Archive for June, 2010

NHS five year plan 2010-2015

Monday, June 14th, 2010

The NHS five year plan 2010-2015
NHS 2010-2015: from good to great. Preventative, people-centred, productive
This sets out the NHS five year plan in the context of a new financial era and it is intended to give people working in the NHS a clear sense of direction and time to plan for the challenges ahead. Key aspects of the plan are:
Implementing our vision: a preventative, people-centred, productive NHS
• It is stated that change will be on an unprecedented scale for patients and staff and hard choices about resources and priorities will have to be made, delivering £15-20 billion efficiency savings over three years from April 2011 (£10billion by 2012/13). Savings are identified in the following areas:
o Productive NHS workforce – £3.5 billion
o Reduced management cost, back office support and procurement – £1.8 billion
o Care closer to home and self care for people with long term conditions – £2.7 billion
o Tighter control of the pay bill
• Reference is made to six challenges; ever higher patient expectations; an ageing society, the dawn of the information; the changing nature of disease; advances in treatments and a changing workforce.
• There is emphasis on reform and that this can only be achieved through clinical leadership and a change in current roles for NHS staff. There is commitment to support staff to make the changes necessary to shape services around the needs of patients – more care closer to people’s homes that are better integrated around people’s needs.
The deal for patient and the public
• The legally binding entitlements to staff, patients and the public are now set out in the NHS Constitution. There are 25 rights in the Constitution and a further 2 have been proposed:
o You have the right to access services within maximum waiting times.
o You have the right to an NHS Health Check every five years if you are eligible for one.
• There is acknowledgement that there should now be a shift from ‘diagnose and treat’ to ‘predict and prevent’ and that personalised care can only be realised by tailoring provision with services and organisations working together across traditional boundaries. Changing behaviours will continue through schemes such as Change4Life, NHS Stop Smoking Service and Total Place pilots.
• The introduction of NHS health checks is set to save thousands of lives by preventing
stroke and heart attacks.
• More screening and earlier diagnosis of cancers is planned through increased GP access and modern laboratory medicine.
• The following priority areas for achieving High Quality Services have been identified:
o further reductions in MRSA
o cancer care
o care for stroke patients
o care for those at risk of heart disease
o care for pregnant women.
• For the three interdependent areas of quality, as per Lord Darzi’s vision organisations will be required to:
o Safety. Focus on a wider set of safety challenges, safer care for patients, zero
tolerance of preventable infections
o Effective. Reduce the number of patients who die from VTE and increase prevention of pressure ulcers.
o Patient experience. Expand the measurement of patient satisfaction and for those to be included in Quality Accounts. There will also be a greater
proportion of provider income linked to patient experience and satisfaction – potentially up to 10%)
• There is clear requirement to have more choice for patients and to transform the care for groups of people with the following long term conditions; diabetes, heart failure, respiratory disease (including COPD), cancer as a chronic disease and dementia.
• More local care is seen to be delivered by GPs and community services rather than having to be seen in an urgent or emergency setting.

The deal for staff
• The focus is clinical leadership, collaborative working, reuniting doctors and nurses, managers and politicians and staff flexibility.
• Change needs to be fast moving as good practice cannot be allowed to spread at its own pace. An evidence base of around 70 examples of best available evidence will be used to escalate improvements. Organisations will be supported nationally but locally led. The Trust will be able to drive this through NETS and Service Improvement.
• With regards to pay, future pay awards will need to strike the balance between rewarding existing staff for increased quality and productivity and the need to maintain security of employment by retraining and redeploying staff to meet additional demand. A sustained pay restraint is required. It is recommended that consultants and very senior managers receive no increase in 2010/11 and GP practice income increases are restricted and they need to make at least 1% cash releasing efficiency savings.
• Work is ongoing exploring the pros and cons of offering frontline staff an employment guarantee locally or regionally in return for flexibility, mobility and sustained pay restraint. This may involve staff working in a different place or even a different organisation. The Trust will need to align training plans to support delivery of local clinical visions and new ways of working in support of retraining and redeployment of staff, utilising the new Staff Passport.
How the system will support NHS staff and organisations to deliver
The key levers include:
• Payment systems support improved quality and efficiency
o 0% maximum uplift for next four years (hospitals)
o Increases in payment linked to quality goals
o Incentivising the shift of care out of hospital settings
o Withdrawal of payments when care does not meet minimum standards
• Helping staff through change
o Empower and enable NHS staff to lead change
o NHS will be given the first opportunity to improve
o Commissioners will have a legal duty to secure best services.
• Strengthening regulation, dealing with failure
• Creating leaner, stronger commissioners
o Freedoms and incentives to high performing commissioners
o Poor performers to demonstrate clear and rapid improvement
o Improve information on management costs
o Significantly reduce management costs in PCTs and SHAs (30% over next four years)
o Permit reconfiguration where it leads to greater coterminosity between PCTs and LAs
• Integrating services, supporting high performing organisations
o Reduce variation in quality among primary care providers and practice based commissioners.
o Increase integration of services
o Alignment of incentives so organisations work better together
o Reform of provider services
o Reduce overheads and transaction costs
o Offer rewards and freedoms for high performers
o High performing FTs to expand their services
o Make it easier for high performing trusts to take over poorly performing organisations.
• Streamlining the reconfiguration process
o Further simplification
o Better engagement.
• Driving innovation
o £220 million Regional Innovation Fund
o Development of NHS Evidence
o NHS Life Sciences Innovation Delivery Board to support adoption of clinically and cost effective innovations

Temple report summary: Time for change

Monday, June 14th, 2010

Temple report- Time for Training: A Review of the impact of the European Working Time Directive on the quality of training
The report Time for Training was commissioned by Medical Education England at the request of the former secretary of state for health Alan Johnson. The report was instigated in response to the concern raised by many specialties, but by surgeons in particular, that after the introduction of the EWTD it was impossible to ensure doctors in training acquired a sufficient number of hours of supervised and hands-on experience to bring them up to an adequate standard. The report was published on June 9, 2010
The report looked at the impact of the 48-hour week on the quality of the training that is necessary to ensure the continuing supply of a world class workforce which is able to deliver high quality services to patients.

Problems with EWTD implementation:
• The reduced hours have necessitated a move to shift patterns of work in many
Specialties (Any doctor working to a rota that requires them to work different duty times at certain points on the rota can be considered to be a shift worker). Shift working has decreased training opportunities and impacted on trainee experience by reduction in trainer and trainee interaction and lack of continuity of patient care. Although with the reduction in hours there should be less sleep deprivation and better work–life balance for trainees, but shift patterns have possibly decreased the quality of life, as work periods, although shorter, are more frequent, less regular and more antisocial.
• The move to resident shift systems to accommodate the 48-hour week means that more trainee doctors are required to cover the out of hours care if the structure of service cover remains the same. This increased requirement for doctors results in an increase in the number of rota gaps. Recruitment challenges due to changes in immigration law have compounded the difficulty in fillings gaps. Rota gaps result in trainees being moved from their daytime, more elective training often at very short notice to fill service gaps. These are usually out of hours where there is minimal supervision and therefore less training opportunity. This results in the trainee missing out on the planned training that day and often the next due to compensatory rest. Although many rotas are compliant with 48 hours on paper, rotas have gaps.
• Rigid, poorly designed rotas result in trainees being unsupported and unsupervised.
• The impact of EWTD is greatest in specialties with high emergency and/or out of hours workloads

The report recommends that high quality training can be delivered in 48 hours. Any current problems will not be solved by either increasing hours or lengthening training programmes, says the report, which shows that despite an increase in consultant numbers of more than 60% over the past ten years, hospitals remain too reliant on junior doctors to provide out of hours services. There is a total of over 15,000 hours available to trainees working a 48-hour week in a seven-year training programme, but these are not all being used effectively for training.

It recommends the following to achieve high quality training within EWTD:
Implement a consultant delivered service: Consultants must be more directly responsible for the delivery of 24/7 care. The roles of consultants need to be developed for them to be more directly involved in out of hours care.

Service delivery must explicitly support training: Services must be designed and configured to deliver high quality patient care and training. Reconfiguration or redesign of elective and emergency services and an effective Hospital at Night programme are two of the ways in which healthcare can be changed to support training and safe services

Make every moment count
• Training must be planned and focused for the trainees’ needs
• Trainers and trainees must use the learning opportunities in every clinical situation
• Handovers can be an effective learning experience when supervised by senior staff, preferably consultants
• The co-ordinated, integrated use of simulation and technology can provide a safe, controlled environment and accelerate learning

Recognise, develop and reward trainers
Consultants formally and directly involved in training should be identified. • They must be trained, accredited and supported.

Training excellence requires regular planning and monitoring
Commissioner levers should be strengthened to incentivise training, ensure accountability and reward high quality and innovation