Consultant Medical Interview

Health and Social Care Bill 2011

The Health and Social Care Bill was introduced into Parliament on 19 January 2011. The Bill took forward the areas of Equity and Excellence: Liberating the NHS (July 2010) and the subsequent Government response Liberating the NHS: legislative framework and next steps (December 2010), which required primary legislation.

The Health and social care Bill proposed to implement a radical reorganisation of the NHS which aimed to devolve responsibility to clinicians, cut management costs, and reduce political involvement in the health system. The Bill was criticised for a number of reasons. The 3-month “listening exercise”, delaying progress of the bill through Parliament, was launched in April 2011 in response to widespread concerns about the impact of the bill. A NHS Future Forum was set up to lead the exercise.  The government presented a revised bill in the parliament based on the NHS future forum recommendations. The Bill went through the Commons in Sep 2011 and is currently in the Lords.

The original Bill presented in Parliament on 19^th Jan 2011 contained provisions covering the following key themes:

• Establish an independent NHS Commissioning Board responsible for the operational management of NHS (i.e. allocate resources and provide commissioning guidance). However, the Secretary of State would still account to parliament for the performance of the NHS and the Bill included wide-ranging powers for him/her to intervene in the system.
• Increasing GPs’ powers to commission services on behalf of their patients. This involves giving groups of GP practices – GP consortia – ‘real’ budgets to buy care on behalf of their local communities from ‘any willing provider’. This was aimed to improve clinical involvement in commissioning and addresses the current weakness in the commissioning arrangements, with PCTs lacking the knowledge and skills to challenge providers about the quality and efficiency of their services.
• Developing Monitor, the body that currently regulates NHS foundation trusts, into an economic regulator with three key functions: promoting competition, setting prices, and ensuring continuity of essential services.  The Bill gave Monitor wide-ranging powers to impose licence conditions to prevent anti-competitive behaviour, apply sanctions to enforce competition law and refer malfunctioning markets to the Competition Commission. This mirrored the approach taken in the utility sector and aimed to open up the NHS to challenge by the Office of Fair Trading and the Competition Commission.
• Cutting the number of health bodies to help meet the Government’s commitment to cut NHS administration costs by a third, including abolishing Primary Care Trusts and Strategic Health Authorities.
• Ensuring all NHS trusts achieve foundation trust status by April 2014
• Extending the role of local authorities in the health system by creating Health and Wellbeing Boards (HWBs) and giving them responsibility for public health. The aim was to strengthen democratic legitimacy and ensure that commissioning is joined up across the NHS, social care and public health. HWBs will be responsible for producing joint strategic needs assessments and developing a joint health and well-being strategy for their local area. The core members of HWBs will be GP consortia, the Director of Adult Social Services, Director of Children’s Services, Director of Public Heath, and the local Health Watch.

The Bill was criticised because of the following:

1. The primary criticism was about the bill’s intention to amend one of the founding pillars of the NHS to read “any willing provider” rather than the current language guaranteeing a needed service exclusively via the NHS and its direct affiliates and partners. These critics noted that the NHS is not allowed to have any bias based on profit or competition; rather it is committed by law exclusively to medical objectivity and patient care, and the changing of the language of the NHS tenets to include “any willing provider” is thinly-veiled code to allow the private sector inside the NHS, disrupting its inner workings or even potentially opening up local NHS operations to the possibility of forced closure because the private industry has out-competed them and corralled them into bankruptcy.

Summary: The Bill signalled a significant shift towards a more competitive market for health care. While increased competition need to be supported in areas where it demonstrates benefits to patients, the Bill appeared to move towards promoting competition at the expense of collaboration and integration

2. GP-led commissioning (GP consortia) was as an opportunity to improve patient care. However, there was considerable disparity in the capability of local health economies to take on the commissioning role and hence the deadline of April 2013 for GP consortia to be established was felt to be too tight. The winding down of primary care trusts (PCTs) and strategic health authorities (SHAs) without providing time for GP consortia to be established caused anxieties regarding services failing or patient care suffering.

Further, the Bill included few requirements on the governance of consortia. The critics pointed out that the consortia governance structure should be clarified to include a wide range of health professionals (including hospitals specialists) and involve the public in their work.

3. The critics also opposed that all NHS trusts should be forced to become foundation trusts by 1 April 2014, given the unacceptable outcomes that have resulted in a small number of cases where the financial imperatives required to achieve FT status have been pursued at the expense of good-quality patient care . It was feared that intensifying the pressure to achieve foundation trust status may lead to distorted priorities and drive trusts to place the achievement of this target above all others, including safe patient care.

4. Bill gave health and wellbeing boards insufficient powers to fulfil their remit in joining up local commissioning.

Revised Bill addressed a number of issues in the original bill and is currently in the Lords. The Government hopes that the Bill will be passed in the Lords and would go for Royal assent before the end of 2011

Key changes in the revised Bill:

1. Competition: There is emphasis now on integration rather than competition with Monitor’s powers now focused on preventing anti-competitive behaviour rather than promoting competition. The Bill signals a more nuanced approach to competition by ruling out competition on price (evidence suggests that price competition reduces quality and increases transaction costs) and a commitment to phase in ‘any qualified provider’ from April 2012 (this should reduce the risk of fragmentation of services).

2. Commissioning: Wider clinical involvement in commissioning, strengthen governance arrangements for local commissioning groups and adopt a more flexible approach to implementing clinical commissioning.

GP consortia will be re-named clinical commissioning groups and will be required to obtain a wide range of clinical advice and consult a number of bodies in developing their commissioning plans. Existing clinical networks (groups of experts working in specialist areas such as cancer) will be strengthened and new clinical senates established to bring together a wide range of health and social care professionals.

Changes made to the governance of clinical commissioning groups: Clinical commissioning groups will also be required to include a nurse and a hospital specialist on their governing body besides two lay members (one to champion patient and public involvement and one to lead on governance).

The April 2013 deadline for establishing GP consortia has been relaxed – clinical commissioning groups will be established either in full or in shadow form by this date, but take on their new responsibilities only when they are ready and willing to do so.

3. The government has relaxed the April 2014 deadline for the remaining NHS trusts to become foundation trusts, although it stresses that the majority will still be expected to meet this deadline.

4. The role of health and wellbeing boards has been strengthened in a number of ways. They will be given a stronger role in the development of local commissioning plans, more responsibility for promoting joint commissioning and health and social care integration, and a lead role in local public involvement. They will also be able to refer commissioning plans back to clinical commissioning groups or the NHS Commissioning Board if they are not satisfied it takes proper account of the local health and wellbeing strategy.

CfWI ‘Recommendation for medical specialty training 2011’ report.

The Centre for Workforce Intelligence (CfWI) has carried out a piece of work to analyse and inform on the numbers of doctors going into medical specialty training following on from foundation training. The work, commissioned by DH, in consultation with SHAs and Medical Education England (MEE), makes recommendations on numbers for the 2011 intake.

The report:

• contains an overall analysis of numbers going into medical specialist training
• contains more detailed analyses for each specialty
• identifies which medical specialties are at risk of over supply as well as identifying the geographical balance.

This report is the first of a number of reports looking at the shape and size of the overall workforce needed for the NHS of the future. As one of the first pieces of work carried out by the CfWI in its current form, and within a constricted time span, the underpinning research is necessarily limited, but the report makes reliable recommendations and identifies emerging messages.

Ref: http://www.cfwi.org.uk/intelligence/projects/recommendation-for-medical-specialty-training-2011

Collins Review (published Oct 2010)

Foundation for Excellence: An Evaluation of the Foundation Programme

The report was commissioned by Medical Education England (MEE) to formally evaluate the Foundation programme. The Terms of Reference for the Evaluation were to assess how successfully the Foundation Programme is delivering against its original objectives, as well as against the future needs of the National Health Service and of trainees. The Evaluation was to recommend changes to the Foundation Programme to ensure that the first two postgraduate years deliver against future needs.

Recommendations:

Issue 1: Lack of a clearly articulated purpose for the Programme

By the end of 2011, the GMC should define, in a revised edition of The New Doctor, the outcomes required to complete the second year (F2) of the Foundation Programme.

Issue 2: Misgivings about the selection of trainees into the programme

A standardised and uniform process should be developed for the recruitment, selection and appointment of Foundation doctors by 2012, taking into account the guidance provided by the GMC in Tomorrow’s Doctors and The New Doctor.

Issue 3: Confusion over the role of the trainee

MEE should work with its members and partners to develop a consensus statement on the role of the trainee by 2012. NHS Trusts and the HR departments which draw up service rotas must have a detailed understanding of the role of Foundation doctors.

Issue 4: Questions about GMC registration of trainees and medical student

The GMC should review the timing of full registration. It should also review the merits of marking on the Medical Register the successful completion of the Foundation Programme.

Issue 5: Dissension over the length of the Programme and its rotations

The length of the Programme should remain at two years for the present, and be reviewed in 2015.  In the meantime F2 must demonstrate that it is a step-up in experience from F1 and be able to prove its overall value beyond doubt.

Issue 6: Perceived deficiencies in careers information and advice

Define good practice for the provision of careers information and advice.

Issue 7: Lack of flexibility in the Programme

Greater flexibility should be available within a single programme, allowing F1 trainees to have greater input into the allocation of their F2 specialty placements and rotations.

Issue 8: Gaps in the curriculum

The Foundation Programme curriculum should be revised to give greater emphasis to the total patient, long-term conditions and the increasing role of community care. It should also reflect the changing ways of working, in particular the need for team-working skills within a multi-professional environment.

Issue 9: Maldistribution of placements by specialty

The successful completion of the Foundation Programme should normally require trainees to complete a rotation in a community placement, e.g. community paediatrics, general practice or psychiatry.  The distribution of specialty posts in the Foundation Programme is predominantly in two specialties and this must be reviewed by 2013 to ensure broader based beginnings, to share the supervision of trainees among a wider number of supervisors and to ensure closer matching with current and future workforce requirements.

Issue 10: Shortcomings in technology-enhanced learning

The importance of learning resources including skills labs and simulated patient environments is reaffirmed. Concerted efforts need to be made across the different organisations involved to co-invest in facilitating innovations in the delivery of education and training.

Issue 11: Equipping and approval of trainers is necessary

A framework for the approval of trainers involved in teaching and assessing trainees is a high priority and the professional standards developed and published by the Academy of Medical Educators provides a useful resource for this.

Issue 12: Assessment is excessive, onerous and not valued

The range of assessment tools and the number of times assessment must be repeated in the Foundation Programme should be reviewed, with a view to reducing these to the minimum required by 2013. The opportunity to avoid repetitive assessments, by improved transfer of information between undergraduate and postgraduate schools, should be actively explored.

Feedback from patients who have been in contact with the Foundation doctor should be part of assessment by 2013 and the GMC should be invited to oversee research to identify best practice in this regard.

All Foundation Programme assessments should be conducted and signed off by resourced and trained assessors by 2013. Assessors should undergo regular review of their performance for this role.

Issue 13: Variability in the deployment and supervision of trainees

Methods must be developed to ensure that all health professionals and employers understand the objectives of the Foundation Programme, become quickly conversant with the prior clinical experience and level of competence of individual F1 and F2 trainees, and support the standard that no Foundation doctor will be required to practise beyond their level of competence or without appropriate supervision.

Issue 14: Variability in the quality of education and learning

The Postgraduate Deans, the GMC and NHS Trusts must clarify the appropriate balance between service and education during F1 and F2 and ensure that the effective monitoring of this balance is being achieved by 2012. Clear pathways must be available for trainees to obtain satisfactory resolution if the appropriate balance is being eroded.

Issue 15: Lack of pastoral support for trainees

Good practice with regard to pastoral care needs to be defined

Issue 16: Inadequate transfer of information about trainees

In the interests of patient safety and in order to help trainees to address issues which have been identified, the transfer of relevant information about medical students and trainees across the continuum of education and training must take place (within carefully defined limits) by 2012.

Ref: http://www.mee.nhs.uk/pdf/401339_MEE_FoundationExcellence_acc_FINAL.pdf

The Royal College of Physicians of Edinburgh’s Health Priorities for Scotland manifesto sets out 12 key priorities that we believe should be the health goals of an incoming Scottish Government to ensure safe, patient-centred medical care of the highest quality and improved public health. These priorities focus on the three areas of patient safety, quality care and public health, and were informed by a survey of College Fellows and Members. While these priorities will initially be advocated to the Scottish Government, many of these are equally applicable to the NHS in England and will form the basis of much of our policy work during the next terms of the Scottish and UK Governments.

The key priorities include:

·   Addressing the ongoing erosion of the balance between training and service needs by protecting training time for both Trainees and their supervisors to ensure that Trainees are adequately trained and patient safety is maintained.

·   Ensuring timely patient access to consultant-delivered care through more flexible working patterns and improved workforce planning.

Other recommendations include:

·   Better access to diagnostic services and alternatives to hospital admission to improve acute care.

·    Improved continuity of care through several measures, including a modest relaxation of European Working Time Regulations.

·    A strategy to improve the quality of audit data available to consultants.

·   The introduction of minimum pricing to reduce alcohol consumption.

Ref: http://www.rcpe.ac.uk/policy/health_priorities.php

What do you mean by Service Line Reporting (SLR)?

SLR means departments are accountable for their income and expenditure. This means that departments will be charged for all the resources it uses i.e. every blood test, every imaging or every cross specialty consult.

The idea is to use resources efficiently to ensure expenditure of departments do not exceed its income.

Watchout: Some departments may underuse resources (to balance books) to the detriment of patients. Proper governance structures and outcome data will be needed to avoid any patient consequences.

What is information governance (IG)?

Information Governance is the way by which the NHS handles all organisational information – in particular the personal and sensitive information of patients and employees. It allows organisations and individuals to ensure that personal information is dealt with legally, securely, efficiently and effectively, in order to deliver the best possible care.

It provides a framework to bringing together the requirements, standards and best practice that apply to the handling of information. It has four fundamental aims:

• To support the provision of high quality care by promoting the effective and appropriate use of information;
• To encourage responsible staff to work closely together, preventing duplication of effort and enabling more efficient use of resources;
• To develop support arrangements and provide staff with appropriate tools and support to enable them to discharge their responsibilities to consistently high standards;
• To enable organisations to understand their own performance and manage improvement in a systematic and effective way.

IG has come about because of concerns about public sector data protection. A board-level Senior Information Risk Owner (SIRO) is required in each organisation for IG.

More info

How do SIRO and Caldicott Guardian differ?

SIRO and Caldicott Guardian should work together.  However,

SIRO

• Is accountable
• Fosters a culture for protecting and using data
• Provides a focal point for managing information risks and incidents
• Is concerned with the management of all information assets

The Caldicott Guardian

• Is advisory
• Is the conscience of the organisation
• Provides a focal point for patient confidentiality & information sharing issues
• Is concerned with the management of patient information