Session 7: NHS Structures and Management Flashcards
Outline a Brief History of the NHS
Creation in 1948 as part of the welfare state “cradle to grave” etc
Three core principles
- Universal (covering everyone - all legitimate residents)
- Comprehensive (covering all health needs)
- Free at the point of delivery - available to all based on need not ability to pay (money comes from general taxation)
Initially Secretary of State for Health has a duty to provide health services.
NHS initially run centrally by Department of Health (top-down bureaucracy, doctors and nurses had quite a lot of autonomy)
Some changes (e.g. around what constitutes a health need) in the 1950s and 1960s - politicians realised it cost a lot more - far more healthcare needs than they’d anticipated “Funding crisis” e.g. dental care is means tested
Increasng role for managers (as in the 1980s it became clear it was not clear who was in charge etc) => more strategic management roles (to run the NHS like a private business, roles including for doctors)
Late 1980s/1990s: Increasing marketisation of provision
- Competition between hospitals: aimed at improving choice and quality, containing costs
- Separation of ‘commissioners’ and ‘providers’ of care: competition => better services, hospitals can no longer be complacent
Describe current NHS reforms (England)
Commissioning
- A key part of markets: commissioners (involved in public health analysis, looking at population needs, overall costs and cost-effectiveness and clinical quality of services provided) choosing between different care providers (can be NHS hospitals or private or voluntary-sector) on patients’ behalf.
- Commissioenrs choose on the basis of patients’ needs, cost, quality
Health and Social Care Act (2012) - more opportunities for private sector to provide services
- Devolves power (especially commissioning) to GPs and others in primary care
- Shakes up the NHS’s structure significantly.
- Increases use of markets, with opportunities for NHS staff to set up their own care organisations (‘social enterprises’)
- Requires efficiency savings of £20bn per annum (over the next 5/6 years on a relatively static budget of c. £100bn despite growing population needs).
- Over the first 18 months since it was enacted in 2013, ~50% of the money went to new providers rather than old NHS providers. New providers include private sector and voluntary sector providers.
Describe NHS structure across the rest of the UK
What is meant by Secretary of State, Department of Health, NHS England?
Secretary of State for Health: Overall accountability for NHS
Department of Health
- Sets national standards
- Shapes direction of NHS (in form of policies/guidelines etc) and social care services
- Sets ‘national tariff’ (set fee for most NHS interventions - for services charged by service providers e.g. hospital trusts, to commissioners e.g. CCGs). This drives up quality as regardless of service provider, service cost is set. This reduces cost competitiveness so providers have to compete by quality.
NHS England (formerly known as the NHS Commissioning Board)
- Authorises Clinical Commissioning Groups
- Supports, develops and performance-manages commissioning
- Commissions specialist services, primary care and some others.
What are Clinical Commissioning Groups?
Formerly known as GP commissioning consortia
Crucial bodies in the new organisation of the NHS
- Brings together GPs, nurses, public health, patients, public and others to commission secondary and community healthcare services.
- Must account for national guidance (from NHS England, NICE etc) in these decisions.
- Take into account needs of local population
Responsible for the flow of much of the NHS budet (around 65%)
- Public health now the responsibility of local authorities
- General primary care services now commissioned by NHS England
How does the money flow from April 2013?
Describe Service Provision and NHS Providers of Care
CCGs and NHS England commission providers to provide care for the populations they serve
- NHS acute trusts (hospitals) for much acute care)
- Community healthcare trusts
- Other providers, including the private sector
Money flows from CCGs and NHS England to NHS trusts and other providers through the commissioning process
Commissioners can place contracts with private/voluntary sector providers too.
NHS Providers of Care
- E.g. acute hospital trusts, community health service trusts, ambulance service trusts, GP practices
- NHS hospital trusts earn most income through the services that CCGs and NHS England commission from them.
- Also get income from the provision of undergraduate and postgraduate training
- High performing trusts can earn greater financial and managerial autonomy by gaining foundation trust (FT) status
What other organisations are invovled?
- Monitor: regulates financial and corporate governance of NHS trusts
- Care Quality Commission (CQC): focus is on quality of care provided to NHS patients
- National Institute for Health and Care Excellence (NICE): provides commissioning guidance to CCGs and quality standards to providers
- Commissioning Support Units: provide analysis and expertise to CCGs to assist with commissioning decisions
- Healthwatch: national and local bodies to facilitate patient and public involvement
- Public Health England: coordination and leadership for public health, now primarily in local authorities.
- Health and Wellbeing Boards: local bodies to facilitate joint strategy around healthcare, social care and public health between CCGs and local authorities
- Clinical Senates: offer CCGs advice from hospital specialists and others
- And others…
What are the questions for the future regarding the NHS?
- Change is ongoing and will continue
- Pressure are perennial: ageing population; shifting burden of disease; new technologies; increasing expectations; financial austerity
- How far can NHS continue to serve its original mission?
- What are the implications of involving the private sector (in a way the NHS is losing money), for better or worse? What about loss of training opportunities for junior doctors if some services are cut?
- Are GPs and colleagues in primary care the right people to make commissioning decisions?
- Will patients really be empowered? Could the NHS become less viable?
- What are the effects of splitting up interdependent services? Is there a risk of undermining their interdependence?
What are the current developments regarding managerial roles?
- Increasing number of ‘managerial’ roles for clinicians
- ‘Clear out’ of layers of ‘bureaucracy’
- High Quality Care for All (2008): all clinicans should have the opportunity to be
- A ‘partner’ (taking responsibility for management of finite resources, making sure resources are used as effectively as possible)
- A ‘leader’ (working with other clinicans and managers to change systems where it will benefit patients) - better quality
- Liberating the NHS: growing management roles for doctors, especially in primary care:
- Resource allocation and decision making (GPs especially; others too)
- Contract management
What are Clinical Directorates and Directors?
Clinical Directorates
- Hospital trusts are usually organised into clinical directorates (like faculties in a university)
- Directorates are usually based on specialty or group of specialties e.g. radiology, women’s health, cardiology
- Each is led by a clinical director, who will be a doctor (not the same as the medical director)
- Alongside the clinical director, the directorate will usually include a lead nurse and a general (non-clinical) manager too.
- Manager has an important role but is subordinate to clinical director
Clinical Director’s role: to manage her/his directorate as a whole
- Provide continuing medical education and other training (for all staff)
- 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
What is the Medical Director?
Responsible for quality of medical care (i.e. care provided by doctors in 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 resource/personnel functions
Medical Director’s Role
- Approves job descriptions; interview panels & 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 organisation’s Board of Directors - a key link between senior management and the medical staff
What are Management Skills, and what is meant by Collegial Relations?
Management Skills
- 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
- Increasing emphasis on the need for doctors to have management skills
Collegial Relations
- Medical culture can be hostile to both clinical and non-clinical managers
- Yet managers since the 1980s have been expected to have a strategic role - not just ‘administer’
- NHS has been prone to hostile and difficult collegial relationships - implications for quality and safety of care - e.g. Bristol Royal Infirmary, Mid Staffs too
- There can be great difficulties in managing change
- Imposing authority
- Treading on toes
- Changing power relationships
What should I do next?
Go over the second lecture - from a clinican’s POV
