A Junior Doctor's NHS: Guide To The
A Junior Doctor's NHS: Guide To The
Foreword Contents
Chapter Foreword Introduction NHS structure Parliament Department of Health (DH) Doctors holding senior roles in the DH Arms Length Bodies Strategic Health Authorities (SHAs) Primary Care Trusts (PCTs) Trusts and Foundation Trusts New providers Regulating the health service Complaints and litigation Commissioning World Class Commissioning NHS finance NHS strategy: policy into practice NHS Next Stage Review: High Quality Care for All (The Darzi Review) Quality in the NHS National Institute for Health and Clinical Excellence (NICE) Clinical governance IT in the NHS The health system in Scotland The health system in Wales The health system in Northern Ireland Page 3 4 5 6 7 8 8 9 10 11 12 12 13 14 15 16 18 19 20 22 23 24 25 26 27
Postgraduate doctors in training are fundamental to the success of the NHS. They are the backbone of medical services and, more importantly, they hold the key to the future of our NHS. As a medical student and a junior doctor I gave little thought to how the NHS worked it was not on my radar; that was someone elses responsibility. Over the years I began to appreciate that this perception was misguided. If I really cared about how well patients were treated then I had a moral and professional responsibility to understand the system in which I practised. Junior doctors who work closely with patients and alongside other ! members of staff on the shop floor 24 hours a day have penetrating insight into how things really work where the frustrations and inefficiencies lie, where the safety threats lurk and how quality of clinical care can be improved. But junior doctors often feel undervalued by their organisation. They are often seen as birds of passage and this can make them feel disenfranchised from the NHS as a whole. This feeling discourages them from engaging enthusiastically with others to change the way NHS organisations work and deliver services. This saddens me, as they are often the most informed and enthusiastic and have the most innovative ideas about how the NHS could be improved for the benefit of staff and patients alike. I want junior doctors to play a bigger role in improving the NHS. Throughout my career I wanted my patients to have the best possible quality of care. I could see some of the problems, but I didnt know how to go about making changes within the system. Over time I realised that making real improvement was a collaborative process; it was not the role of one person alone. Change only happens when clinicians, managers, policy makers, and all sorts of people who are expert in the different aspects of healthcare have the will to work together to achieve the same goal or vision. Young, enthusiastic doctors can add significant insight, but unless you know how to channel it and how the system works, nothing will happen. I had to learn by experience, but if I had understood the system properly from the beginning, I would have avoided a great deal of trial and error, as well as frustration. This is why I want you to have this guide. Junior doctors have sometimes felt at the mercy of management or policy. Lets change that. Instead I invite you to be part of it. By all means use this guide for general interest, to answer interview questions, to understand policies, buzzwords and management speak. Use it to immerse yourself in the system in which you work. But more importantly, I hope that you will also use it to empower yourself and your colleagues to get to know how the NHS works and to really make it your own. You are an integral part of the NHS system and you are tomorrows clinical leaders.
Introduction
Beyond the hospital or clinic, apart from occasional interactions with management, many junior doctors are not really sure what happens in the upper echelons of the NHS. How the NHS, the Department of Health and the government interact can be hazy, and as for the various bodies in between, it can seem a little unclear. Even when you think you know, reforms often mean that the structure has changed. If you are going for an interview, have a particular reason for needing to understand, want an update/refresher, or just think it might be useful to know how your organisation actually works (or are embarrassed that you dont), you have several options. You could comb the internet. You could look at some of the dense tomes that are published. You could talk to people. Or you could let us do it all for you and summarise it into what you need to know. We hope you find A Junior Doctors Guide to the NHS helpful. Dr Layla McCay ST3 doctor working on secondment with Professor Sir Bruce Keogh in the Medical Directorate, Department of Health. Dr Sarah Jonas ST5 doctor working on secondment with Professor Sir Bruce Keogh in the Medical Directorate, Department of Health. June 2009
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NHS structure
This is a simplified diagram giving an overview of the NHS structure in England.
NHS providers Other provider organisations Regulatory bodies Independent contractors Commissioners
5.b
Monitor
Primary Care Services: GP practices, dental practices, community pharmacies, optometrists etc
Ambulance Trusts
5.a
1.The Department of Health enacts the will of Parliament through policy development 2.Strategic Health Authorities (SHAs) manage the NHS locally. They occupy the middle tier between Primary Care Trusts and the Department of Health. They do not manage NHS Foundation Trusts. 3.Commissioners are responsible for ensuring adequate services are available for their local population by assessing needs and purchasing services. 4.NHS providers, independent contractors and other provider organisations are responsible for actually providing these services. 5.Regulatory bodies ensure they run appropriately, are well managed (including financially), and that they provide a safe, quality service. a.The Care Quality Commission (CQC) regulates and inspects providers of health and adult social care in both the public and independent sectors. b.Monitor regulates the finances and governance of NHS Foundation Trusts. P.S. This information is correct at the time of publication (June 2009), but, as is the nature of the NHS, we cant promise that some of it wont change.
Parliament
Parliament is responsible for approving legislation and forming the framework in which the health service operates. Parliament also holds the Department of Health to account for their spending of taxpayers money and operation of the National Health Service. This accountability is supported by the National Audit Office, which audits the accounts of all government departments and reports to Parliament on the economy, efficiency and effectiveness on their use of public funds.
n Leading health and wellbeing on behalf of the government working with other government departments, third and private sectors, and international partners. n Accounting to parliament and the public answering parliamentary questions and communicating to the public via the media, letters, visits and speeches. Three people are responsible for managing the DH:
How health laws are made (not all laws go through every stage):
Consultation papers on proposed change
Green Paper
Proposal for change of law
White Paper
Pre-legislative scrutiny often by Select Committee
Debate of the Bill in Parliament (House of Commons and Lords): final Bill to be agreed by both houses
Draft Bill
Permanent Secretary
Bill
Act
Bill given Royal Asent by the Queen becomes an Act and thus Law
Senior civil servant responsible for leadership and management of the DH, ensuring that it operates efficiently and coherently as a department of state in support of ministers.
Permanent Secretary
Secretary of State overall strategic responsibility for the work of the Department. Minister of State for Health Services responsibilities include NHS policy and strategy, finance, system management and regulation, commissioning and departmental management. Minister of State for Public Health responsibilities include public health, health protection, emergency preparedness, health inequalities, health improvement programmes, medicines and pharmaceuticals, research and development. Minister of State for Care Services responsibilities include social care, mental health, prison/offender health, third sector, carers, equality and human rights. Parliamentary Under-Secretary of State for Health Services responsibilities include healthcare quality, patient safety, workforce, dentistry, chronic disease, child health. Parliamentary Under-Secretary of State (Lords) commissioned to review health services.
Policy and strategy Workforce Social care, local government and care partnerships Communications Chief Information Officer Equality and human rights Government Adviser on Inequalities
Write to the Secretary of State for Health, Department of Health, Richmond House, 79 Whitehall, London, SW1A 2NS
The role of the UK Governments principal medical adviser dates back to Victorian times. The CMO provides independent advice to the Secretary of State for Health, other Health Ministers, Ministers of other Government departments and the Prime Minister. Responsibilities include developing policies and programmes to reduce health inequalities and to protect and improve the health of the public and reviewing policy in new, changing and contentious areas of health. Over the years the CMO has shown a particular interest in improving safety and quality of care in the NHS.
Responsible for establishing the NHS as an international centre for research excellence and commissioning research to underpin policy and practice in health and healthcare, by running the National Institute for Health Research and the Policy Research Programme.
North West
Responsible for the full range of medical education, including Modernising Medical Careers (MMC), and reports directly to the NHS Medical Director.
This new position commenced in November 2007. This is an operational role with responsibility for clinical quality, safety and strategy; this includes the medicines supply chain into the UK, including policy relating to drugs, pharmacy and the pharmaceutical industry. The role has oversight of funding and work programmes of NICE, the NPSA (National Patient Safety Agency), and Medical Education England. The occupant is also Deputy CMO.
The Directors of Immunisation, Emergency Preparedness and Pandemic Influenza Pre specific clinical areas such as cancer, heart disease, stroke, diabetes, renal disease, trauma, transplantation, mental health, and maternal and child health.
Responsible for providing regional leadership, vision, advice, advocacy and implementation.
Strategic Health Authorities are responsible for: n Developing strategic plans for improving health services in their region n Ensuring local health services are accessible, of a high quality and performing well n Increasing the capacity and capability of local health services so they can provide more and higher quality services n Ensuring national priorities and policies for example, programmes for improving cancer services are explained and integrated into local health service plans n Offering services to Trusts where pooling of regional resources is helpful n Managing corporate affairs for the region, including strategic direction and communication n Holding all NHS organisations (except NHS Foundation Trusts) to account for performance
PCTs can directly provide services to patients, for instance community services.
Governance
PCTs work to improve the health and wellbeing of their local population by assessing needs and working directly with other local partners (e.g. local authorities, childrens services and housing services) to provide services to meet these needs.
PCTs hold service providers to account via contracts. They can ask regulators to intervene if the providers are not meeting expected standards. PCTs are held to account by the relevant SHA. The PCT board is accountable to the relevant SHA board. PCTs deliver services to the population via: n Acute Trusts n Mental Health Trusts n Ambulance Trusts n GP practices n Dental practices n Community pharmacies n Optical practices n Community hospitals n And more Find our more about your PCT here: http:// www.nhs.uk/ServiceDirectories/Pages/ PrimaryCareTrustListing.aspx
PCTs control the vast majority of the NHS budget and are responsible for commissioning the healthcare services for their area. They commission services (including acute care, primary care and mental health care) for the whole of their population, with a view to improving their populations health. All services are NHS-funded but may be provided by voluntary or independent sector organisations as well as by NHS organisations. (The process of commissioning is described on pages 14 and 15.)
n Must meet financial requirements to become one n Independent from SHA/DH control n Regulated by Monitor who reports directly to Parliament n Increased financial obligations to maintain surplus
Freedoms include:
n Keep receipts from capital sales n Decide how to meet national targets rather than being performance-managed n Borrow money under strict conditions n Set terms and conditions for staff locally
Trust Board
Functions:
n Sets strategic direction, define objectives and agree plans n Monitors performance and ensure corrective action n Ensures effective financial stewardship n Ensures high standards of corporate governance and personal behaviour n Appoints, appraises and remunerates senior executives n Ensures dialogue between the Trust and the local community
Chairperson provides leadership to the board. Chief Executive Officer (CEO) ensures that board decisions are implemented, the organisation works properly and financial stewardship is maintained, as accountable officer. Non-Executive Directors are lay members who provide independent judgement and critical detachment; they perform special functions relating to areas of interest. Executive Directors hold operational responsibility for different areas in the organisation, e.g. Directors of Medicine, Nursing, Finance, Strategy, Communications, Governance, Corporate Affairs, Operations, Workforce etc. Trust board meetings should be open to the public. Find details on the relevant trusts website: http://www.nhs.uk/ServiceDirectories/Pages/AcuteTrustListing.aspx
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New providers
In the UK, there have always been healthcare providers other than the NHS; however, historically these providers have mainly provided care to those who either had private insurance or paid directly and there was very little provision of NHS care. Since 1997 many other providers have entered the NHS market. The new providers can be divided into three groups: treat patients within the NHS. The second phase of Treatment Centres has been more integrated within the current NHS facilities, and has increased contractual obligations to quality. Any future procurement of this kind of service is likely to be taken forward locally.
NHS complaints
First steps informal Go through Patient Advice Liaison Service (PALS) can help with resolution or refer to complaints manager (all NHS bodies must have one)
2. Third sector
1. Private sector
This sector is managed and owned by private companies. It has been established in the secondary care market as a provider to insurance companies, but increasingly provides NHS services, either through free choice (e.g. elective care) or through winning contracts to provide specific services via commissioning. The first phase of Independent Sector Treatment Centres was created to increase the capacity to
This includes voluntary groups and charitable organisations, co-operatives, Trusts, community interest groups and foundations, working for instance in the mental health and substance misuse sectors. These groups are often able to bridge the gap between care sectors.
Local resolution
3. Social enterprise
Social enterprises are organisations that are run along business lines, but where any profits are reinvested into the community or into service developments. Encouraging social enterprise in health and social care is a key part of the patient-led reforms.
Independent Complaints and Advocacy Service (ICAS) provide free advice and assistance for making complaints
Other options
The NHS Constitution states that people should receive a timely and appropriate response Independent professional advice, independent review, mediation
Legally can use this step at any stage, but usually when other steps have been exhausted
Care Quality Commission The Care Quality Commission replaced the Healthcare Commission, Mental Health Act Commission, and the Commission for Social Care Inspection in April 2009. Its role is to regulate the quality of both health and adult social care in England as an independent regulator. Visit http:// www.cqc.org.uk Monitor This body assesses Trusts applying for Foundation Trust status to ensure they are legally constituted, financially sound and well-governed. The regulator ensures that, once authorised, NHS Foundation Trusts continue to meet the terms of their licence. Monitor reports directly to Parliament. Visit http:// www.monitor-nhsft.gov.uk
Audit Commission The Commission audits NHS Trusts, PCTs and SHAs to review the quality of their financial systems. It also publishes independent reports which highlight risks and good practice to improve the quality of financial management in the health service and, working with CQC, undertakes national value for money studies. Visit http://www.audit-commission.gov.uk
A Special Health Authority within the NHS, responsible for handling negligence claims (including employee negligence) made against member NHS bodies in England through the following schemes (membership is voluntary):
of Health. If the NHS body no longer exists, the relevant SHA occasionally becomes the legal defendant.
Regulators of treatment
Medicines and Healthcare Regulatory Agency This Agency monitors the safety of new medications and products and licences new medicinal products. Visit http://www.mhra.gov.uk
Regulation of professionals
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Individual professionals within the NHS are also regulated, through the professional regulatory bodies, such as the General Medical Council, the Nursing and Midwifery Council, the Health Professions Council, the General Dental Council, the General Optical Council, and the General Osteopathic Council.
covers clinical negligence claims relating to incidents occurring after April 1995. If a claim is made, the NHS body remains the legal defendant but the NHSLA takes responsibility for handling the claim and meeting the costs.
has 2 schemes, the Liabilities to Third Parties Scheme (LTPS), which covers falls, bullying, stress, defamation, injury, and the Property Expenses Scheme (PES), which covers theft and damages. The NHSLA has risk management programmes to raise standards and minimise negligence claims. Adherence to the programme results in reduction in cost of contributions; 96% of negligence claims are settled out of court by the NHSLA.
covers clinical negligence claims relating to an incident that occurred before April 1995. Funded centrally by the Department
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Commissioning
Commissioning is the process of determining:
n the health needs of the population n the resources available n how to organise service provision
Access pop. needs
Improving commissioning is key to improving quality of care. World Class Commissioning (WCC) is a statement of intent for how the NHS will secure (from locally available resources) maximum improvement in locally prioritised health and wellbeing outcomes. PCTs will become World Class Commissioners by developing 11 organisational competencies. They will be assessed against these competencies by an annual commissioning-assurance process.
Patient feedback Design services strategies and service Performance management Shaping supply Clinical decisions
Competencies
1. Locally lead the NHS
Actively steer the local health agenda as leaders of the local NHS.
6. Prioritise investment
Develop outcome-focused strategic priorities and investment plans.
Manage demand
PCTs are responsible for buying services from local providers. The first step in this process is a Joint Strategic Needs Assessment to determine the healthcare needs of the local population.
services to their patients, so that services better represent patients preferences. Practices can group together but the PCT retains the legal responsibility. Practices can use 70% of the savings made for reinvestment for new services or more equipment for existing ones.
This is a process conducted in partnership by local government, PCTs and the local community to identify areas for priority action to improve local health and wellbeing through Local Area Agreements. The JSNA has been a statutory requirement since 1st April 2008 and helps commissioners to specify outcomes that help providers shape services to address local needs.
For services serving populations of greater than a million people, there is a small amount of commissioning for specialist services at the SHA level (through regional specialist commissioning groups) and at the national level ( the National Commissioning Group). This grouping of commissioning allows PCTs to pool the risk of unlikely but expensive treatments.
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NHS finance
Where does the money for the NHS come from?
The budget for the NHS in 2008/9 was 96 billion and will rise to about 110 billion in 2010/11. Most money comes from general taxation and National Insurance (NHS portion) receipts. A small proportion comes from other sources, such as: n Treatment charges (including prescriptions) n Dental charges n Charges for road traffic and personal injury victims (money claimed from insurers) n Overseas visitors n Capital receipts
Parliament
DH
Given the size and importance of health spending, the Treasury commissioned a report by Derek Wanless to look at future trends for healthcare and how spending would change. The Wanless report (2002)* concluded that costs would be driven up; the main cause would not be an aging population but patients demanding more choice and higher quality services. He recommended that improving spending on IT and communication would be key, as would changes in skill-mix and ways of working, and that the role of primary care needed enhancing. *Securing our future: taking a long-term view. Final Report. April 2002
PCTs
SHAs
NHS Trusts
Spending limits for Government Departments for the three years from 2008/09 to 2010/11 were the outcome of the Comprehensive Spending Review (CSR) announced by Treasury in October 2007. Spending Reviews are usually run every two years. As part of the CSR the DH enters into a set of agreements with the Treasury regarding what
4% 4%
3%
12%
59% 14%
General taxation National insurance Capital receipts Charges & misc Trust interest receipts & loan repayments
76.2%
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lished in May and June 2008 (July 2007 in London). High Quality Care for All was published in June 2008.
Policy is the translation of governments political priorities and principles into programmes and courses of action to deliver desired change (Modern policymaking, National Audit Office, November 2001).Policy develops in response to rising expectations, changes in population, developments in medicine and the need to tackle quality (including safety, effectiveness, patient experience, access and value for money).
DH Strategic Framework
of the NHS to achieve a properly resourced NHS that is clinically-led, patient-centred and locally accountable, and to consider the case for a new NHS constitution (www.dh.gov.uk/nhsconstitution).
This is the translation of the PSA into a framework for implementation to allow organisations to plan change. It shows how the high-level objectives of DH mesh with the wider Government performance framework.
able on the Department of Health website http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/DH_085825 The regional visions are available on SHA websites and on the Department of Health website http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085400 Aims of the report:
n To ensure that improving quality is the
There is a wide variety of methods of identifying policy need, including evidencebased analysis of current problems, response to things going wrong, public inquiries, alerts raised by pressure groups and media campaigns, financial restraints, and reaction to political pressure.
The Operating Framework is published annually by the NHS Chief Executive and sets out the priorities for the NHS over the next year and the strategies for addressing them.
carried out, led by nearly 2,000 clinicians and engaging 65,000 healthcare staff, social-care staff, patients and members of the public. The 2,000 clinicians were part of 8 clinical pathway groups (maternity and newborn care, childrens health, planned care, mental health, staying healthy, long-term conditions, acute care and end-of-life care) in each of the 10 SHAs. They looked at the evidence available and engaged widely to produce a vision for the future. The groups also considered the barriers to delivering these visions. These barriers were addressed in High Quality Care for All, an enabling report designed to support local delivery of the regional clinical visions.
Policy is developed by civil servants in consultation with stakeholders (the individuals and groups affected by the strategy and policy proposals, including healthcare staff), pressure groups, experts, academics, lobbyists and politicians. Ministers make final policy decisions.
Local Delivery Plans (LDPs) LDPs are local translations of the DH Strategic Framework. They cover SHA areas and form the basis of the relationship between DH and SHAs. NHS planning takes place locally, within the national framework. PCTs develop strategic commissioning plans to deliver the improvements in outcomes that they have identified their population needs.
viding high-quality, joined-up services for those suffering long-term or life-threatening conditions
n To ensure that primary and secondary
NHS a vision based less on central direction and more on patient control, choice and local accountability.
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Safeguarding quality
Measure quality n Metrics local, national, international n PROMs (patientreported outcome measures) n Clinical dashboards
Publish quality performance n Quality Accounts n NHS Choices n CQC periodic review n International measures
Recognise and reward quality n PCT contracts, including CQUIN payment framework n Best practice tariffs n Clinical Excellence Awards n Quality and Outcomes Framework (QOF) n Accreditation
Clinical leadership n Practice-based commissioning, service line reporting, social enterprise n SHA Medical Directors & clinical advisory groups n Quality Observatories n National Quality Board n National Clinical Directors
Care Quality Commission (CQC) The CQC is the new health and adult social care regulator. It will register providers of health and adult social care to provide assurance that they meet essential levels of safety and quality, and will use its enforcement powers to address failings.
Stay ahead n Learning from Never Events n CQC Special Reviews n SHA duty to innovate n Innovation funds & prizes n Academic Health Science Centres n Health Innovation & Education Clusters
Staying ahead
Clinicians reported that there was too much guidance that it was too difficult to find the most up-to-date guidance and to know what was required and what was good practice. In response, the role of NICE was expanded to set quality standards, which will distil the range of guidance available into a short set of key markers of high-quality care in a particular clinical area. NICE will also manage NHS Evidence, a new online portal to access quality-assured evidence and practice at http://www.evidence.nhs.uk. NICE will continue to evaluate drugs (more quickly on key drugs) and other health interventions for clinical- and cost-effectiveness.
effectiveness, and patient experience) and further work over the next few years is needed to develop new indicators. These will include PROMs (patient-reported outcome measures).
All registered healthcare providers working for, or on behalf of, the NHS will be required by law to publish Quality Accounts for the public. These will be reports on the quality of services they provide (safety, experience and outcomes). The Care Quality Commission will publish an independent assessment of provider and commissioner performance using nationally agreed indicators of quality. The CQC will also carry out general reviews and investigations of issues of interest to the public and will submit an annual report to Parliament.
Innovation is the successful implementation of new ideas. A number of policies support innovation. The Health Innovation Council champions innovation for the NHS and helps develop innovation proposals. Best Practice Tariffs enable the NHS to pay prices that reflect the cost of best practice rather than the average cost. SHAs have a new legal duty to promote innovation funds. SHA Regional Innovation Funds will identify, grow and diffuse innovation through funding and prizes. Health Innovation and Education Clusters bring together the talents of different sectors for education and learning and run joint innovation programmes reflecting local needs. Academic Health Science Centres bring together a small number of health and academic partners to focus on world class research, teaching and patient care. Their purpose is to promote the application of new discoveries in the NHS and around the world.
Measuring quality
High-performing teams not only have good clinical leadership, but are also defined by their willingness to measure their own performance and use this information to continuously improve. To support front-line teams to select indicators and benchmark themselves against others, a Menu of Assured Quality Measures will be published, pulling together indicators from existing sources. Existing commonly used indicators do not give full coverage of all pathways and all aspects of quality (safety,
The CQUIN (Commissioning for Quality and Innovation) Payment Framework will make a small percentage of hospital funding conditional on quality of care. Schemes will be agreed locally between providers and commissioners. The Quality and Outcomes Framework (QOF) already rewards quality in primary care.
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Clinical governance
Clinical audit Openess Clinical effectivness
The system through which NHS organisations are accountable for continuously monitoring and improving the quality of their care and services and safeguarding high standards of care and services.
Scally G and Donaldson LJ. Looking forward: Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998; 317: 61-65
NICE will be responsible for NHS Evidence, where anyone will be able to access clinical and non-clinical evidence and best practice, with clear descriptions of high quality care and how to deliver it. This will support commissioning the most clinically and cost-effective diagnostics, treatments and procedures. The new NHS Constitution will set out the right of all patients to receive interventions positively appraised by NICE when clinically appropriate, helping to minimise perceptions of a postcode lottery of access to care. For more information about NICE, visit http://www.nice.org.uk To explore NHS Evidence, visit http://www.evidence.nhs.uk
Clinical audit
Risk management
The review of clinical practice against defined national standards is a cyclical process in which care is continuously measured, improved and re-measured, thereby enabling continuous improvement.
There are three areas of risk: 1) Risk to patients (patient safety) 2) Risk to staff (infection, radiation) 3) Risks to the organisation (financial, poor quality, legal, reputational, staff employment) These are all managed by identifying possible risks and developing solutions before the event, and having a mechanism for learning where things went wrong.
Clinical effectiveness
The measure of how well a particular intervention works in practice. This is obviously important in clinical practice but can be further enhanced by measuring appropriateness and value for money. In the NHS NICE takes on the role of assessing the clinical and cost effectiveness of treatments in a systematic way for the whole NHS. Aligning audit with the Trusts current priorities can help lead to changes in policy and practice
Good practice is continuously evolving in response to research evidence; however, there is often a long delay between research findings being known and implementation in clinical settings. Tools (such as the critical appraisal of papers) have developed in this area, but there is still a need for improvement.
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IT in the NHS
NHS Connecting for Health (NHS CFH) supports information technology (IT) systems for the NHS in England. It works with both local NHS organisations and suppliers in introducing new IT systems and services to improve the way health information is stored and shared. Specifically, NHS CFH is responsible for: n New IT systems and services together known as the National Programme for IT (NPfIT) n Existing business-critical national NHS IT systems (originally delivered by the former NHS Information Authority), and n Legislative and digital policy advice on information systems for the NHS. The National Programme for IT in the NHS underpins the modernisation of the NHS. It helps the NHS to meet patients growing expectations about choice, convenience, quality and responsiveness. It also supports complex modern care, where treatment is delivered by a team of healthcare staff based in different buildings or organisations across primary and secondary care, or out in the community. The complexity of this care requires information to be shared effectively computer systems support this function. Responsibility for implementing NPfIT systems and services at local level lies with SHAs.
Parliamentary Committees involved in NHSScotland: n Health and Sport Committee: health policy, public health, and community care n Finance Committee: public expenditure n Public Audit Committee: considers reports produced by the Audit General for Scotland, including reports on NHS expenditure
Scottish Executive Health and Wellbeing Directorates (SEHD) is responsible for NHSScotland policy
NHSScotland is funded by general taxation and National Insurance through the UK Government, which allocates public money to the Scottish Government for distribution within its departments. NHSScotland has rejected market-based reforms and there is currently no role for internal market within Scottish healthcare.
electronically, with detailed records shared locally between NHS organisations caring for the patient and Summary Care Records available across England to support emergency and out-of-hours care
n Picture Archiving Communications Systems (PACS) digital x-rays and scans for
The head of SEHD is also the chief executive of NHSScotland and is accountable to the Scottish Parliament. SEHD develops strategies, implements policy, and holds the NHS to account for its performance. Scotlands CMO is the Scottish Governments medical adviser, with responsibility for clinical effectiveness, quality assurance, accreditation and research.
faster diagnosis
n NHSmail the only email and directory service endorsed by the BMA and RCN for
The Scottish Intercollegiate Guidelines Network (SIGN) improves quality by reducing variation in practice and outcome by publishing national clinical guidelines. The Scottish Medicines Consortium (SMC) develops advice on new drugs for the NHS in Scotland. Scotland adopts NICE guidelines for interventional procedures and some technology appraisals.
NHSScotland abolished Trusts in favour of integrated boards, responsible for protecting and improving health, delivering hospital and community services, developing a local health plan, allocating resources, and performance management. There are 14 area Health Boards. In each area, an NHS Board oversees the NHS locally. Within each Board, Community Health Partnerships manage primary and community services.
NHSScotland works through managed clinical networks to integrate systems of care for specific conditions.
record transfer between GP practices (GP2GP) and QMAS (GP payment system) More information is available at http://www.connectingforhealth.nhs.uk
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The Welsh National Assembly is responsible for NHS Wales (since 1999)
The Assembly can pass secondary legislation, but not primary legislation. Assembly committees involved in NHS Wales: n Health and Social Services Committee: develop policy, scrutinise legislation, and advise on budget allocation n Audit Committee: public expenditure
Community Health Councils (CHCs) hold NHS Wales to account by the public
Devolved powers were returned to the Northern Ireland Assembly in 2007. The Assembly can pass both primary and secondary legislation. Assembly committees involved with Health, Social Services and Public Safety: n Health and Social Services Committee: advise and assist the Minister for Health, Social Services and Public Safety. The committee undertakes a scrutiny, policy development and consultation role with respect to the Department of Health, Social Services and Public Safety and plays a key role in the consideration and development of legislation. n Public Accounts Committee: consider and reports on accounts laid before the Assembly.
Health and Social Care Department sits within the Welsh Assembly Government
There are 19 of these statutory lay organisations, which work to improve the quality of local healthcare.
Established in 2004, this department advises the Assembly on health and social care policy and strategy, contributes to legislation, manages health and social care delivery, and is responsible for funding NHS Wales. The head of department is Chief Executive of NHS Wales; three regional offices act as local agents.
The Assembly Government allocates resources each year to LHBs and Health Commission Wales to pay for the costs of hospital treatments provided by NHS trusts and other independent healthcare providers.
Wales has 22 LHBs which receive 75% of the NHS budget and work with local authorities, including housing and education, to deliver a public health strategy.
NICE provides clinical guidelines, technology appraisals and interventional procedure guidance for NHS Wales. The Welsh Assembly works with DH to deliver a common quality agenda.
The Department of Health, Social Services and Public Safety (DHSSPS) is responsible for health, social services and public safety
In April 2007, 19 HSS Trusts were merged to create six Health and Social Care Trusts. They have responsibility for delivering the full range of health and social care. By 1 April 2009 the following was due to be established: n A single Regional Health and Social Care Board (RHSCB), responsible for commissioning, performance management/ improvement and financial management. n A Regional Agency for Public Health and Social Well-being (RAPHSW), responsible for health protection, health improvement and addressing existing health inequalities. n A Regional Business Support Organisation (RBSO), responsible for supporting the health and social care sector. n a Patient and Client Council (PCC), providing a strong voice for patients, clients and carers.
The NHS in Northern Ireland is called Health and Social Care (HSC) and it provides integrated health and social care services. It has retained the commissionerprovider split.
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