An introduction to the NHS and its many functions

1. An introduction to the NHS and its many functions Chris Locke Chief Executive ,Nottinghamshire Local Medical Committee (Ltd)

2. The NHS: origins and characteristics • Established 5 July 1948 • Accessible to all on basis of need and “free at the point of delivery” • Comprehensive, providing care “from the cradle to the grave” • Funded (almost) entirely from general taxation • Currently consumes between 7-9% GDP

3. Who runs the NHS ? Parliament Select Committees (Health, Public Accts, & Public Administration) Secretary of State Junior Minister 1 (Commons) Junior Minister 2 (Commons) Junior Minister 3 (Lords)

4. Structure of the NHS Ministers NHS Chief Executive (Permanent Secretary) Department of Health Board National Clinical Networks Strategic Health Authorities Arms Length Bodies Acute, MH and Ambulance Trusts Primary Care Trusts Foundation Trusts

5. The purchaser/provider split • The NHS was originally a monolithic structure run for government by local appointed hospital boards and executive councils • There were no targets, but little data, and spiralling costs • In 1990s govt. reforms made hospitals self governing Trust ‘providers’, and health authorities/PCTs and GP fundholders‘commissioners’ ( purchasers) of services.

6. The purchaser/provider split • Following abolition of fundholding GPs supported Health Authorities/PCTs in commissioning a “primary care –led NHS” • Since 2001 govt has encouraged competition between providers, including the private sector, in a pluralistic healthcare ‘market’ • Since 2005 GPs have participated in practice based commissioning with providers bound by fixed tariffs under payment by results

7. Differences within UK • Devolved government has seen Wales , Scotland and Northern Ireland set the clock back in many respects • They have abandoned purchaser provider split in favour of direct management by Health Boards with local accountability and no PBC • They have discouraged private sector role • Wales has abolished prescription charges, Scotland aims to follow !

8. Categories of NHS Trusts • Acute Trusts providing medical/surgical care, usually centred on district general or teaching hospitals (often more than one) • Specialist Mental Health and learning disability Trusts • Ambulance Service Trusts • Care Trusts which combine community and/or mental health services with social care services

9. Characteristics of NHS Trusts • NHS Trusts earn income through service level agreements with PCTs ,much of which now governed by payment by results (PBR) • They must break even financially • They must achieve minimum quality standards • They are self governing (through Trust Boards) but accountable to SHAs • However all Acute Trusts are expected to become Foundation Trusts by 2010

10. What are Foundation Trusts? • Independent ‘public benefit organisations’ • Financially and managerially autonomous within NHS • Accountable to local people through its members and governors • Regulated by Monitor, not accountable to SHAs (but still performance- managed by Care Quality Commission)

11. Benefits of Foundation Trusts • Freedom to retain operating surpluses • Freedom to use income from land sales • Able to borrow capital for investment • Technically free of government interference though bound to adhere to NHS policy directives • Theoretically more accountable to patients and service users

12. What are Primary Care Trusts ? • Commissioners of health services for local population (in partnership with Local Authorities and with help of GPs) • Providers of community services • Managers of primary care contractors ( GPs, Dentists, pharmacists, opticians) • Local guardian of public health • Accountable to government through SHAs

13. Future of PCTs • Community services have undergone ‘market testing’ and most have become or are in the process of becoming semi autonomous ‘arms length’ organisations - some may become independent Trusts (like they were in 1990s!) • Conservatives likely to restructure what remains creating fewer, leaner commissioning authorities and to devolve a lot of market management responsibility to GP clusters

14. What is ‘Payment by Results’? • Based on principle that ‘money follows the patient’ • Objective is to make system more cost effective/efficient • Nationally applicable (maximum) tariffs for all elective and some other procedures, based on national reference costs, eg average length of stay etc. called Healthcare Resource Groups.

15. The role of the GP in the new NHS • Generalist diagnostician • NHS ‘gatekeeper’ • Patient advocate • Guardian of the patient’s lifetime health record • Commissioner of services

16. The GP as NHS ‘Gatekeeper’ • GPs act as the universal filter through which patients must pass in order to access drugs and secondary care treatment • They are vital to the smooth running and cost effectiveness of the NHS • They now not only advise patients about what secondary care treatment they need and where to access it, but facilitate choice of provider through choose and book system

17. Patients and GPs • Universal patient registration is one of the determining features of the NHS • Every citizen has the right to register with GP or be assigned one by their PCT • Before new contract GPs responsible 24/7, still have ongoing responsibility ‘in hours’ • Patients now have right to see a GP at their practice on same day, if urgent, and within 48 hours otherwise

18. What is Practice Based Commissioning? • Began officially in 2005, origins in fundholding & GP-led Health Authority commissioning • Involves dividing PCT budget into capitation based practice level budgets • Practice budgets still largely indicative or virtual, ie PCT still hold money but allows practices or clusters a major say in how it is spent but some have earned autonomy.

19. Funding the NHS • The NHS consumes 15% of all Tax and NI revenues • In 2008/9 it cost over £96 Billion of which £11 Billion was spent on drugs • Over 80% of NHS funding is spent in hospitals • Major investment in the NHS in light of the Wanless report due to finish in 2011/12 • Most Trusts and PCTs financially stable but recession expected to trigger cuts in services.

20. NHS Staff NHS is UK’s largest employer (one of largest in the world) employing 1.3 million people (in 2008) of whom there were: - 133,000 doctors - 408,000 nursing grades - 142,000 therapists, technicians, scientists - 179,000 admin and clerical grades - 40,000 managers

21. Drugs in the NHS • The purchasing and control of the vast majority of drugs for the NHS from the pharma industry is managed through the pharmaceutical price regulatory scheme • Under PPRS pharma companies need NHS agreement to price rises and have to share data on sales, costs, profitability and assets • Availability of new drugs is however often dependent on approval by NICE

22. Clinical governance Introduced in 1990s, a key characteristic of NHS comprising the following components: • Adherence to quality standards (audit, evidence based practice, continuing improvement) • Clinical risk reduction (adverse event monitoring, learning from mistakes, tackling poor performance) • CPD (multi disciplinary education/training, PPDs and annual appraisal)

23. National Institute for Clinical Excellence • NICE is one of a number of important “arms length bodies” operating within the NHS • It examines the evidence for, and makes recommendations on, new and existing medicines/treatments and on appropriate treatment of specific conditions and determines which are safe for routine use • Its decisions, often controversial, are not binding on clinicians but must be taken into account by them when treating patients.

24. ‘Rationing’ in the NHS • NHS organisations must fund treatments recommended by NICE and are reluctant to provide those not recommended by them • Patient interest groups sometimes challenge this • The NHS is fixated on reducing health inequalities • PCTs have to respond to local health needs and prioritise funding accordingly • Therefore the share of funding spent on some conditions varies –hence the ‘postcode lottery’

25. The NHS and private treatment • NHS patients only pay for: prescriptions (at fixed rate) dentistry and eye tests (subsidised) • Public opt to go private to obtain speedier treatment and more comfortable facilities • Complex rules allow patients to switch from private to NHS but not more than once and are designed to prevent ‘queue jumping’ • NHS hospitals can generate income from ‘hotel services’ (in private wings)

26. Private providers • Private sector welcomed to deliver services to NHS patients under service contracts • They are expected to work under NHS rules, ethos and standards and compete with mainstream NHS for similar tariffs • Government putting out tenders for independent treatment centres, mobile diagnostics and privately run GP practices .

27. The Care QualityCommission • Another ‘arms length body’, their job is to assess the management, provision and quality of all NHS and social care services • They review each Trust’s performance and publish their annual performance rating along with other information on the state of NHS • They inspect, enforce standards, investigate service failures (inc private sector) and will register providers including (from 2012) GPs.

28. Monitor • Separate regulatory body set up to deal with Foundation Trusts • They set the benchmark for achieving FT status, then monitor and report on FTs’ performance (to Secretary of State) • Independent of SHAs and engaged in ‘turf war’ with Care Quality Commission • Accused of being concerned only with financial performance and ignorant of other priorities.

29. Strategic Health Authorities • Manage public health agenda within their regions • Manage strategic planning, oversee PCT budgets and major investments • Oversee education, research and training • Commission specialist/tertiary services • Manage the performance of PCTs and Trusts and oversee migration to Foundation status

30. Patient involvement Patients are encouraged to help influence NHS policy and its operation through: • Public consultation (‘listening exercises’ and patient experience surveys) • ‘Expert patients’ in clinical networks • Local involvement networks (replacing patient forums) • GP Practice patient participation groups

31. Patient Safety • The National Patient Safety Authority is another ‘arms length body’ (established 2001) • It manages safety aspects of hospital design, cleanliness and food • It also helps NHS bodies address concerns about doctors’ performance (through National Clinical Assessment Service which it runs) • It also conducts confidential enquiries into patient deaths, suicide/homicide etc.

32. Safety and litigation • NHS bodies belong to a risk pooling scheme run by the NHS Litigation Authority • This handles most claims for clinical negligence levelled against NHS bodies • In 2008/9 this involved 9,800 claims costing the NHS £769 million in damages and costs • Patient safety, learning from mistakes ,critical incidents etc a major part of clinical governance

33. The ‘Patient Led’ NHS • The thrust of present govt policy for the NHS is to make it patient centred • Everything is designed to offer patients more ‘choice’ and more say in how services are run • Choice is currently confined to a choice of provider but could in future involve choice of specialist or GP, based on available performance data, and choice of a limited range of treatments (and patient held budgets)

34. The ‘Patient led’ NHS • Currently NHS hosts disparate IT systems unable to communicate with each other • NHS Information spine intended to facilitate universal access and recording allowing safe treatment wherever patient pitches up • Multi layered access protocols and audit trails fail to convince sceptics fearful of breaches of confidentiality, commercial exploitation and ‘big brother’ government.

35. The ‘Patient Led’ NHS • Choose and Book allows patients to book appointments at time of consultation or soon after • NHS Choices offers information on which patients can base choice of consultant/GP • The NHS Constitution (2009) guarantees the patient’s right to services, while emphasising the patient’s responsibilities for their own health and proper use of NHS.

36. Darzi reforms • An attempt to re-establish core NHS values • Emphasis on outcomes (now NHS priority) • Reinforces contestability (competition), patient choice and improved access (through controversial, and discredited, Darzi centres) • Requires Trusts and PCTs to cultivate clinician engagement and clinical leadership • Advocates goal of more integrated services.

37. ‘World class commissioning’ Concept devised in 2008 comprising: • Stakeholder consensus on priorities/outcomes • Facilitating choice through published data • Integrated services • Effective management of healthcare market • More regulation of providers and monitoring of commissioners • Emphasis on competition and collaboration .

38. Likely changes under Conservatives • Abolition of SHAs and all quangos except NICE and CQC ? • PCTs to become geographically larger but leaner commissioning health authorities? • New GP contract in which PBC compulsory? • Real budgets and GP provider opportunities? • Commissioning streamlined and market management and PBR made more effective?.