HaDSoc Week 7

Question 1

Describe (briefly) the history of the NHS

Answer 1

Created 1948
With three core principles:
-universal
-comprehensive
-free at the point of delivery - available to all based on need
Secretary of State had duty to provide health services
Initially run centrally by DOH
Some changes in 1950s and 60s - opticians, dental, prescriptions paid for apart from specific circumstances e.g. Pregnancy
Increasing role for managers - doctors asked to take on management roles instead of just patient care
Increasing marketisation of provision - competition between hospitals - improving choice and quality, containing costs
Separation of commissioners and providers
Commissioning - choosing between different health care providers on behalf of patient on basis of patient need, quality and cost
Health and social care act 2012 - devolves power especially commissioning to primary care, shakes up NHS structure, increases use of markets with opportunities for NHS staff to set up their own care organisations, requires efficiency saving of £20bn per annum with an annual budget of £100bn
Devolution - Scotland, Wales, Northern Ireland and England

Question 2

What are commissioners ?

Answer 2

CCGs
Act as customers
Choose between different care providers on patients behalf - on the basis of patients need, cost and quality - Given the budget for the healthcare service - Have to pay the same amount no matter who they go to - therefore looking for the best value care not the cheapest

Question 3

Describe the current structure of the NHS

Answer 3

Secretary of State: overall accountability for the NHS - member of parliament
Department of Health: sets national standards, shapes direction of NHS and social care services, sets ‘national tariff’ - fee for services charged by service providers e.g. Hospital trusts to commissioners (CCGs)
NHS England - authorises clinical commissioning groups (CCGs), supports, develops and performance manages CCGs, commissions specialist services and primary care as well as others
CCGs - regional - bring together GPs, nurses, hospital doctors, public health, patients and public to commission secondary and community healthcare services - use national guidance in these decisions (NHS england and NICE) - responsible for the flow of most (65%) of the NHS budget
Public health and budget responsibility of local authorities and Public health England

Money flows fro CCG and NHS England to hospital and community trusts
Opportunity for competition with private sector and voluntary sector - NHS England and CCGs can chose to commission private services if they are better quality etc.

NHS hospital trusts earn the most money through the services that NHS England and CCGs commission from them
Also get income from provision of undergraduate and postgraduate training
High performance trusts earn greater financial and managerial autonomy - gain foundation trust status - can borrow money to try and compete against private sector

Commissioning support units - set up to provide technical support to CCGs - crunch data, contract negotiations and technical contract management
Clinical senates - bring together a whole range of medical professions to offer advice to CCGs on particular patient groups or conditions - they don’t have to listen to the advice though

Health and wellbeing boards - responsibility of local government - bring together key players in health and social care system including councillors - aim to improve care in a holistic way across health, social care and other public services - talk to CCGs and their electorate

Healthwatch - exists at a national and local level - at local level responsibility of local government - represents views of public and patients - for them to engage in how services are planned - difficult to achieve in reality

Monitor: regulates financial and corporate governance of NHS trusts
CQC: focus on quality of care provided to NHS patients
NICE: provides commissioning guidance to CCGs and quality standards to providers

Question 4

What are some questions for the future of the NHS?

Answer 4

How far can the NHS continue to serve its original mission? - ageing population, shifting burden of disease, lack of staff, increasing expectations
What are implications of involving the private sector for better and worse? - private means they only care about money not quality of care v.s. Privatisation provides motivation to improve quality of care
Are GPs and primary care staff the right people to make commissioning decisions?
Will patients really be empowered?

Question 5

What are the recent developments regarding managerial roles for doctors and why have they occurred?

Answer 5

Increasing number of managerial roles for clinicians
Clear out of layers of bureaucracy
High quality of care for all 2008 - all clinicians should have the opportunity to be a partner (managing finite resources) and a leader (working with other clinicians and managers to change policies and systems to benefit the patient)
Liberating the NHS 2010 - growing management roles for doctors especially in primary care - resource allocation and decision making (GP especially), contract management

Question 6

What are some management roles for doctors and what do they involve?

Answer 6

Medical director (overall responsibility for medical quality)
Clinical director (overall responsibility for directorate)
Consultant (responsibility for team)
General practitioner - practice principal or partner
Any level involves managerial responsibilities of some kind
Many other senior and middle managerial roles rarely filled by doctors in UK (e.g. Chief executive) but often nurses and AHP

Question 7

What are clinical directorates?

Answer 7

Divisions of hospital trusts like faculties of a university e.g. Surgery, women and children etc.
Usually based on speciality or group of specialities e.g. Cardiology
Each is led by a clinical director who is a doctor
Alongside this them there will be a (non-clinical) general manager and a lead nurse - subordinate to the CD

Question 8

Describe the role of a clinical director

Answer 8

Providing continuing medical education and other training
Design and implement directorate policies on junior doctors’ hours of work, supervision, tasks and responsibilities
Implement clinical audit
Develop management guidelines and protocols for clinical procedures
Induction of new doctors

Question 9

Describe the role of a medical director

Answer 9

Senior to a clinical director
Responsible for quality of medical care provided by the hospital
Communicates between the board and the medical staff
Leadership of medical staff: sets out strategy, exemplifies positive values, helps to implement change

Will work in partnership with Human Resources / personnel functions
Approves job descriptions, interview panels and equal opportunities, discretionary pay awards
Disciplinary processes
Leads on organisation’s clinical policy and clinical standards
Strategic overview of medical staff’s role in the organisation
Sits on the organisations Board of Directors - a key link between management and the medical staff

Question 10

What skills are required for management?

Answer 10

Strategic - ability to analyse, plan, make decisions
Financial - ability to set priorities and manage a budget
Operational - ability to run things, execute plans
Human Resources - ability to manage people and teams

There is increasing emphasis on the need for doctors to have these skills

Question 11

How have collegial relationships been historically in the NHS and what are the implications of this?

Answer 11

Medical culture can be hostile to both clinical and non clinical managers
Managers expected to have a strategic role - not just administer
Implications for quality and safety of care - Bristol royal infirmary and Mid Staffs - club culture
Can be great difficulty in managing change - imposing authority, treading on toes, changing power relationships

Question 12

What is the GMC guidance on managing teams?

Answer 12

Each member of the team should know where responsibility lies for clinical and managerial issues and who is leading the team - problem lies in people not knowing their role in the team or when communication is poor
Systems should be in place to facilitate collaboration and communication between team members
Systems should be in place to monitor, review and, if appropriate, improve the quality of the team’s work
Teams should be appropriately supported and developed and should be clear about their objectives

Question 13

What is a profession?

Answer 13

A type of occupation able to make distinctive claims about its work practices and status
In healthcare usually refers to occupation requiring registration

Question 14

What is professionalisation?

Answer 14

The social and historical process that results in an occupation becoming a profession

Question 15

Describe healthcare professionals generally

Answer 15

Most formal healthcare is provided by members of registered occupations
Members usually committed to an organised professional community and have a strong sense of professional identity
Have specified tasks and roles within organisations (boundary disputes are frequent)

Question 16

What does professionalisation involve?

Answer 16

Asserting an exclusive claim over a body of knowledge or expertise
Establishing control over market and exclusion of competitors
Establishing control over professional work practice
This is not fixed through time e.g. Nurses can now prescribe

Question 17

Describe the history of the professionalisation of medicine

Answer 17

Royal college of physicians founded in 1518 (Henry VIII) - requirements : to be Anglican, a degree from oxford or Cambridge (not medical) - wasn’t very scientific (1790 oral exam in Latin still main entry requirement) - elite status (not based on knowledge but social background e.g. Rich men)

Physicians only catered for the wealthy
Apothecaries and barber surgeons treated the rest - apprenticeships
Most healing took place domestically
Women took care of others in childbirth and knew how to make lotions and potions

19th century - qualification of physician still restricted to ‘gentlemen’
Other healers - teeth pullers, bone setters, itinerant healers
Queen Vic did not recognise army surgeons as officers and gentlemen
1815 - Apothecaries’ Act began reform process
1858 Medical Act - GMC given power of registration of doctors - controlled entry and removal from medical register - approved and inspected medical schools - doctrine of clinical autonomy (only doctors could monitor and control the work of other doctors)
Professional self regulation - interests of the profession seen as best guarantee of interests of the public
GMC assumed that an individual admitted to the profession could be assumed to be of good character and competence - socialisation and peer-norming would be enough (start to behave like a doctor)
Eventually led to the end of the self regulatory model

Question 18

What is socialisation?

Answer 18

The process by which professional learn during their training and education, the attitudes and behaviours necessary to assume their professional role
During training and subsequently individuals learn to internalise and cooperate with the collective norms of the professional group and learn to align their conduct with the profession’s standard
Similar to the way children develop awareness of social values and norms and a distinct sense of self
Occurs through the interaction with others –> informal and formal curriculum: formal - knowledge tested through exams, informal - attitudes beliefs performance noted but not formally examined

Question 19

How is socialisation implemented in medicine?

Answer 19

Medical education is critical in turning a lay person into a professional
But becoming a doctor is not just about learning information and technical skills
Also about developing particular types of orientations to patients, colleagues and fellow workers and reproducing or challenging particular norms

Question 20

What are some claims for the right to self-regulation of professions?

Answer 20

1. Degree of skill and knowledge required - non-professionals not equipped to evaluate or regulate
2. Responsible - can be trusted to work conscientiously without supervision
3. May be trusted to undertake proper regulatory action if individual does not perform his work competently or ethically

Question 21

Describe some critique of professions

Answer 21

Thomas Wakley (lancet editor) said :

• professions are protected monopolies
• claims of virtue are self-serving and strategic
• seek to optimise their own interests not their clients

Question 22

Describe some criticism of the self-regulatory model

Answer 22

Freidson (1970) :
Self-regulation promoted a self-deceiving vision of the objectivity and reliability of its knowledge and the virtues of its members
Medicine’s very autonomy has led to insularity and a mistaken arrogance about its mission in the world

Question 23

Give some examples of “bad apples” of the medical profession

Answer 23

Bristol inquiry - 1984-1995 - 29 babies died, 4 left brain damaged - professional ethics and education as part of problem, club culture - resistance to external scrutiny, criticism or control
Alder Hey inquiry - 1988-1996
Rodney Ledward - 1998 - botched operations, poor quality of care, appearing drunk, rough and brutal treatment of patients
Harold Shipman - 2000 - committed 236 murders - convicted in 1976 of obtaining controlled drugs by deception, possession of controlled drugs and forging prescriptions - GMC did not take further disciplinary action - allowed to set up a single handed practice in 1991 - used deception and forgery to obtain large amounts of controlled drugs
Richard Neale - 2000 - able to gain registration in UK despite being struck off in Canada
Peter Green - 2000 - GP in Loughborough convicted of indecent assault on male patients
Michael Haslam and William Kerr - 2000-2003 - psychiatrists convicted of indecent assault for abusing female patients
Clifford Ayling - 2001 - inappropriate sexualised behaviour, incompetence, brutality
Davinderjit Bains - 2013
Myles Bradbury - 2014

Question 24

What were some of the systemic issues that led to tragedies such as the Bristol inquiry?

Answer 24

Informed staff found it difficult to act
Patients who told health professionals were often greeted with disbelief or discredited
Whistleblowers were not always believed
NHS disciplinary procedures were found to be “cumbersome, costly and inhibiting”
“He was always so nice…”
Rules of professional propriety :
- doctors discouraged from raising concerns about each other
- etiquette rule forbidding close monitoring of other doctors
- a shared sense of personal vulnerability
- high costs associated with sanctioning
- problems of quality of evidence and absence of supportive processes
- credibility gap (e.g. Mentally ill patient making claims about a doctor - who would you believe ?)

Mostly informal controls - social norms exerted powerful corrective force - “terribly quiet chat”, “protective support”, diverting patient flow, push-out
Worked for most doctors but not the bad apples

Government left the running of the NHS up to doctors as part of an uneasy “compact”
Highly fallible administrative systems - lacked clarity about who was in charge and on what authority

Failure of those in positions of authority in the NHS or in the regulators, to detect signs of unacceptable or incompetent professional behaviour and to take effective and timely action to protect patients

Question 25

How did self-regulation come to an end?

Answer 25

Mid 2000s - GMC fails to develop satisfactory system of revalidation
Initiative to reform seized from the GMC
Scandals not only motivated but legitimated reform
Move away from self-regulatory model
Authority for setting standards, monitoring practice and conduct and management relocated from inside the profession

White paper (2007) - proposed wide-ranging reforms - many of these have now been implemented

GMC now parity of lay and professional members
all members appointed independently
Council overseen by the professional standards for health and social care (loss of autonomy in control)
Civil rather than criminal standard of proof
Sweeping reform of processes

Question 26

What happens when someone is referred to fitness to practise and what are the potential reasons that they could be referred?

Answer 26

Referred to the medical practitioners tribunal services

Reasons:
Misconduct
Poor performance
Criminal conviction or caution in the UK
Physical or mental ill-health
Determination by a regulatory body in the UK or overseas

Question 27

What actions can the MPTS take?

Answer 27

Agree undertakings with the doctor
place conditions on their registration
Suspend their registration
Remove them from the medical register

Question 28

Describe revalidation

Answer 28

Previously you stayed on the medical register unless physically removed

Since 2012 have to revalidation licensed doctors every 5 years

Regular appraisals with their employer - based on GMP - patients can help by giving feedback about the care they received

Medical royal colleges set the content and standards for each speciality
Doctors have to provide evidence that shows they are fit to continue practising
Responsible officer has to make assessments of the evidence as part of the appraisal process

Question 29

What are the aims of revalidation?

Answer 29

Aims to assure patients (positive affirmation)
Maintains and improves practice
Provides support to doctors in keeping their practice up to date
Identifies concerns about doctors at an early stage
Encourages patient feedback
Acts as a driver for improving clinical governance at the local level and improving standards of patient care

Question 30

What does revalidation involve?

Answer 30

A local evaluation of a doctors practice through annual appraisals that consider the whole of their practice

1. Participate in annual appraisals that have GMP at their core
2. Maintain a portfolio of supporting information to bring to their appraisals as a basis for discussion
3. Have a positive recommendation from a responsible officer

Question 31

What evidence is needed for revalidation?

Answer 31

Continuing professional development
Quality improvement activity
Significant events
Feedback from colleagues 
Feedback from patients
Review of complaints and complements

Question 32

What are responsible officers?

Answer 32

Healthcare organisations have a duty to appoint a responsible officer whom:

• is a doctor responsible for dealing with local performance and conduct issues in liaison with the GMC
• have a duty to share information with other organisations about the performance and conduct of healthcare workers where needed to protect patients or public

Question 33

Do junior doctors need to undergo revalidation?

Answer 33

Yes
Record annual review of competence progression process, using record of in-training assessment
Responsible officer is based in your local education and training board (Deaneries)

Question 34

What is meant by the rise of managerialism?

Answer 34

Doctors and other NHS staff are increasingly being expected to perform more managerial roles
From administration to management
Appointing consultants
Agree detailed job descriptions
Insist on implementation of government policies
Expected to ensure compliance with guidelines and clinical governance

Question 35

What is new professionalism?

Answer 35

Doctors are quite reasonably frustrated with how much work they have to do to prove themselves when they could be spending more time on their patients
Concerns that the regulatory bodies have gone too far in the other direction
Loss of clinical autonomy
Narrative of the health professional as untrustworthy, self interested, grasping is being increasingly challenged
Argument that distrust-fuelled regulation is wasteful and corrosive
If we go too far with regulations we could do more harm than good - doctors so concerned with ticking the right boxes that they are distracted from the core job of caring for patients
Undermining of clinicians role as patient’s advocates
Doctors often anxious about a system they may see as unfair and burdensome
Need to find a balance