Consultant Medical Interview

This report was commissioned by General Medical Council to carry out a UK-wide review into the factors which impact on the mental health and wellbeing of medical students and doctors. GMC wanted to look into the issues about the environments in which doctors work, and the impact of systems pressures on medical practice.

The report was published in November 2019.

The report identifies a need to address the wellbeing of doctors faced with higher workloads, whose own health impacts on patient care.  The report identifies eight recommendations (under 3 broad headings) to support the wellbeing of medical students and doctors, and enable them to deliver safe, and good, patient care.

Recommendations

Autonomy/control – the need to have control over our work lives, and to act consistently with our work and life values.

1. Voice, influence, and fairness: To introduce mechanisms for doctors in primary and secondary care to influence the culture of their healthcare organisations, and decisions about how medicine is delivered.

How: Clinical leaders and managers should consult doctors (and other healthcare staff) and gather feedback about how healthcare teams are established and maintained, how their work is organised and delivered and the response to concerns to ensure a focus on learning not blame.

• Work conditions: To introduce UK-wide minimum standards for basic facilities in healthcare organisations.

How: All healthcare employers should provide all doctors with places and time to rest and sleep, access to nutritious food and drink, the tools needed to do their job and should implement the BMA’s Fatigue and Facilities charter.

• Work schedule and rotas: To introduce UK-wide standards for the development and maintenance of work schedules and rotas based on realistic forecasting that supports safe shift swapping, enables breaks, takes account of fatigue and involves doctors with knowledge of the specialty to consider the demands that will be placed on them.

How: NHS England, NHS Wales, NHS Boards in Scotland, and the Department of Health (Northern Ireland) should fully implement the BMA’s and NHS Employers’ Good Rostering Guide in all healthcare environments.

Belonging – the need to be connected to, cared for, and caring of others around us in the workplace and to feel valued, respected, and supported.

• Team working:  To develop and support effective multidisciplinary team working across the healthcare service.

How: All healthcare organisations should review team working and ensure that all doctors are working in effectively functioning and, ideally, multidisciplinary teams. The teams should have a shared purpose and clear objectives (one of which is team member wellbeing). Team members should be clear about their roles and meet regularly to review their performance, including inter-team/cross-boundary working. Quality improvement should be a core function of all teams.

• Culture and leadership:  To implement a programme to ensure healthcare environments have nurturing cultures enabling high-quality, continually improving, and compassionate patient care and staff wellbeing.

How: All UK healthcare organisations that have not already done so, should start and implement a programme of compassionate leadership across all healthcare sectors; and they should obtain feedback from doctors and healthcare staff to evaluate its effectiveness. It should include mechanisms to ensure clinical leads and other leaders of doctors at all levels in the healthcare system are recruited, selected, developed, assessed, and supported to model compassionate and collective leadership.

Competence – the need to experience effectiveness and deliver valued outcomes, such as high-quality care.

• Workload: To tackle the fundamental problems of excessive work demands in medicine that exceed the capacity of doctors to deliver high-quality safe care.

How: All organisations that oversee the work of doctors should undertake, in collaboration with doctors, a programme to review workload in their organisations. This will help them to use resources in the most efficient way, to ensure workloads do not exceed doctors’ ability and capacity to deliver safe, high-quality care. Initiatives are underway across the UK to increase staffing numbers and this should be supported by additional solutions including, but not restricted, to:

• A programme to deploy and develop alternative roles to enable doctors to work at the top of their competence, supported by effective multidisciplinary team working in all areas of healthcare, and to support doctors to return to work after a break in practice.
• A review of new technologies being used in UK healthcare systems to increase efficiency, working with the voluntary sector, and focusing on preventive care. 
• A programme of process improvements that increase productivity especially by supporting communication in regular team meetings between healthcare staff

• Management and supervision – to ensure all doctors have effective clinical, educational, and pastoral support and supervision to thrive in their roles.

How: All organisations that employ doctors should ensure:  

• Each has a well-trained line manager supporting them to perform their roles effectively and ensuring their basic work needs are met. They should also obtain feedback to ensure this is in place (in primary care, this might be a peer mentor or coach).  
• Management, support, educational and clinical supervision are included in the job plans of those in such roles, and their workloads are balanced to ensure protected time to provide these functions.
• Training, learning and development – to ensure the systems and frameworks for learning, training, and development:  
• Promote fair outcomes.
• Are sufficiently flexible to enable doctors and medical students to grow and develop throughout their careers and to better manage their wider life circumstances.

How: Approach and practical solutions could include: a.  Monitoring using established (academic, peer-reviewed) measures. B.  Improvement, development, and implementation of the GMC’s NTS (National Trainee Survey) to ensure high-quality measurements across all areas.

Charlie Massey, the GMC’s Chief Executive, said:

‘Medicine has always been a high-pressure career, but doctors are telling us that the demands on them are now so great they risk becoming unmanageable. As a result, their own health suffers, and patient care is compromised.

‘Solutions are not easy, but this report shows that there are already many examples of great practice to build from. As a regulator, we will use all our influence and powers to support doctors and medical students.’

Charlie Massey added:

‘Doctors need to feel they are part of a just and compassionate culture. They must receive appropriate and consistent support.

‘For patients to get the care they need doctors must work and train in safe, supportive and inclusive environments.’

Reference

1. https://bit.ly/3gobZUj
2. https://bit.ly/3ejGclH

GIRFT is a national programme designed to improve the quality of care within the NHS by reducing unwarranted variations.

It is the brainchild of Professor Tim Briggs at the Royal National Orthopaedic Hospital in London. The programme is pursuing the holy grail of modern medicine – higher quality at lower cost. The programme began with orthopaedics and is now being rolled out to 35 different surgical and medical specialties across the English NHS.

By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings.

GIRFT methodology

The programme comprises a series of 35 surgical and medical work streams, each led by a prominent clinician chosen from the specialty they are reviewing. Each clinician heads a project to compile a data and insight driven report into their specialty, combining publicly available information, including Hospital Episode Statistics (HES), other relevant registry or professional body data, and the results of a questionnaire issued to all the trusts being reviewed. The report will look at a wide range of factors, from length of stay to patient mortality, and individual service costs through to overall budgets.

A report is produced and issued to every trust being reviewed, which is then followed by a meeting at the trust with medical staff and senior trust managers. At each meeting the clinical leads review the findings with their peers, which provides more context to unwarranted variations and opens up a discussion around individual practice and any challenges the trusts face. It is also an opportunity to share best practice and any solutions that have already helped reduce variations.

After at least 40 trust reviews have been completed, the clinical lead oversees the creation of a national GIRFT report into their specialty. The report presents the original data, GIRFT’s findings, examples of best practice and an action plan of proposed changes and improvements. Crucially this action plan provides detailed evidence of the benefits changes can bring and is supported by an implementation programme managed by GIRFT.

At trust level the recommendations found in each specialty are collated into a single implementation plan. Trust data is uploaded to the Model Hospital portal (https://model.nhs.uk/), which will be the gateway for accessing GIRFT information for all providers and commissioners.

How effective has it been?

It is led by frontline clinicians who are expert in the areas they are reviewing. This means the data that underpins the GIRFT methodology is being reviewed by people who understand those disciplines and manage those services on a daily basis. The GIRFT team visit every trust carrying out the specialties they are reviewing, investigating the data with their peers and discussing the individual challenges they face and are supportive and encourage change in behaviour and practice.

On the limited evidence to date, it is producing real gains in procurement, productivity and quality. The success of GIRFT will depend crucially on buy in from all stakeholders and sustained success will depend on engagement of both clinicians and managers and commitment to taking action.

Tip- before the interview check whether there is a GIRFT programme in your speciality and read it up on the website (ref 2 below)

Ref-

1. https://www.kingsfund.org.uk/publications/tackling-variations-clinical-care
2. https://gettingitrightfirsttime.co.uk/

NHS England’s 2014 Five Year Forward View (5YFV) and the subsequent Next Steps on the NHS Five Year Forward first introduced the concept of Accountable care organisation (ACOs) and Integrated care systems (ICSs) as an approach to integrate primary and acute medical care in the NHS.

They were cited as a similar model to the Primary and Acute Care Systems (PACS) and Multispeciality community providers (MCPs). Both of these models, MCPs and PACS were precursors to the development of ACOs/ICSs in the NHS. In PACS, hospitals often take the lead in joining up acute services with GP, community, mental health and social care services. The emphasis in MCPs is on GPs working at scale to forge closer links with community, mental health and social care services. Following the publication of 5YFV, NHS England established nine PACS and 14 MCP ‘vanguards’ to trial the models, covering around eight per cent of the population of England.

What are ACOs?

The term Accountable Care Organisations (ACOs) refers to an area-based model of healthcare provision, where a single body takes responsibility for the health needs of its entire population. Although there is no fixed definition of ACOs, most usually include the following elements:

• They involve a provider or, more usually, an alliance of providers that collaborate to meet the needs of a defined population.

• These providers take responsibility for a budget allocated by a commissioner or alliance of commissioners to deliver a range of services to that population.

• ACOs work under a contract that specifies the outcomes and other objectives they are required to achieve within the given budget, often extending over a number of years.

The intention of ACOs is to operate in a more integrated manner than healthcare models that pay per procedure carried out, as well as a greater focus on prevention and health promotion.

What are ICSs?

ICSs would see CCGs and providers (such as NHS trusts, GPs and community healthcare providers) within a Sustainability and Transformation Partnership (STP) area working together to manage funding for their defined population.

The major difference between ACSs and ICSs is that with ACOs “there will be a single contract with a single organisation for the majority of health and care services in the area.” ICSs also involve CCGs as commissioners, getting them to work more closely together with providers such as NHS trusts and GPS, to plan care for their populations. ACOs however only integrate providers, with no formal role for CCGs.

What are the main forms of integrated care?

There are three main forms of integrated care:

•            Integrated care systems (ICSs) have evolved from STPs and take the lead in planning and commissioning care for their populations and providing system leadership. They bring together NHS providers and commissioners and local authorities to work in partnership in improving health and care in their area.

•            Integrated care partnerships (ICPs) are alliances of NHS providers that work together to deliver care by agreeing to collaborate rather than compete. These providers include hospitals, community services, mental health services and GPs. Social care and independent and third sector providers may also be involved.

•            Accountable care organisations (ACOs) are established when commissioners award a long-term contract to a single organisation to provide a range of health and care services to a defined population following a competitive procurement. This organisation may subcontract with other providers to deliver the contract.

ICPs are at various stages of development across England and ICSs have been established in ten areas, two of which – Greater Manchester and Surrey Heartlands – are part of the government’s devolution programme.

Why are these controversial?

The language of accountable care originated in the United States at the time of President Obama’s health care reforms, and its use in the NHS has raised concerns that it could result in health and care services coming under the control of private companies. However, if ACOs are established in the NHS, they will be a means of delivering care and not funding it. The principles of a universal and comprehensive NHS funded through taxation and available on the basis of need and not ability to pay will not be affected.

The proposed ACO contract could result in more NHS services being managed by private companies but this seems unlikely to happen in many cases because:

The experience of Hinchingbrooke Hospital in Cambridgeshire, where the private company, Circle, had to hand back its contract to provide NHS services because of insufficient funding suggests that there are limited opportunities to generate profits from NHS contracts. This is not surprising when deficits are endemic among NHS organisations following several years of austerity. It is hard to envisage how private companies would perform better financially than NHS organisations when they would be taking responsibility for the services provided by these organisations if they competed successfully for an ACO contract.

Rather than opening up the NHS to increased privatisation and competition, as some have claimed, these developments are likely to have the opposite effect. The vestiges of market-based reforms remain, but they have taken a back seat as the need for NHS commissioners and providers to work together to make decisions on the use of resources has been given higher priority. The risk this creates is the possibility of legal challenges from private companies who feel that commissioners are not using competitive procurement as required under the law and instead are keeping contracts within ‘the NHS family’.

Why is the change needed?

NHS is under severe pressure due to rising demand and funding constraint. It has been clear for some time that simply working our current hospital-based model of care harder to meet rising demand is not the answer. Rather, the NHS needs to work differently by providing more care in people’s homes and the community and breaking down barriers between services. The NHS also needs to give greater priority to the prevention of ill health by working with local authorities and other agencies to tackle the wider determinants of health and wellbeing.

This aim is being pursued through the new care models, STPs and the evolution of some STPs into integrated care systems. These developments hold out the promise of a different way of working in the NHS with an emphasis on places, populations and systems. Successful integrated care systems will take more control of funding and performance with less involvement by national bodies and regulators.

Will these changes lead to cuts in NHS budget?

While financial issues are very important, it would be wrong to see these developments as a means of the NHS balancing its books. Recognising that the NHS is required by parliament to keep within its spending limit, and that this is proving difficult, these developments are primarily about improving health and care, and in so doing seeking opportunities to deliver its financial objectives. Integrated care and population health should not be expected to save money but have the potential to enable resources to be used more effectively.

This is an attempt to give local leaders more control over the use of the collective resources at their disposal, thereby enabling them to back the ambitions set out in STPs with flexibility to move money around.

What has this way of working achieved?

Early evidence from the new care models suggests some progress is being made in moderating rising demand for hospital care.

Data collected by NHS England, for example, shows that PACS and MCPs in aggregate have seen lower growth in per capita emergency admissions to hospitals than the rest of England. Some new care models have reported absolute reductions in emergency admissions per capita.

What do these developments mean for commissioning?

One of the consequences of these developments is that the commissioner/provider split that has underpinned health policy since the early 1990s is unravelling. Providers and commissioners are working together to establish ICPs and ICSs. Clinical commissioning groups (CCGs) are either merging or agreeing to collaborate and are working closely with local authorities in many areas to develop joint or integrated commissioning.

Commissioning in the future is likely to make use of longer term, outcome-based contracts. The current system of Payment by Results, which was designed for an environment in which choice and competition predominated, will then be superseded, in many cases, by population-based budgets. Commissioning will become more strategic and concerned with the funding and planning of new models of integrated care rather than the annual contract round that has added little value to the NHS in recent years. Commissioners will have a key role in holding providers to account for delivering outcomes agreed in contracts.

What next?

The NHS long term plan released in Jan 2019 commits that By April 2021 ICSs will cover the whole country, growing out of the current network of Sustainability and Transformation Partnerships (STPs). ICSs will have a key role in working with Local Authorities at ‘place’ level and through ICSs, commissioners will make shared decisions with providers on how to use resources, design services and improve population health (other than for a limited number of decisions that commissioners will need to continue to make independently, for example in relation to procurement and contract award). Every ICS will need streamlined commissioning arrangements to enable a single set of commissioning decisions at system level. This will typically involve a single CCG for each ICS area. CCGs will become leaner, more strategic organisations that support providers to partner with local government and other community organisations on population health, service redesign and Long Term Plan implementation.

Ref

1. https://www.kingsfund.org.uk/publications/making-sense-integrated-care-systems#cuts
2. https://researchbriefings.files.parliament.uk/documents/CBP-8190/CBP-8190.pdf

The NHS Long Term Plan was published in January 2019. It is a new 10 year plan for the NHS to improve the quality of patient care and health outcomes. There’s been concern – about funding, staffing, increasing inequalities and pressures from a growing and ageing population. NHS Long Term Plan takes all three of these realities as its starting point to redesign patient care to future-proof the NHS for the decade ahead.

The NHS Long Term Plan aims to make sure the NHS is fit for the future, providing high quality care and better health outcomes for patients and their families, through every stage of life.

It details how this would be achieved through three main themes:

1.    Giving everyone the best start in life;

• reducing stillbirths and mother and child deaths during birth by 50%
• ensuring most women can benefit from continuity of care through and beyond their pregnancy, targeted towards those who will benefit most
• providing extra support for expectant mothers at risk of premature birth
• expanding support for perinatal mental health conditions
• taking further action on childhood obesity
• increasing funding for children and young people’s mental health
• bringing down waiting times for autism assessments
• providing the right care for children with a learning disability
• delivering the best treatments available for children with cancer.

 2.    Delivering world-class care for major health problems to help people live well;

• Providing education and exercise programmes to tens of thousands more patients with heart problems, preventing up to 14,000 premature deaths
• Faster and better diagnosis, treatment and care for the most common killers, including cancer, heart disease, stroke and lung disease, achieving survival rates that are among the best in the world.
• Supporting families and individuals with mental health problems, making it easier to access talking therapies and transforming how the NHS responds to people experiencing a mental health crisis (by spending at least £2.3bn more a year on mental health care)

3.    And helping people age well by

• increasing funding for primary and community care by at least £4.5bn
• bringing together different professionals to coordinate care better
• helping more people to live independently at home for longer
• developing more rapid community response teams to prevent unnecessary hospital spells, and speed up discharges home.
• upgrading NHS staff support to people living in care homes.
• improving the recognition of carers and support they receive
• making further progress on care for people with dementia
• giving more people more say about the care they receive and where they receive it, particularly towards the end of their lives.

The NHS Long Term Plan also describes the actions that will need to be taken at local, regional and national level to make the ambitious vision a reality.

1. Doing things differently:  by giving people more control over their own health and the care they receive, encourage more collaboration between GPs, their teams and community services, as ‘primary care networks’, to increase the services they can provide jointly, and increase the focus on NHS organisations working with their local partners, as ‘Integrated Care Systems’, to plan and deliver services which meet the needs of their communities (see chapter on Accountable Care Organisation)

2. Preventing illness and tackling health inequalities: NHS will increase its contribution to tackling some of the most significant causes of ill health, including new action to help people stop smoking, overcome drinking problems and avoid Type 2 diabetes, with a particular focus on the communities and groups of people most affected by these problems.

3. Backing the workforce:  continue to increase the NHS workforce, training and recruiting more professionals – including thousands more clinical placements for undergraduate nurses, hundreds more medical school places, and more routes into the NHS such as apprenticeships. We will also make the NHS a better place to work, so more staff stay in the NHS and feel able to make better use of their skills and experience for patients.

4. Making better use of data and digital technology: provide more convenient access to services and health information for patients, with the new NHS App as a digital ‘front door’, better access to digital tools and patient records for staff, and improvements to the planning and delivery of services based on the analysis of patient and population data.

5. Getting the most out of taxpayers’ investment in the NHS: continue working with doctors and other health professionals to identify ways to reduce duplication in how clinical services are delivered, make better use of the NHS’ combined buying power to get commonly used products for cheaper, and reduce spend on administration.

What happens next?

The local NHS organisations will work with each other, local councils and other partners to develop and implement their own strategies for the next five years. These strategies will set out how they intend to take the ambitions that the NHS Long Term Plan details, and work together to turn them into local action to improve services and the health and wellbeing of the communities they serve – building on the work they have already been doing.

The local NHS organisations are expected to publish local plans for 2019-20 by April 2019 and publish local five year plan by autumn 2019.

Ref: https://www.longtermplan.nhs.uk/

BMA response to NHS long term plan

“While the Government has highlighted plans to expand capacity and grow the workforce, very little has been offered in the way of detail. Given that there are 100,000 staff vacancies within the NHS, the long-term sustainability of the NHS requires a robust workforce plan that addresses the reality of the staffing crisis across primary, secondary and community care. This will require additional resources for training, funding for which has not been mentioned in the long-term plan.

“There is also a pressing need to address immediate and short-term pressures given that doctors and NHS staff are routinely struggling to cope with rising demand and, as a result, are subject to low morale, stress and burnout. As well as the toll on wellbeing, this has a detrimental impact on recruitment and retention and, unless this is addressed, we risk a workforce plan without the doctors in the future to deliver it.

“The BMA supports increased investment in general practice and community care. This is imperative for effective future planning given the ageing population and the fact that doctors are treating patients with more complex needs, though we await further detail on how this will be delivered.

 “With patients experiencing unacceptable waits in A&E, and with waiting lists for surgery and appointments growing, we also need immediate, practical solutions and the necessary investment for hospitals to deliver both in the long and short-term. 

 “A renewed focus on prevention is welcome but the reality of the situation is that we are seeing a significant increase in obesity and related diseases along with worsening health inequalities exacerbated by years of cuts to public health budgets. The Government must go further than what is outlined in the long-term plan and commit to population-wide measures, such as a minimum unit price for alcohol, restricting sugar levels in food, and greater restrictions on junk food marketing, if we are to achieve necessary improvements to the health of the public. 

“Narrowing inequalities cannot occur without adequate provision of social care which is not covered in the long-term plan. The BMA eagerly awaits the publication of the green paper on social care this year which must fully align with the long-term plan for the NHS.

 “Ultimately, there is a need for honesty about how far the £20.5 billion over five years will stretch. This is well below the 4% uplift that independent experts have calculated is required and below historic spending levels since inception of the NHS. World class care requires world class funding and the investment in the long-term plan will still leave the UK falling behind comparative nations like France and Germany.

 “If we are to truly transform the care we give to patients, and create a sustainable, world-class health service, this long-term plan must deliver beyond grand ambition and address the realities faced by doctors, NHS staff and patients today.” deWhenU

In response to the Shape of Training report (SoTR), the four UK Departments of Health agreed at the UK Scrutiny Board in February 2014 to form a steering group (STSG- Shape of training steering group) to consider how to take forward the report’s recommendations.

The UK Shape of Training Steering Group (UKSTSG) reported in March 2017. It offers policy advice and describes a structure and process for the implementation of the key recommendations arising from the SoTR that is practical, proportionate and will cause a minimum of service disruption.

UKSTSG has worked with individual Royal Colleges to develop their proposals for curricula change to meet this challenge; namely train doctors with more general skills and train doctors who can work better at the interface between primary and secondary care.

Full report here

As a result of the work above, a new curriculum (link) has been approved by GMC for physician specialties.

This new curriculum focusses on the achievement of high level capabilities in practice (CiPs), successfully moving away from the often criticised ‘tick box’ approach for previous curricula. It will produce doctors with the skills needed to manage patients presenting with a wide range of general medical symptoms and conditions which will address the future workforce needs as set out in the Shape of Training report. The curriculum also incorporates the GMC’s generic professional capabilities (GPCs) to emphasise the importance of these professional qualities as well as helping to promote flexibility in postgraduate training.

The IM (Internal Medicine) stage 1 programme will comprise the first three years post-foundation training, during which there will be increasing responsibility for the acute medical take and the MRCP(UK) Diploma will be achieved. It will include mandatory training in geriatric medicine, critical care, outpatients and ambulatory care. IM stage 1 training will replace core medical training (CMT) from August 2019.

Future training pathway for physician specialties

JRCPTB, on behalf of the Federation of Royal Colleges of Physicians, has produced a model for physician training that consists of an indicative seven year (dual) training period leading to a CCT in a specialty and internal medicine. Stage 1 training in internal medicine will comprise the first three years post-foundation training followed by competitive entry into specialty plus internal medicine dual training (see training pathway for group 1 specialties). A minimum of three years will be spent training in the specialty (there will be variation across specialties) and there will be a further one year of internal medicine integrated flexibly within the programme. This will ensure that CCT holders are competent to practice independently at consultant level in both their specialty and internal medicine.

This model will enhance the training in internal medicine for all physicians. In particular, it will promote the management of the acutely unwell patient with an increased focus on chronic disease management, comorbidity and complexity in the main specialties supporting acute hospital care.

Model for physician training – Group 1 specialties (dual CCT)

A number of specialties managed by JRCPTB will continue to deliver non-acute, primarily outpatient-based services (see training pathway for group 2 specialties). These specialties will recruit into ST3 posts from IM2. Trainees who have completed the full three year IM stage 1 programme will not be precluded from applying for group 2 specialty training. Alternative core training pathways may be accepted for some physician specialties and will be defined in the relevant curricula.

Model for Physician training – Group 2 specialties (single CCT)

A list of specialties that will dual train with internal medicine (group 1) and those that will not (group 2) is given below.

 

Sustainability and transformation plans (STPs) are five year plans detailing how local areas will work together to implement the ‘Five Year Forward View’ and achieve financial balance by 2020. STPs will be the main gateway to funding from 2017/18.

For these plans to be developed, England has been divided into 44 STP geographic ‘footprints’ made up of NHS providers, CCGs, local authorities and other health and care services. These organisations will work together to create a plan based on local health needs.

The average population size for a STP is 1.2 million people (the smallest area covers a population size of 300,000 and the largest 2.8 million). A named individual has been chosen to lead the development of each STP.

The proposed scope of STPs is broad, however, there are three headline areas: improving quality and developing new models of care; improving health and wellbeing; and improving efficiency of services. The timelines for developing STPs and the process for approving them have been somewhat fluid.  The plans are likely to be assessed and approved in phases, depending on their quality. From April 2017, STPs will become the single application and approval process for accessing NHS transformation funding, with the best plans set to receive funds more quickly.

What do the STP mean for NHS?

STPs represent a shift in the way that the NHS in England plans its services. While the Health and Social Care Act 2012 sought to strengthen the role of competition within the health system, NHS organisations are now being told to collaborate rather than compete to respond to the challenges facing their local services. This new approach is being referred to as place-based planning.

This shift reflects a growing consensus within the NHS that more integrated models of care are required to meet the changing needs of the population. In practice, this means different parts of the NHS and social care system working together to provide more co-ordinated services to patients – for example, by GPs working more closely with hospital specialists, district nurses and social workers to improve care for people with long-term conditions.

It also recognises that the growing financial problems in different parts of the NHS can’t be addressed in isolation. Instead, providers and commissioners are being asked to come together to manage the collective resources available for NHS services for their local population

But developing STPs is not a simple task. STP footprints are often large and involve many different organisations, each with their own cultures and priorities. Perhaps the biggest challenge facing leaders is that STPs are being developed in an NHS environment that was not designed to support collaboration between organisations. Leaders of NHS providers, for instance, find themselves under significant pressure from regulators to improve organisational performance. This means focusing primarily on their own services and finances rather than working with others for the greater good of the local population.

 Will STP be beneficial to local population?

This will depend on finalised STP plans. However, the aim to integrate health and social care services more closely and to provide a platform for improving population health is laudable.

There are some reasons to be cautious about the kind of benefits that will be delivered. For example, concerns have been raised that leaders have focused their efforts on plans for reconfiguring acute hospital services, despite evidence that major acute reconfigurations rarely save money and can fail to improve quality too (and in some cases, even reduce it).

However, STPs could provide a foundation for a new way of planning and providing health services based around the needs of local populations. While STPs are primarily being led by the NHS, developing credible plans will require the NHS to work in partnership with social care, public health and other local government services, as well as third sector organisations and the local community.

Ref: Kings Fund

It sets out how NHS Improvement will oversee NHS trusts and NHS foundation trusts, helping them to determine the level of support they need.

The Single Oversight Framework is designed to help NHS providers attain, and maintain, Care Quality Commission ratings of ‘Good’ or ‘Outstanding’. The Framework doesn’t give a performance assessment.

The framework applies from 1 October 2016, replacing the Monitor ‘Risk Assessment Framework’ and the NHS Trust Development Authority ‘Accountability Framework’.

How it works

The Framework will help NHS Improvement identify NHS providers’ potential support needs across five themes:

• quality of care
• finance and use of resources
• operational performance
• strategic change
• leadership and improvement capability (well led)

NHS Improvement will segment individual trusts according to the level of support each trust needs. NHS Improvement can then signpost, offer or mandate tailored support as appropriate.

Ref: http://tinyurl.com/jd6mwn8

It came into being on 1^st Apr 2016. It is the operational name for an organisation that brings together:

• Monitor
• NHS Trust Development Authority
• Patient Safety, including the National Reporting and Learning System
• Advancing Change Team
• Intensive Support Teams

NHS Improvement is responsible for overseeing foundation trusts and NHS trusts, as well as independent providers that provide NHS-funded care. It offers the support these providers need to give patients consistently safe, high quality, compassionate care within local health systems that are financially sustainable. By holding providers to account and, where necessary, intervening, it help the NHS to meet its short-term challenges and secure its future.

Currently, NHS is under severe pressure. More is asked of NHS every year as the population grows and changes. The public funding for NHS is not growing so fast.  A lot of NHS trusts and foundation trusts are facing big challenges. Their task is to meet the nation’s healthcare needs within the NHS budget. How can they extend services and maintain or improve the quality of what they do and at the same time keep a lid on the cost. The answer is to work together with the local communities, other NHS and social care organisations in remodelling local health care systems. With everyone’s input systems can be designed to deliver high-quality affordable care indefinitely but none of this is easy.

NHS improvement works alongside NHS trusts and foundation trusts to help them overcome these challenges. NHS Improvement supports their efforts to

1. Care quality
2. Operational efficiency &
3. Financial management

NHS improvement also holds trusts to account in meeting national standards in all these areas. NHS improvement as part of their statutory duty intervenes in Trusts which can’t meet these standards to protect and promote the interests of people who use health care services. As sector regulators, NHS improvement also sets the rules determining the tariffs for NHS services and make sure that procurement, choice and competition operate in patient’s best interests.

NHS Improvement helps the trust help themselves in 3 main ways:

1. First, they provide the board members and managers with more of the skills, systems and information they need to prevent, pre-empt and tackle their particular issue and to continuously improve.
2. Second, they give trusts practical evidence-based help. They advise on how to make services more efficient without eroding quality for instance by managing waiting list differently. They can suggest on how to improve clinical quality without overspending. NHS improvement tries hard to avoid duplicating. Their first instinct is to check what expertise is out there and link people together so they are a hub for sharing existing good practice and knowledge across the sector
3. Third, NHS Improvement spells out what success looks like for the trusts so that everyone knows what they are aiming for and how to measure progress.

NHS improvement work with other national partners at the centre of the health system like NHS England and the Care quality commission to make sure they all speak with one voice to the sector and the individual messages and actions are consistent.

Ref: https://improvement.nhs.uk

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Consultant Outcomes Publication (COP) is an NHS England initiative, managed by HQIP (Healthcare Quality Improvement Partnership), to publish quality measures at the level of individual consultant doctor using National Clinical Audit and administrative data. The data is published on NHS choices website (http://www.nhs.uk/service-search/performance/Consultants#view-the-data).

The information published so far includes how many times each participating consultant has performed certain procedures and what their mortality rate is for those procedures. The data shows where the clinical outcomes for each consultant sit against the national average. The data is risk adjusted to ensure outcomes are calculated as if all consultants operated on the ‘average’ patient.

COP began in 2013. The medical specialties included in COP 2014 includes Adult Cardiac surgery, Bariatric surgery, Colorectal surgery, Head and neck surgery, Interventional Cardiology, Thyroid and Endocrine surgery, Orthopaedic surgery, Upper GI surgery, Urological surgery, Vascular surgery, Lung cancer, Urogynaecology and Neurosurgery.

The aim of COP is to drive up the quality of care in the NHS and improve transparency.

Prof Sir Bruce Keogh, National Medical Director of NHS England, said: ‘We know from our experience with heart surgery that putting this information into the public domain can help drive up standards. That means more patients surviving operations and there is no greater prize than that’.

The reporting of the data was led by Prof Ben Bridgewater from the Healthcare Quality Improvement Partnership (HQIP). Prof Bridgewater is a practising heart surgeon who leads the successful cardiac consultant-level reporting which paved the way for this work.

Prof Bridgewater said: ‘Ultimately there is one patient and one responsible consultant. This means the public can now know about the care given by each doctor and be reassured an early warning system is in place to identify and deal with any problems

Due to data protection legislation, consultants had to agree to have results from their operations published and around 98% have.  The names of those consultants who have not agreed to have data published and the trusts they work in can be seen on NHS choices website.

Some surgeons object to the principle of attributing surgical results to an individual when those results are dependent on effective teamwork between surgeon, anaesthetist, theatre and ward nurses and physiotherapists. Prof Sir Bruce Keogh counters that the patient enters the agreement for surgery with the surgeon and someone has to be accountable for the team’s outcomes.

What will the NHS do where consultants have high mortality rates?

Any hospital or consultant identified as an outlier will be investigated and action taken to improve data quality and/or patient care.

The General Medical Council (GMC) (with eight UK professional healthcare regulators) has underlined its commitment to a professional duty of candour for doctors in a statement issued in Oct 2014

Health professionals must be open and honest with patients when things go wrong. This is also known as ‘the duty of candour’.

Every healthcare professional must be open and honest with patients when something goes wrong with their treatment or care which causes, or has the potential to cause, harm or distress.

 

This means that healthcare professionals must:

 

•tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong;

•apologise to the patient (or, where appropriate, the patient’s advocate, carer or family);

•offer an appropriate remedy or support to put matters right (if possible); and

•explain fully to the patient (or, where appropriate, the patient’s advocate, carer or family) the short and long term effects of what has happened.

 

Healthcare professionals must also be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested. Health and care professionals must also be open and honest with their regulators, raising concerns where appropriate. They must support and encourage each other to be open and honest and not stop someone from raising concerns.

‘The awful reality that emerged from Mid Staffs and indeed other inquiries was that doctors knew about GMC guidance but were not empowered by it. They felt it was acceptable to ‘walk by the other side of the ward’ knowing that there was unsafe and unacceptable practice going on. We must all do what we can to make sure that does not happen again. The statement above is an important milestone and makes it clear that the professional duty of candour sits with every healthcare professional, regardless of their field of practice.

 

The government in Nov 2014 has introduced a further duty of candour on secondary care organisations registered with CQC – one required, and enforceable, by law.

 

This new statutory duty of candour will apply to all other care providers registered with CQC from 1 April 2015. The key principles are:

 

1. Care organisations have a general duty to act in an open and transparent way in relation to care provided to patients. This means that an open and honest culture must exist throughout an organisation.

2. The statutory duty applies to organisations, not individuals, though it is clear from CQC guidance that it is expected that an organisation’s staff cooperate with it to ensure the obligation is met.

3. As soon as is reasonably practicable after a notifiable patient safety incident occurs, the organisation must tell the patient (or their representative) about it in person.

4. The organisation has to give the patient a full explanation of what is known at the time, including what further enquiries will be carried out. Organisations must also provide an apology and keep a written record of the notification to the patient.

5. A notifiable patient safety incident has a specific statutory meaning: it applies to incidents where a patient suffered (or could have suffered) unintended harm that results in death, severe harm, moderate harm or prolonged psychological harm.

6. There is a statutory duty to provide reasonable support to the patient.

7. Once the patient has been told in person about the notifiable patient safety incident, the organisation must provide the patient with a written note of the discussion, and copies of correspondence must be kept.

 

Doctors are most likely to be the organisation’s representative under the statutory duty. It is important that you cooperate with your organisation’s policies and procedures, including the requirement to alert the organisation when a notifiable patient safety incident occurs.

 

An area of difficulty may be deciding whether an incident reaches the threshold for notification under the statutory duty. This may be confusing, as the threshold is low for the doctor’s ethical duty (any harm or distress caused to the patient) while the thresholds for the contractual and statutory duties are higher and slightly different (at least moderate harm).

 

Ref:

http://www.themdu.com/guidance-and-advice/guides/statutory-duty-of-candour/statutory-duty-of-candour