Health), allocated new places through a competitive bidding process taking account of regional priorities, innovation, quality, graduate entry, widening participation and value for money Universities scrambled to secure new student places and the money that went with them.
In England there had been no new schools for 30 years but in June 2000 and March 2001 Alan Milburn announced new schemes. In 1999, 2000 and 2001 the HEFCE invited bids for the additional places. The pattern of medical education was changing radically, as indicated by a map prepared by the HEFCE. The Wanless Review (2002) agreed that the need for substantial increases in the demand for health care workers over the next 20 years might lead to a substantial shortage of doctors.
The welcome but abrupt rise in numbers took place between 1997-98 and 2006-07 with a 71 per cent increase in medical school places. Intake to English medical schools increased from 3,749 in 1997-98 to 6,194 in 2006-07, partly because of new medical schools some established in collaboration with existing medical schools, bringing the number of medical schools in England to 24. By 2008-9 the number of doctors graduating from medical schools had increased to around 5,684.
Medical schools in London had found difficulty in providing adequate clinical experience; similar problems now appeared elsewhere. Reduction in bed numbers, lack of clinical academics, and changing patterns of work that reduced the time middle grade doctors had for student teaching compounded the problem. Medical schools found it increasingly hard to choose from the many applicants with good A level results. Most of them adopted an additional UK clinical aptitude test (UKCAT) and the Graduate Australian Medical School Admissions Test (GAMSAT) was used for several UK graduate entry medical schools. Alan Maynard was scathing about the policy of self-sufficiency, seeing ‘nothing wrong with employing people trained in excess by misguided foreign states’.
|New medical (joint) schools ||New stand-alone school||New schools initially associated with existing schools|
|Peninsula Medical School (PMS -Plymouth & Exeter) opened 2002 (later gaining a dental school)||East Anglia - opened 2002 (UEA)||Newcastle with Durham|
|Hull York - opened 2003 (HYMS)|| ||Warwick initially associated with Leicester, independent from 2007|
|Brighton and Sussex - opened 2003 (BSMS)|| ||Keele initially a teaching site for Manchester but independent from 2007|
| || ||Nottingham at Derby|
Medical school intakes 2005-06 onwards
2005-06 planned total intake
2005-06 planned home intake
2005-06 planned overseas intake
University of Birmingham
University of Brighton
University of Bristol
University of Cambridge
University of East Anglia
University of Hull
University of Keele
University of Leeds
University of Leicester
University of Liverpool
King's College London
Queen Mary, University of London
St George's Hospital Medical School
University College London
University of Manchester
University of Newcastle
University of Nottingham
University of Oxford
Peninsula Medical School
University of Sheffield
University of Southampton
Source: Higher Education Funding Council website
See also intake
The new medical schools took full advantage on the GMC reforms, integration of basic and clinical sciences, use of community settings for teaching, early contact with patients and a wider basis for student selection. Some like Keele began as a clinical site for an existing school (Manchester). When government announced funding for new medical schools, Keele University applied, admitting its first students in 2007. Universities previously without a medical school lacked the experience of older established institutions. New schools might not understand the close linkages of service and education and the need to ensure that student placements matched the clinical linkages and networks that were needed. They stressed the role of the community in teaching, encouraged joint training of medical, nursing and other health professions.
Traditionally more students from social class one were accepted into medicine than the combined totals of classes 3,4 and 5. Many thought that tomorrow's doctors should reflect the diversity of the community which led to attempts to recruit students from a wide social and ethnic range (e.g. Leeds at Bradford) and also to attract graduates of other disciplines. Some schools attempted to attract bright students from low achieving schools. An extended medical degree programme at King's College was established in 2001, accepting students with comparatively poor A level results, taking 6 years rather than 5. Extra academic support was needed, but such students had a high rate of success. The move from student grants to student loans was thought to have led to the entry of more students from a middle class background.
A number of proposals met the objective of widening participation:
Universities of Bradford and Leeds – a collaborative scheme to recruit students from a broader range of social and ethnic backgrounds
University of Birmingham – to attract an increasing number of students from local socially deprived areas
University of Southampton – to enhance multi-professional training and curriculum innovation.
Graduate entry courses
New forms of medical course, reducing the length from five to four years, were introduced on the recommendation of the Medical Workforce Standing Advisory Committee (MWSAC), were for mature students and graduates in other fields, not necessarily scientific. Ten courses were introduced at well established schools and Warwick separated from Leicester in 2007 to become a solely graduate medical school. Perhaps up to a thousand students a year would eventually qualify in this way and clinical facilities were expanded by the use of hospitals not previously used to students.
Leicester and Warwick
|Oxford||Queen Mary (London)|
The CMO summarised progress in a document Medical Schools - Delivering the Doctors of the future.
In 2007 the University of Birmingham was commissioned to carry out an independent review into the expansion of medical school student numbers and reported on the many changes, including the increased number of mature entrants and reduced number from social classes 1 and 2.
The University of Buckingham - a private university - planned the UK's first private medical school, and to provide a postgraduate qualification.
Changes to the curriculum
Medical student education was changing and, in line with guidance from the General Medical Council in 1993 (Tomorrow's Doctors) the slant in all schools altered. The vast increase in medical knowledge meant that swathes had to be moved into the period of postgraduate training. Medical students in some schools might now qualify without having delivered a baby or repaired a tear. The stress on factual knowledge decreased and more was placed upon self-learning, communication skills and sociological understanding. The GMC guidance was revised in 2003 (& again in 2009) and continued to stress "touchy-feely" qualities as well as the need for a knowledge base, and keeping up to date. The medical student's curriculum tried to integrate scientific knowledge and clinical practice from the earliest weeks and to encourage students to be problem solvers. Education became "outcome focussed" and "topic" based. Problem based learning, and teaching across professional disciplines was introduced particularly in the new schools. Students were increasingly learning outside the walls of the teaching hospital. The foundation in biomedical sciences now included cell biology, molecular biology and genetics; and in the US the events of 9/11 led to the addition of problems of bioterrorism. Older professionals - and some patients - were worried lest excellent interpersonal communications masked ignorance of basics, such as the ability to name the main bones or know the anatomical positions of nerves. The decision in 2002 by the new Peninsula medical school to remove anatomical dissection of the body completely from its medical course was not reassuring but anatomy was now studied in different ways including sophisticated imaging.
Earlier there had been a downward trend in the number of applicants for medical schools, perhaps due in part to the reduction in the number of students taking chemistry at A level, a requirement of most schools. The selection ratio, the number applying for each place, began to rise in 2002 and the demography of the student population was changing. Compared with the general population, white males were under represented, while conversely there was a substantial proportion of men and women from an Asian background. A report by the British Medical Association in 2004 showed that
- In 2003, 21% of those accepted into medical school were over 21, compared to 9% in 1996
- In 2003, 61% of entrants to U.K. medical school were female, compared to 29% in 1963
- 59% medical school applicants came from the highest social classes
- In recent years applicants from these groups were twice as likely to be accepted as those from working class backgrounds
- Medicine attracts a higher proportion of ethnic minority students than other courses, but acceptance rates vary between ethnic groups
- 73% of medical school applications from white and Asian students are successful, compared to 39% for students from black African backgrounds
source The Demography of Medical Schools, BMA 2004. This report was updated in 2009
The NHS and the medical profession was having to adapt to the increasing number of women in the profession, just over a third of hospital doctors and GPs. The high proportion might, in the view of Professor Carol Black PRCP have substantial long term effects. Medicine was being feminized whilst previously it had been dominated by white males. Would the profession maintain in the future the same status and influence, in view of the difficulty women had in doing all the things formerly seen as part of professional life - research, teaching, medical politics, societies, committees, regulatory bodies and government advice? (Independent 2 August 2004)
In 2005 a new type of professional was proposed, Medical Care Practitioners (MCPs), modelled on the US Physicians Assistants, to help doctors and nurses to treat patients in both primary care and hospital settings. After training and under the continuous supervision of a physician, healthcare professionals would be able to:
- Obtain full medical histories and perform appropriate physical examinations such as breast checks
- Diagnose, manage and treat illnesses within their competence such as depression, gout and eczema
- Request diagnostic tests such as ECGs and interpret the results
- Provide patient education and preventative healthcare advice regarding medication, common problems and disease management such as diabetes care, chronic respiratory conditions and angina
- Prescribe medications as appropriate
- Decide on appropriate referral to, and liaison with, other professionals.
Developments in medicine such as interventional radiology, and changing policies, affect the number and skills of the doctors needed, a need met either by planning decisions 10-15 years previously or immigration. In the last years of the 20th century some 40% of doctors entering the NHS came from overseas. The decision to expand medical student intake in the 1990s to achieve self-sufficiency was confounded by the inability to give priority to home-trained graduates over skilled people from overseas who had a right to enter the UK job market. The medical market place is increasingly international, but how did one take account of doctors training in Europe and British citizens who go to overseas medical schoolsand then want to return, let alone well qualified doctors from elsewhere in the world? .
The Calman scheme, which mainly affected the later years of training, was followed in 2004 by a new initiative, Modernising Medical Careers (MME). In 2004/5 the Postgraduate Medical Education and Training Board was established to develop a single, unifying framework for postgraduate medical education and training taking over the responsibilities of the Specialist Training authority of the medical Royal Colleges and the Joint Committee on Postgraduate General Practice Training. MME, like Calman, had its origin within the Department of Health and the desire to shape medical training to meet the needs of the hospitals and the NHS, rather than the education and training. It aimed to reform the SHO grade that contained half of all doctors in training, criticised for combining a high work load with poorly structured training opportunities. In 2005 a Foundation Programme Curriculum was introduced that would provide a structured two-year training to give trainees exposure to a broad spectrum of specialties including accident & emergency, obstetrics & gynaecology and anaesthetics. Each trainee would experience primary care and the chance of experience in smaller specialties and academic medicine, not normally available at this stage of training. The second year would effectively replace the SHO grade, require high quality training with progress dependent on competence rather than time in post. As in the case of Calman education seemed to be placed ahead of service needs, but. the changes to a tried and trusted system, produced problems for both. Young doctors, rotating through multiple posts, would probably make a smaller contribution to running the service. Trusts would be relying increasingly on staff grades and consultants or perhaps, as in the US, physicians assistants.
Subsequently doctors would opt for either a general practice registrar or a specialist registrar post (SpR - at least four years) with formal training programmes. There are two types of specialist registrar training. In type I there is the assumption that training should lead to consultancy, and there are annual in-training assessments. Satisfactory performance leads to the award of a Certificate of Completion of Specialist Training (CCST) and entry to the Specialist Register held by the GMC. The Specialist Training Authority (STA), supported by a recommendation from the relevant royal college or faculty, decides whether or not an individual doctor has met the standard required for a specified training programme, to merit the award of a CCST. Type II specialist registrars have fixed term training appointments, and the programmes are designed to meet the needs of the individual doctors, but they do not lead to a CCST. Doctors are able to transfer from a type II to a type I post if they are successful in open competition. London teaching hospital trusts are best supplied with training posts.
By 2006 the new scheme was in operation and it ran into difficulties. In 2007 it was worse. Young doctors from several years were competing for a single year's posts, and computer system of the Medical Training Applications Service which was expected to provide a level playing field was flawed, as it failed to select appropriate junior doctors for training posts. Inappropriately qualified candidates might take precedence over better trained ones. Doctors in SHO posts had to compete with those from the growing UK medical school output and with doctors who had come from overseas under the Government’s Highly Skilled Migrants Programme (HSMP) so there were far too many applicants, 28,000 applicants for 15,500 training places. The system could not cope with the volume of applications, limited the number of applications doctors could make, made judgments on doubtful criteria ignoring past experience, and failed to produce adequate short lists for interviews. Many faced the blighting of their careers, and possible emigration. The medical profession that had been party to the development of the system, but whose warnings had sometimes not been heeded, was united in protest along with hundreds of candidates. Professor Alan Crockford, the National Director of Modernising Medical Careers resigned. Sir Liam Donaldson, the chief medical officer, rejected the suggestion that he to should go.
The Department of Health announced an urgent independent review chaired by Sir John Tooke, Dean of the Peninsula Medical School, Chair of the Council of Heads of Medical Schools and Chair of the UK Health Education Advisory Committee. This examined the genesis of the problem and issued an interim report in October 2007. Modernising Medical Careers (MMC had been, Sir John said, a sorry episode from which nobody had emerged with credit. According to his hard-hitting interim report the changes to medical training introduced since 2002 had been rushed, poorly led and badly implemented. They did not provide doctors with enough broad experience because it encouraged them to specialise early in their careers, nor did they allow for enough flexibility to meet NHS needs. The report called for fundamental reforms for the system had been introduced without any clear definition of what it was meant to achieve, while weak departmental policy development, implementation and governance made it even worse. The way the programme was designed “was unlikely to encourage or reward striving for excellence”, the interim report concluded.
The Department agreed with the profession a modified and more local process for the coming year and the handling of applications from outside the country. With increased English medical school entry from 3,749 in 1997 to 6,451 in 2007, the NHS was less dependent on international medical graduates (IMHs). If UK medical graduates, trained at great cost, could not obtain specialist training because of a large number of applicants from outside Europe, then it was right to consider change; shortly after restrictions on IMG job applications were put in place.
The NHS Confederation and its branch, NHS Employers, saw manpower planning as a major issue. Medical graduates had unrealistic expectations and there was a need to persuade people to enter fields where the demands were greater, even if they are less glamorous
Modernising Medical Careers was not flexible enough and in future those being trained must be able to move between specialties and into research and academia, or into a post that does not head towards being a consultant. A linear pathway with no opportunity to change helped nobody.
Depending on the management of international competition, if we cannot control the entry of international medical graduates we are seriously overtraining medical students in the UK
There needs a greater understanding of the relationship of education and the service and what each requires of the other.
Sir John Tooke's final Report was published in January 2008 after extensive consultation on which there had been substantial agreement. The report argued for the separation of the first two years, allowing universities to guarantee a first medical post to their graduates. To the previous proposals was added the need to ring fence the money needed to train the next generation of doctors to prevent the NHS spending it on other priorities as it had in 2007 when the service was in financial deficit. It also recommended that postgraduate education should be managed by a new body, NHS Medical Education England (NHS-MEE), and taken out of the hands of the Department of Health after its mismanagement of funding and job applications.
The Department of Health's response in February 2008 glossed over the gravity of the problems there had been, said there had already been much progress, accepted many recommendations (some "in principle") and categorised many of the more difficult ones as requiring further work. Substantial ones such as a ring-fenced budget and NHS-MEE were in this category of "not now but we might think about it." Among the recommendations accepted was to bring the Postgraduate Medical Education and Training Board into the General Medical Council by 2010, bringing all stages of medical education and training under one roof. In May 2008 the Commons Select Committee on Health was also highly critical of the chaotic planning and poor coordination with the Home Office over immigration controls.
Trusts' first priority was to keep the service running within restrictions on working hours for doctors in training and the European Working Time Directive. BMJ 2003;327:961-964 . They increasingly appointed doctors to hospital posts created for this purpose despite the Department of Health ceilings on training grade numbers, as Trusts tried to comply The new posts were generally in acute specialties and did not conform to the standard NHS grades and were on terms and conditions set by individual trusts. Those roughly at SHO level were usually referred to as 'trust doctors', and those with 3 or more years relevant experience as staff grade, hospital specialist or 'associate specialist', non-consultant career grade posts. The doctors appointed were often from outside the European Economic Area, had widely varying experience and might not have specialist qualifications. They were employed to work, not study, and there was often no strategy for their education or supervision. The number of such posts increased rapidly and in 2003 there were around 5000 doctors on local contracts for whom the national grade was unclear. It was hard to move from such posts to consultant ones. Some remained in such jobs until retirement. Their growing numbers, and the limited extent of career development open to non-consultant grade doctors, created increasing problems, an underclass of doctors, something strenuously avoided in the early years of the NHS. In 2005 negotiations began on new contracts and pay scales for these doctors.
European Working Time Directive
The Directives substantially changed the way medical care was provided in hospital and had more effect than the "new deal" on junior doctors' hours. To cover the work hospitals needed more doctors than existed in the current training-post quota. Covering nights and weekends would be difficult as the Directives specified
No more than 48 hours work per week,
11 hours continuous rest in 24 hours,
24 hours continuous rest in 7 days,
20 minute break in work periods of over 6 hours
for night workers an average of no more than 8 hours work in 24.
Guidance to the NHS suggested several options including developing new healthcare practitioner posts, sometimes utilizing experienced nurses to take on work currently carried out by doctors,
Examining the pattern of work at night, when the demand for surgery was low (mainly obstetrics and emergencies) and more physicians and specialists in intensive care were needed. Smaller emergency night teams, with a different skill mix, could cover a hospital at night
Fewer tiers of cover linked with new working patterns
New EWTD compliant service models which also improve the quality and safety of patient care
The problems of providing a safe service were complex and hospitals struggled to conform. In the middle of the night a patient needed somebody to take complex decisions, and the competence to carry out specialised procedures, impossible without appropriate training and experience. If hours of work were to be limited, at least five specialist registrars were needed in each subject, and if educational commitments were taken into consideration, double that number. Ten were needed in order to have one specialist registrar for 24 hours every day with a reasonable amount of work in ‘normal hours’ for training, skill development and in-patient management, and cover for leave.
The effect of the Calman pattern of training and the European Working Time Directives was to reduce substantially the time between becoming a senior house officer and appointment as a consultant from some 30,000 hours to 8,000 or less. It seemed inevitable that the experience and skills of newly appointed consultants would be less than in the past, probably as generalists and almost certainly in advanced subspecialties. The NHS - and many European health care systems - would need to undergo dramatic changes even to comply with rules specifying an average working week of 58 hours, reducing five years later to 48 hours.
A survey of emergency cover at 211 hospitals by the Royal College of Physicians showed that in June 2003, 14 months before the Working Time Directive was due to be implemented, 166 acute hospitals in England (78.7%) did not have sufficient specialist registrars to provide continuous cover of acute medical admissions; if middle grade "Trust" doctors were used on a rota in addition 134 acute hospitals (63.5%) would still not have sufficient to establish workable full-shifts.
World wide, job dissatisfaction within the medical profession was growing and the reasons ranged, according to The Lancet, far wider than money. Apart from overwork, stress, and underfunding of the health service, surveys suggested poor opportunities for training, the rising trend in medical litigation, bullying, and racism. One factor increasingly generating intense frustration among doctors was the steady erosion of their autonomy over management of patients as the NHS, and elsewhere health-maintenance or health-insurance organisations, tightened their rules on the pattern of clinical work and how and which patients could be treated.
The loss of doctors from the NHS remained stable. Surveys of those qualifying from 1977 onwards showed that some 80% of both men and women were working in medicine in the NHS. The proportion working in general practice however had fallen. There was an accelerating trend for consultants to retire early, and greater demand for them in a "consultant delivered" rather than a "consultant led" service. There were higher numbers of women doctors in the hospital service (33% in 1998), some of whom chose to take a career break. About half the women were working part-time. Studies suggested that young doctors viewed commitment to the NHS differently. While prepared to be committed to fulfill a reasonable contract, they demanded time for self-fulfillment and family responsibilities in a way that previous generations of doctors had not.
It was generally agreed that there was a shortage of indigenous, UK trained, doctors both in general practice and in hospital medicine that could only be remedied in the long term by increasing student numbers as a result of which medical schools were expanded. The NHS continued to rely extensively on doctors from overseas. 10% of Senior House Officers came from the European Economic Area, and 28% from outside it. Year on year, half or less of the doctors registering with the GMC had received their medical education outside the UK. To try to meet the pledges on the number of NHS doctors made in the NHS Plan, Government began a world-wide advertising campaign for consultants and GPs in September 2001. Sir Magdi Yacoub, recently retired from transplant surgery, was recruited as a global talent scout for the NHS, an initiative similar to one employed during the 1960s 'brain drain' and no more successful. Pay awards in 2001 aimed to increase recruitment, particularly into training posts for general practice. A national "returners" scheme was launched in December 2002 encouraging doctors who had retired or given up medicine to come back to the NHS. New contracts for GPs and consultants in 2004/5 raised pay to unprecedented levels but a further factor now appeared, the 'feminisation' of medicine. The high proportion of women medical students was now feeding into the training grades and it seemed that women doctors remained very selective about the specialties they chose. Specialties with a major on-call commitment, for example cardiology and gastroenterology, were substantially less popular with women than oncology or radiology.
New registration by country and area of qualification
| ||UK||EEA excluding UK||Non EEA||Total|
[EEA is a new name for the EC. The term EEA means countries who are either members or who have bilateral agreements with the EEA (for example, a bilateral agreement between the EEA and Switzerland came into force recently) Source GMC 2001/2002]
For many years the UK pay system for consultants was a fixed salary (with incremental points) and selective bonus payments (distinction awards) that were introduced early in the history of the NHS. Consultants with a "full-time" contract could undertake limited private practice, with remuneration no higher than 10% of their NHS salary. Those with a part time contract (including maximum part time at 10/11 of a full time salary) could undertake unlimited private practice.
By the end of the 1990s both the doctors and the government thought that the contract, though modified over the years, was now inappropriate and substantial revision was necessary. Private practice remained a bone of contention. After some years of manoeuvering the consultants' negotiating body, the CCSC, published proposals in October 2000 and the Government published its own the following February. The latter were reminiscent of those of the 1974 Labour administration and reflected the NHS Plan. The government, supported by NHS managers, wished to tighten the grip over consultants and reduce their freedom especially as far as private practice was concerned. There would be a substantial increase in the number of specialists, not a new idea, but welcome. Proposals to merge distinction awards and discretionary points onto the pay scale, and to make the system more open and "fair", were also welcome. Clinicians were concerned about proposals to review consultants' job plans and to introduce appraisal systems. Most controversial was a suggestion introduced into the NHS Plan at the last minute that newly appointed consultants would work exclusively for the NHS for the first seven years of their career, providing eight fixed sessions and more of the service delivery out of hours. Existing ‘full-time’ consultants, although having the right to undertake limited private practice, would have to prove that they were fulfilling NHS requirements. Full time commitment would bring significant financial rewards. However the BMA opposed in principle the view that consultants should be able to do nothing outside their NHS contract and saw the proposal as a vindictive attack of uncertain legality. A contract along the government lines might have unintended consequences, for example the encouragement of younger doctors to emigrate, or older ones to devote themselves entirely to private practice.
The doctors' leaders spent two years negotiating a contract that would give consultants considerable increases in pay in return for agreeing to be better "corporate citizens," fitting in with what managers and politicians thought best for the NHS, and working flexibly - possibly "unsocial hours". In June 2002 the contract was put to the profession. The basic working week would be of ten four-hour sessions instead of 11 sessions of three hours; this made possible a longer normal working day and might enable the service to 'work around the clock' rather than merely 9 a.m. - 5 .p.m. Government abandoned attempts to place private practice off limits for younger consultants, but the consultants' obligations to the NHS were set out more precisely. Young consultants would have to offer the NHS two additional sessions before they did any private practice, and consultants 7 years into their appointment an extra one. To deter consultants from early retirement there would be annual increments over 20 years. There would be greater managerial control over the consultants’ working week and an agreed job plan and work timetable.
The new contract offered more money in return for accepting greater managerial control and the potential to be obliged to work unsocial hours. The negotiators misinterpreted the mood of consultants and both the junior doctors and the consultants rejected it. In October 2002 consultants in England and Wales rejected it by a margin of two to one. Specialist registrars, the consultants of the future, rejected it by five to one. The BMA CCSC chair Dr Peter Hawker resigned. Three major areas of concern had swung opinion against the contract in England and Wales; deeply unhappy relationships between NHS managers and doctors, fear that consultants would be subjected to unreasonable or unachievable demands because of pressures on NHS managers to meet government performance targets that consultants often see as not in the interests of patients and that on top of emergency work, doctors would be forced into working unsocial hours on a routine and long term basis.
New negotiators asked the government to renegotiate the contract, suggesting comparatively minor changes. The government refused but when John Reid became Secretary of State, he accepted that consultants could opt out of evening and weekend work and eased restraints on newly appointed consultants in respect of private practice .In October 2003 consultants and specialist registrars voted by 3 to 2 to accept the deal.
The contract was based upon job planning and it rapidly became obvious that consultants had frequently and genuinely been working more than their contracted hours. Now the Department and NHS management wished everything to be spelt out, consultants did just that. The bills escalated, for apart from their clinical commitments the deal entitled them to 2 1/2 sessions for study, research and similar relevant and important activities. The costs of the new contract proved far higher than had been predicted by the Department of Health, sometimes throwing hospitals into financial deficit. Back pay alone might amount to tens of thousands of pounds, and it was joked that the consultants' car park resembled the most up to date car showroom. In April 2007 the National Audit Office confirmed formally what had become apparent. The pre-existing workload of consultants had been underestimated, and that they now received some 25% more money without apparently working any longer hours.
New careers and new roles opened up for the qualified and experienced nurse. Within hospitals the introduction of "Modern Matrons" provided promotion opportunities in a role that resembled the specialist nurse practitioner or, in previous decades, the "Salmon 7" grade. 'Modern Matrons' took on supervisory and management functions. Christine Hancock, the General Secretary of the Royal College of Nursing, in March 2001, said that nursing had witnessed great changes both in terms of extending nurse practice and increasing political influence; this was a continuing process. Whether the traditional ones were being performed to earlier standards was open to question. Nurses were in increased demand in hospital to take on functions sometimes previously the role of junior doctors; in primary health care to manage chronic disease, and in NHS Direct to act as an information and referral point for the public.
In 1988 the Government had accepted a new university-based system of nurse education, Project 2000 aiming to create a programme firmly in educational hands where trainees had real student status. Entry to nursing had previously been controlled partly by nursing schools associated with a training hospital, and partly by the regulations governing the state based examinations that included academic criteria. After the introduction of Project 2000 the United Kingdom Central Council for Nursing, Midwifery and Health Visiting, later the Nursing and Midwifery Council, continued to demand minimum academic criteria such as O-levels and national vocational qualifications. It was however the universities (often the new ones - previously Polytechnics) that selected students and their admission criteria might vary, being higher at universities of prestige.
The number entering each college was determined by a workforce confederation coterminous with a strategic health authority. Trusts had played a major part in determining training intake but their calculations had not taken into account non-NHS demand for nurses, for example in the rapidly expanding nursing home sector and NHS Direct. The size of the entry was progressively reduced during the 1990s, a time at which there had been no retention problem. By the latter years of the nineties the vibrant economy offered many more possibilities to young people, and for the first time ever there was a shortfall in candidates for nurse-training places, fuelling a staff shortage. A King's Fund report suggested that people were more critical of nurses than was once the case. Perhaps there were now fewer altruistic young women and more alternative careers were available. Parents might view nursing as a low status occupation, poorly paid, and not the best choice for their children.
While service based training had untoward effects, the new "uncoupled" system also had its problems. There were tensions and recriminations between the universities and the NHS. Nursing academic staff found it hard to manage the multiple roles of teacher, researcher, administrator and clinician. Because nursing students were not now members of the staff, but 'supernumerary' their clinical experience had lessened. Some colleges of nursing began to increase the time spent in a clinical environment Newly qualified nurses were often ill fitted to take responsibility. Sometimes hospitals, disillusioned by the inadequate literacy and numeracy of newly qualified nurses, introduced their own recruitment tests to ensure the safety of patients. In one hospital over half the candidates failed, and the failure rate was lower from some colleges than in others. Mentoring schemes were necessary.
Frank Dobson, then Secretary of State, attributed the nursing shortage in part to Project 2000. The emphasis on the academic element had put off some potential recruits. A better balance between practical and academic components of nurse training, was needed and students should have more contact with the NHS earlier in their courses. A Department of Health strategy, Making a Difference, had two messages, nurses and nursing were valued and should be more powerful, but was critical of the academic drift. Perhaps nursing had taken the wrong path in its brief time in higher education. (Davies C, From Conception to Birth, Nuffield Trust 2002)
Nurses should have better working conditions, a more flexible career structure allowing breaks in training, and better paid ‘consultant’ nursing posts for the most highly qualified. A new model of nurse training with an accent on developing practical skills earlier became the standard across England. The NHS as well as educational interests should be involved in selection, students would go to the wards earlier in the course, for longer periods and had a "home" hospital to encourage them to feel more part of the NHS. The Nursing and Midwifery Council, replaced the UKCC in April 2002, more training places were created, and proposals for cadet schemes were encouraged. A Commission for Pre-Registration Education was established to explore recruitment and educational issues and the Commission's report, Fitness for Practice, in September 1999, found that at registration nurses lacked practical skills. It recommended a shorter preliminary theoretical programme. Early in the course there should be clinical placements, more experience of the 24 hour per day, seven days per week nature of health care, and a period of at least 3 months supervised clinical practice towards the end of the course.
It had been hoped that basing education in the universities would reduce the drop-out rate but a National Audit Office report (February 2001) showed that 20% of student nurses left during their course and a further 20% did not subsequently join the NHS. Increasingly nurses were in different jobs and in different ways. Modernising nursing careers was published in September 2006 by the UK's four health departments, and identified four priorities for development, to develop a competent and flexible nursing workforce, update career pathways and career choices, prepare nurses to lead in a changed health care system and modernize the image of nursing and nursing careers.
In 2007 the Department opened consultation on a new structure for nurses' careers. Draft proposals reflected changing health needs and the way health care was now delivered. Five broad pathways were suggested, for example
Children, family and public health
First contact, access and urgent care
Long term care
Acute and critical care
Mental health. and psychosocial care
The Nursing and Midwifery Council (NMC) reviewed pre-registration education which culminated in a proposal in 2009 for an all graduate nursing work force.
Nurse shortage was a global challenge. Demand continued to grow but in many developed countries the supply was falling. An ageing nursing workforce was caring for increasing numbers of elderly people. Low levels of trained nursing staff could lead to poor care, to low morale and loss of staff. A landmark study of the effect of nurse/patient ratios in acute surgical units in Pennsylvania hospitals showed that the chance of patients dying within 30 days of admission increased by 7% for every patient over four for whom a registered nurse was responsible. (JAMA. 2002;288:1987-1993)
The NHS in England employed over 300,000 whole time equivalent registered nurses and midwives. Since 1997 the number leaving the professions outstripped the number of entrants. In 1997-8, for example, 16,392 nurses and midwives joined the UKCC register and 27,173 left perhaps as a result of an increase in the number of nurses and midwives retiring and changes in post-registration education and practice (PREP) requirements in 1997. Nurses and midwives who had not maintained their practice were removed from the register. The average age of the nursing and midwifery population (in the NHS and on the register) was rising. Nearly half of NHS nurses and midwives are aged over 40, but the number leaving nursing remained roughly constant at 3-3.5% per year from death and retirement. Attempts to solve the situation included improving retention, broadening the field of recruitment (including mature entrants), attracting 'returners' and importing nurses from other countries - a few of which had an oversupply.
Registered Nurses (England) total whole time equivalents
*source - NH Information centre
Nursing assistants (support staff, not included.) source of data
There was a sense of déjà vu. Britain was not alone in looking at the possibility of substituting less skilled and cheaper staff grades. Inner city and teaching hospital trusts were worst affected by staff turnover, which could easily be 25-35% annually, for outside the conurbations recruitment of local students was easier, and housing costs were lower. As jobs became more flexible and nurses took on roles previously performed by doctors, support workers picked up work previously undertaken by nurses. With the additional resources available to trusts from 2000 onwards, the number of support workers (healthcare assistants, nursing auxiliaries and scientific support staff) grew. To cover vacancies, and partly for reasons of economy, they were in demand. By 2006 there were nearly 290,000 in England. Professional training and regulation became significant issues. Some had little training, others had National Vocational Qualifications and some nursing assistants were in fact qualified nurses who preferred the more ‘hands-on’ role of the nursing assistant. Frequently they substituted for trained nurses, undertaking responsible and complex nursing work. In 2000 the Royal College of Nursing (RCN) voted to admit trained health care assistants to its ranks. In the 1980s most nursing homes had been closed, partly to save money and partly because many nurses wished to 'live out'. Now many nurses, particularly those recruited from overseas, would have been glad of a roof over their heads, and Labour appointed a "czar" to stimulate the provision of new accommodation. To improve recruitment, the 1999 pay award for newly qualified staff was 12.5%, far above the level of inflation. Pay awards continued to be comparatively generous to nurses, annually and through re-grading exercises. Extra payments were made to nurses in London and the south-east, where problems were worst. The NHS Plan (2000) recognised the shortage and promised 20,000 more nurses by 2005.
Nurses, making up 70% of the workforce and costing up to 35% of a Trust's budget, were inevitably under cost scrutiny. Trusts might not have the money to recruit staff even if they were available and Professor Alan Maynard questioned whether higher salaries would accomplish much, when many of the problems of recruitment stemmed from poor ward staffing levels and the characteristics of many nursing jobs. Accommodation, particularly in London with its high prices, deterred recruitment.
The costly use of agency nurses increased. The Audit Commission said that in 1999-2000 the NHS in England spent over £790m on temporary nursing staff, 20% more than the previous year. They were an expensive but an essential part of the workforce. With six weeks' annual leave and rostering systems that meant that nurses might only work 14 days per month, the opportunities to put in additional hours of to work for an agency, increasing one's income, were considerable.
Nurse movement between countries
A nursing qualification is a passport to a job around the world. By 2001 some 5,000 British nurses annually were applying for jobs overseas, and the NHS in turn remained substantially and increasingly dependent on nurses who had trained overseas coming to Britain. The Department of Health established a website to encourage recruitment from India, Spain and the Philippines. Requests from overseas nurses to register with the NMC rose rapidly. Most came from non-EU countries particularly the Philippines, but also South Africa, Australia, New Zealand and the West Indies. Hospital teams went to the Philippines, which was becoming the main source of foreign nurses. The Philippines trained more nurses than it needed (a Government policy as remittance income is a key source of economic growth), had a rigorous US style four year degree course, and it proved possible to recruit substantial numbers of hard working and responsible staff members. Patients liked them. Overseas nurses might work as ancillaries while they adapted to British ways. Some were on temporary visas; others planned to stay permanently. Almost a third worked in inner London area.
Countries such as South Africa and Zimbabwe could ill afford the loss of professional staff trained at substantial cost. In 2001 over two thousand nurses were recruited from sub-Saharan Africa where 20-30% of the population were HIV positive. UK hospitals soon found themselves treating their own nurses.
Analysis of the statistics showed
A steady increase in numbers on the register, and of UK trained nurses in particular, to the highest number ever
Rapidly rising levels of overseas-trained nurses and midwives coming onto the register; numbers from the Philippines peaked and then declined.
The fact that men now represent more than one in ten of those on the register for the first time
The continued long-term trend of an ageing workforce
A steady increase in the number of nurses going to work in Australia, the USA and New Zealand.
An upsurge in UK nurses and midwives going to European countries, largely reflecting re-migration back to the Irish Republic
Initial registration of overseas nurses/midwives with the UKCC and the NMC
New UK trained nurses
Other countries including EU
2004/5* 10 further countries joined EU
Source: UKCC press release 14 June 2000 and August 2001, NMC release May 2002, and statistical analyses of the Register
*the fall compared with 2001/2 may be due in part to the build up of a backlog of applications.
New UK registrations
New EU registrations
New o/s registrations
Total leaving the register
Hospital nursing had changed radically as patients came and went far more often and treatment was of a complexity undreamt of by the founders of the NHS. Nurses were pursuing new pathways and nursing was far less homogenous; some were managers, writers of care plans, or doctor-replacements undertaking triage, administering intravenous fluids or diagnosing illness. Developments such as NHS Direct and walk-in centres were based upon nurses rather than doctors as the first point of contact with the NHS. Cost considerations, the need to improve access and shortage of doctors - quite apart from the expertise of nurses who often had substantial clinical experience and further training - were leading to acceptance of the nurse-practitioner in England as in the US twenty years previously. Studies showed that nurses were effective in many roles, for example single consultations about predominantly minor illness in general practice. These was a major expansion of nurse prescribing, and in the 1990s it became possible for community nurses to prescribe independently from a limited formulary. From 2000 further changes in legislation altered restrictions and from May 2006 independent nurse prescribers in England were able to prescribe any licensed medicine for any medical condition within their competence. Courses of several weeks for independent nurse prescribers were established, nurses prescribing antimicrobials, asthma drugs and statins. Increasingly they were part of clinical teams.
The Department of Health's Chief Nursing Officer set 8 clinical benchmarks that related to fundamental aspects of nursing care, such as nutrition, and skin and mouth care. In addition were ten "key roles" that nurses might undertake, in a developing health service, roles that crossed previous skill boundaries.
To order diagnostic investigations such as pathology tests and X-rays
To make and receive referrals direct, say, to a therapist or pain consultant
To admit and discharge patients for specified conditions and within agreed protocols
To manage patient caseloads, say for diabetes or rheumatology
To run clinics, say, for ophthalmology or dermatology
To prescribe medicines and treatments
To carry out a wide range of resuscitation procedures including defibrillation
To perform minor surgery and outpatient procedures
To triage patients using the latest IT to the most appropriate health professional
To take a lead in the way local health services are organised and in the way that they are run.
Hospital clinical nurse specialists were also on the increase. Some took over functions traditionally undertaken by hospital junior staff or family doctors, pre-admission clinics, minor injury services, emergency psychiatric assessment or the coordination of termination of pregnancy. The European Working Hours Directives that limited the time junior doctors could spend on duty led many hospitals to look at the possibility of nurse-substitution. The nurses involved had often spent ten or more years in their profession, and many years in their particular specialty. Government introduced the idea of the "consultant" nurse, few in number but paid on a significantly higher scale, stressing the need to break down the division between the responsibilities of the doctor and that of the nurse. In some fields nurses increasingly lead services, admitted and discharged patients, and made autonomous clinical decisions, organizing programmes of care. Mental illness was one of these. The largest group were Macmillan nurses providing palliative care, followed by specialists in diabetes, asthma, stoma wound care, infection control and AIDS.
Too posh to wash
The rising profile of hospital acquired infection was a challenge to nursing and ward management. Liquid soaps appeared outside the wards; patients were encouraged to complain if nurses did not wash their hands. Yet the quality of basic patient care was sometimes far below the acceptable. A report by the Healthcare Commission following two outbreaks of Clostridium difficile in which at least 90 patients died, showed dirt, disgusting conditions in wards and toilets, with patients being asked to use their bed rather than a bedpan. Though an extreme example, in many hospitals patients were often either too sick to eat or feed and wash themselves. The recruitment of staff from an aggressive society where the love of one’s brother was not always evident, created a new dynamic in the wards, mitigated by nurses from gentler cultures overseas. Many nurses still delivered exemplary care, but it was distressingly clear to the elderly or their relatives that basic levels of care were often not provided. Some seemed to believe that the caring aspect of nurses' roles should be devolved to health care assistants to enable registered nurses to concentrate on treatment and technical nursing. However Beverly Malone, General Secretary of the RCN, told a press conference at the College's 2004 conference that "the argument that you are too posh to wash is ridiculous. A nurse who doesn't want to provide basic care has missed what an important part this plays in nursing. Nurses that don't want to 'wash' have missed the point of what it is to be a nurse. When bathing a patient, nurses are also assessing them, checking their breathing and emotional wellbeing."
The conscientious nurse faced massive problems. Staff shortage because it was difficult to recruit, even if the budget was there, lowered staff morale on the wards. This in turn, resulted in nurses leaving the profession for other, less stressed and better paid, jobs, a vicious circle. and the proportion of qualified nurses was falling. Could staffing levels that pushed staff beyond their limits of stamina and compassion be condoned? How could nurses who had received what was planned as a rigorous and systematic education be party to such poor quality of care? Two thirds of hospital beds are now occupied by people over 65. The Standing Nursing and Midwifery Advisory Committee, reporting in March 2001 on Caring for Older People, found major problems.
"Studies suggest that there are deficits in the core nursing skills required to meet the needs of older patients. Too many nurses see fundamental skills, such as bathing, helping patients to the toilet and assisting with feeding as tasks that can be delegated to junior or untrained staff. The emphasis on qualified staff being involved in patients’ activities of daily living may have shifted as other aspects of the nursing role, such as technical and managerial components have developed. But skilled nursing care cannot be delivered from a distance or through agents. It is a “hands-on” activity. ….. In the past, any qualified nurse would have been expected to be able to assist with activities of daily living, including the management of incontinence, nutrition and skin integrity. However, this may not now be the case. Nurses may identify these areas as requiring specialist skills. …. The rapid expansion of specialties within nursing and the developing role of the allied health professions, e.g. physiotherapy, occupational therapy and dietetics, mean that several separate professional groups are now responsible for aspects of care, such as nutrition, that were previously nursing domains. There are also a large and growing number of nursing specialties, such as tissue viability, continence and infection control, whose areas of expertise overlap with traditional nursing practice. Increasing specialisation may have had the unintended detrimental effect of de-skilling adult nurses."
"Care Pathways" were developed as a way of systematizing the treatment patients received for example breast cancer, building upon the long standing nursing procedures. They were predicted to be a key NHS resource for ensuring that patients were looked after along the lines specified in the National Service Frameworks. They were available on line through the developing National Electronic Library.
Nursing uniform remained a vexed issue. Few nurses now had ever seen the traditional uniform save in films and documentaries. Trouser suits or clothing appropriate to an operating theatre (particularly in intensive care units) was becoming the norm. Academics wrote of the traditional wear as a badge of servitude, akin to the domestic dress of the 19th century servant. Uniform was redolent of a class and power structure in society, and should therefore be opposed. Some hospital wards experimented with the total abolition of nursing uniform. Nurses might like this, although it made it harder for patients to identify who was, and who was not, a nurse. Other service industries, placing an accent on ‘customer care’ had uniformed staff, but nurses in the NHS were moving in the opposite direction. Cross infection appeared to be a serious problem; few hospitals now had laundries where uniforms were washed at high temperatures, reducing bacterial contamination. Nurses usually washed them at a lower temperature at home, and might wear them to and from work for several days. A survey at Southmead hospital showed that more than a third of nurses' uniforms were contaminated by significant organisms before going on duty. (Journal of Hospital Infection, Volume 48, Issue 3, July 2001, 238-241)
After the introduction of the general management function after Sir Roy Griffiths' Management Review (1983), nurse influence on management was lessened. Few hospitals now had a senior nurse who could be seen as a role model and a champion from whom leadership could be expected. An increasing perception that not all in nursing was well, that the wards might be dirty and noisy, and that patients did not always get the care that they needed, led to a re-evaluation. The NHS Plan (2000) recognised a need for a new generation of managerial and clinical leaders, including "modern matrons" with authority to get basics right on the ward. And, recognizing the dirty state of some hospital wards, the plan provided additional money to help to get the wards cleaner. As a result, ward housekeepers were introduced, and ward environment budgets under the control of sisters and charge nurses.
In April 2001 Alan Milburn, the Secretary of State, said that Matrons would be brought back but the new role was not that of past Matrons, being more like the Nursing Officer (Grade 7) of the Salmon Report. Their job was to be visible, with the authority to get things done, lead the nursing team in groups of wards, demonstrate to other nurses the high standards NHS patients should expect, make sure patients got quality care, and that cleaning and food standards were met. They would oversee the spending of ward budgets and resolve problems for patients. They might be concerned with infection control, and might have the power to order tests, admit and discharge patients, run clinics, triage patients and, where appropriate, prescribe medicines. The Royal College of Nursing welcomed the decision. Christine Hancock, its General Secretary, said '"Patients have been crying out for someone they know to be in charge on hospital wards," a welcome recognition of the validity of ideas for some while condemned by the nursing establishment as out-moded. Over the next few years increasing numbers were appointed. The numbers in the grade of "nurse consultant" or "modern matron" grew to over 1000 in 2007.
In November 2001 the Secretary of State announced that ward sisters and charge nurses were to get control over ward staffing budgets to give more power to senior nurses to manage the staff on their wards, plan rosters, shift patterns and assess the need for agency or bank nurses. Ward sisters would decide on the mix of grades, mix of skills and mix of jobs on each ward so that nurses can maximise the amount of time spent at the patient's bedside.
For ten years Labour had set the agenda and paradoxically the private sector became involved in NHS provision as never before. The problem of long waiting times for treatment was largely solved, public satisfaction with the NHS increased, but there was now a perception that there was poor access to the family doctor service and that hospital infection was out of control. In basic research nanotechnology, stem cell research and genetic medicine were forging ahead supplemented by rapid advance in pharmaceuticals and the technology of imaging. Patient expectations continued to rise. Each expensive new technology raised costs and increased demand as treatment became more effective and less traumatic. Government faced the dilemma of reconciling national standards because of parliamentary accountability with the need to decentralise decision making. Spending on the health service had risen dramatically and the pay of doctors, nurses and managers was much higher. Hospital staffing had never been so substantial, patient turnover was more rapid, waiting lists had improved greatly, treatments ever more sophisticated, family doctors had given up nights on call, and nurses were carving out new careers. Compared with the situation they had inherited, the NHS did appear "to have been saved" but problems remained.. Financial problems were building up. The cover provided out of hours had deteriorated as a result of the opting out of GPs. Health inequalities persisted nationally and internationally. Labour's popularity was falling and there was increased interest in the health policies of the Conservatives.