35,99 €
Mehr erfahren.
- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Clinical Governance: A Guide to Implementation for Healthcare Professionals provides a comprehensive overview of what is meant by clinical governance and how it can be implemented in practice. It explores the evolution of clinical governance, its key components, legal implications, the barriers to implementing it, and its impact.
Clinical Governance provides step-by-step practical advice, facilitating better understanding of the key principles of clinical governance. This third edition has been fully updated throughout to incorporate a more integrated approach to achieving clinical governance, with an additional chapter on education and training. Each chapter includes reflective questions, activities and case studies taken from clinical practice as well as a full list of references and further reading.
Sie lesen das E-Book in den Legimi-Apps auf:
Seitenzahl: 322
Veröffentlichungsjahr: 2011
Ähnliche
Table of Contents
Cover
Dedication
Title
Copyright
Foreword
Preface
Chapter 1: Introduction and Background: Clinical Governance and the National Health Service
Introduction
Background
Political
Public
Professional
Summary
Key points
Suggested reading
References
Chapter 2: What is Clinical Governance?
Introduction
The evolution of clinical governance
Origins of clinical governance
Corporate governance and the NHS
Defining clinical governance
What is clinical governance?
The key components of clinical governance
Non-clinical services that support clinical governance
Controls assurance: Its relationship with clinical governance
Standards for better health
The need for national healthcare standards
Defining the healthcare standards
Describing healthcare standards for better health
The standards versus existing systems
Applying the healthcare standards to an example of practice
Criteria for evaluating the standards
Conclusion
Key points
Suggested reading
Useful websites
References
Chapter 3: A Guide to Clinical Governance
Introduction
The key components of clinical governance
Healthcare organisations and the achievement of quality care
Risk management
Managing performance
Quality improvement
Quality information
Accountability
Conclusion
Key points
Suggested reading
References
Chapter 4: Applying Clinical Governance in Daily Practice
Introduction
Introducing clinical governance into healthcare organisations
Clinical governance: What is a baseline assessment and development plan?
What does a clinical governance action plan look like and why are they necessary?
Clinical governance action plan
Case study 1: Applying the principles of clinical governance to an organisation
Case study 2: Applying the principles of clinical governance to a team
Case study 3: Systems and processes associated with the application of a clinical governance framework at individual level
Conclusion
Key points
Suggested reading
References
Chapter 5: Identifying and Exploring the Barriers to the Implementation of Clinical Governance
Introduction
The potential barriers affecting the implementation of clinical governance
The barriers associated with clinical governance
Culture
Management
Leadership
Communication
Education and training
Knowledge
Support
Conclusion
Key points
Suggested reading
References
Chapter 6: Clinical Governance and the Law
Introduction: defining terms
Litigation in the NHS: caring in a rights-based culture
To sue or not to sue
How the courts determine competent clinical practice
The law and clinical guidelines
Personal updating: knowledge and clinical guidelines
Good guidelines practice
References
Chapter 7: The Impact of Clinical Governance in the National Health Service
Introduction
Clinical governance friend or foe?
Revealing the impact of clinical governance
Accountability
Organisational structures
Continuous quality improvement
Performance management
Culture
Recipe for successes
Conclusion
Key points
Suggested reading
References
Chapter 8: Education and Training for Clinical Governance
Introduction
Clinical governance education and training within health care: turning myths into reality
Conclusion
Key points
Suggested reading
References
Chapter 9: Conclusion: The Future of Clinical Governance for Healthcare Professionals
References
Index
End User License Agreement
List of Tables
Chapter 2: What is Clinical Governance?
Table 2.1 A critical review of professional perspectives in defining clinical governance.
Chapter 4: Applying Clinical Governance in Daily Practice
Table 4.1 Baseline assessment checklist.
Chapter 5: Identifying and Exploring the Barriers to the Implementation of Clinical Governance
Table 5. 1 High profile case demonstrating clinical governance issues.
Table 5. 2 Cultural barriers affecting the implementation of clinical governance.
Table 5. 3 Types of culture (adapted from Hawkins and Shohet (1989) in Northcott (1999)).
Table 5. 4 The Manchester Patient Safety Framework (MaPSaF).
Table 5. 5 Management styles and their applicability to clinical governance.
Table 5. 6 Four main reasons for resisting change (adapted from Kotter and Schlesinger (1979) in McSherry et al. (2001)).
Table 5. 7 Leadership style and applicability to clinical governance. (Adapted from Marquis and Hutson (2000).)
Table 5. 8 Personality type traits. (Adapted from McSherry and Simmons (2001).)
Chapter 7: The Impact of Clinical Governance in the National Health Service
Table 7. 1 Research studies reporting on the impact pf clinical governance (in chronological order).
Chapter 8: Education and Training for Clinical Governance
Table 8.1 Targeting clinical governance education and training with an organisation.
List of Illustrations
Chapter 1: Introduction and Background: Clinical Governance and the National Health Service
Fig. 1.1 The drivers of clinical governance.
Chapter 2: What is Clinical Governance?
Fig. 2.1 Key components of clinical governance.
Fig. 2.2 Healthcare governance in the NHS.
Fig. 2.3 The six faces of healthcare governance.
Fig. 2.4 The interdependent relationship of healthcare standards.
Chapter 3: A Guide to Clinical Governance
Figure 3.1 Clinical excellence and its association with organisational management styles.
Figure 3.2 Promoting a culture for evidence-based practice within clinical governance. (Reproduced from McSherry & Haddock (1999). Used with permission from MA Healthcare Limited.)
Figure 3.3 Key components of clinical governance. (Modified from the McSherry & Haddock (1999) template outlining clinical governance. Used with permission from MA Healthcare Limited.)
Figure 3.4 Framework for performance management.
Figure 3.5 Continuous quality improvement: the route to clinical excellence.
Figure 3.6 A model to aid the facilitation of CPD into healthcare organisations.
Chapter 4: Applying Clinical Governance in Daily Practice
Fig. 4.1 Management structure associated with clinical governance.
Fig. 4.2 Applying the principles of clinical governance at organisational level.
Fig. 4.3 Service improvements facilitated by the application of a clinical governance framework at team level.
Fig. 4.4 How the key components of clinical governance can be applied to an individual.
Chapter 5: Identifying and Exploring the Barriers to the Implementation of Clinical Governance
Figure 5.1 Internal and external factors influencing the implementation of clinical governance.
Figure 5.2 Key themes linked to the barriers affecting the implementation of clinical governance.
Figure 5.3 Internal and external factors supporting clinical governance.
Chapter 8: Education and Training for Clinical Governance
Fig. 8.1 The NHS structures that require clinical governance educational awareness sessions.
Guide
Cover
Table of Contents
Begin Reading
Pages
C1
ii
iii
v
iv
vii
viii
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
29
25
26
27
28
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
138
137
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
Dedication
To my late parents Wilfred and Dorothy McSherry who I miss dearly. You are always in my thoughts and would have been proud to share this with me.
Rob McSherry
To Samuel Patrick Avison, my grandson.
Paddy Pearce
Clinical Governance
A Guide to Implementation for Healthcare Professionals
Third Edition
Rob McSherry
Professor of Nursing and Practice DevelopmentSchool of Health and Social Care,Teesside University, Middlesborough
and
Paddy Pearce
Assistant Director of GovernanceNHS North Yorkshire and York, Thirsk, North Yorkshire
with a contribution by
John Tingle
BA (Law Hons), MEd, BarristerReader in Health LawDirector of the Centre for Health LawNottingham Trent University, Nottingham
This edition first published 2011
First edition published 2002 by Blackwell Publishing Ltd
Second edition published 2007 by Blackwell Publishing Ltd
© 2002, 2007 Blackwell Publishing Ltd
© 2011 Rob McSherry and Paddy Pearce
Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing programme has been merged with Wiley’s global Scientific, Technical, and Medical business to form Wiley-Blackwell.
Registered office
John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, United Kingdom
Editorial offices9600 Garsington Road, Oxford, OX4 2DQ, United Kingdom 2121 State Avenue, Ames, Iowa 50014-8300, USA
For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell.
The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.
Library of Congress Cataloging-in-Publication DataMcSherry, Robert.
Clinical governance : a guide to implementation for healthcare professionals/Rob McSherry and Paddy Pearce, with a contribution by John Tingle. – 3rd ed.p.; cm.Includes bibliographical references and index.ISBN 978-1-4443-3111-0 (pbk. : alk. paper)1. Medical care-Quality control. 2. Medical audit. 3. Clinical competence. I. Pearce, Paddy. II. Tingle, John. III. Title.[DNLM: 1. State Medicine-standards. 2. Clinical Medicine-standards. 3. Medical Audit. 4. Patient Care Management-standards. 5. Quality Assurance, Health Care.
W 225 M478 2011]RA399.A1M375 2011362.1068-dc222010014066
Foreword
The National Health Service today looks very different to the National Health Service of 1948. The early years were filled with optimism. Indeed, the costs of the National Health Service were predicted to fall as the health of the nation improved. The early years were characterised by community spirit and those working in the system believed they were contributing to a great project. The public were tremendously relieved that they would no longer have to forgo health care for lack of money.
Demand grew, costs spiralled and the system reached breaking point. A second era began with a major restructuring in 1982 aiming at simplifying the multi-tiered and fragmented National Health Service structures that had developed. The introduction of general management, performance indicators and the internal market aimed to streamline the service, break up the monolithic bureaucracy and create a responsive, financially accountable organisation.
We have now entered a third era, that of quality. Clinical effectiveness, patient safety and patient experience are to be placed at the centre of everything the National Health Service does. Clinical Governance is an essential part of this project to improve the very nature of the healthcare that is delivered. In helping further understanding of the concept, the factors that affect it and the potential impact it represents, this third edition of Clinical Governance offers a valuable contribution to the work being done to make this improvement. Through the processes of clinical governance, clinicians lead from the heart of the system. The setting of standards, collection of data and continuous quality improvement are the bedrock of the future National Health Service.
In his report on the future of the NHS, High Quality Care for All, Lord Darzi wrote of quality as being the ‘guiding principle’. When I formulated the concept of clinical governance ten years ago, this was a dream. Today it is becoming reality.
Professor Sir Liam DonaldsonChief Medical OfficerDepartment of Health
Preface
We are delighted to present this third edition of Clinical Governance: A Guide to Implementation for Healthcare Professionals. In this edition we have retained many of the key features of the original text particularly with regard to:
The evolution of clinical governance
What clinical governance is
What the key components of clinical governance are
The legal implications of clinical governance
The barriers to implementing clinical governance in clinical practice
The impact of clinical governance
In this edition we have developed the original theme of healthcare governance towards a more integrated approach to achieving clinical governance with the additional chapter on Education and training for clinical governance. Yet again in this edition we aim to answer the above by using reflective questions, activities and case studies taken within today’s healthcare services. The information contained in the book is based upon a combination of the authors’ clinical experiences, knowledge and understanding of ‘clinical governance an integrated approach’ derived from reading and reviewing the associated literature.
Rob McSherry
Paddy Pearce
Chapter 1Introduction and Background: Clinical Governance and the National Health Service
Rob McSherry and Paddy Pearce
Introduction
This chapter briefly describes the term ‘clinical governance’, identifying the key drivers for its inauguration into the National Health Service (NHS). The term ‘clinical governance’ became prominent following the publication of New Labour’s first White Paper on health, The New NHS Modern and Dependable (Department of Health 1997). Within this document the government sets out its agenda of modernising the NHS by focusing on quality improvements. Clinical quality is rightfully assigned centre stage by ‘placing duties and expectation on local healthcare organizations as well as individuals’ (DH 1997, p. 34) to provide clinical excellence. The vehicle for delivering clinical quality is termed ‘clinical governance’, which ‘is being put in place in order to tackle the wide differences in quality of care throughout the country, as well as helping to address public concern about well-published cases of poor professional performance’ (King’s Fund 1999, p. 1). We believe that a complicated series of multiple factors have contributed to the development of clinical governance agenda within healthcare. These can be distilled and categorised into three main drivers: political, professional and public demands, all attempting to revive a failing NHS and improve the quality of care that the public should rightfully expect in a modern society (McSherry 2004).
Background
Why the need for clinical governance?
The literature offered by Scally and Donaldson (1998), Harvey (1998) and Swage (1998) attributes the need for clinical governance because of a decline in the standards and quality of healthcare provision, a point reinforced by the government. ‘A series of well publicized lapses in quality have prompted doubts in the minds of patients about the overall standard of care they may receive’ (DH 1997, p. 5). Upon reviewing the early literature (Donaldson & Halligan 2001) on clinical governance we have noted that a key question had not been fully addressed in establishing why there was a perception in the decline of standards and quality. Possible reasons for this perception could be attributed to the following. Firstly, healthcare professionals and the public are better informed and educated and are interested in health-related issues, thus demanding high quality service provision. Secondly, quality and clinical standards have taken a back seat to other financial and resource management issues. Thirdly, political and societal changes have led to a consumerist society where patients and their carers expect to choose where and when they access healthcare. Fourthly, high quality care is seen as a prerequisite. Within this chapter it is our intention to explore the factors that may have contributed to the introduction of clinical governance.
Activity 1.1Reflective question.
Write down the factors that you feel may have led to the introduction of clinical governance.
Read on and compare your answers with the findings at the end of the chapter.
No single factor has and transformation led to the government’s current position for modernisation, reform. We argue that patients’ and carers’ expectations and demands of all healthcare professionals have significantly increased over the past decade. In the 1980s and early 1990s, public awareness of healthcare provision was increased through target facilitation by the publication of significant documents; notably, The Patient’s Charter (DH 1992) and The Citizen’s Charter (DH 1993) both of which were readily and freely made available to the public. On the one hand, these charters may have increased patients’ and carers’ expectations of healthcare by offering information about certain rights to care. On the other hand, the responsibilities of the patients to use these rights in a responsible way have been over used, resulting in higher demands for care and services in an already busy organisation. Between 1990s and 2005, we have seen a huge emphasis placed on patient and public involvement (PPI) in the planning, delivery and quality assessment of care. Public and patient involvement has been targeted at both a national and a local level both directly and indirectly through the establishment of Patient Advisory and Liaison Services (PALS; DH 2000a) within every NHS organisations. Nationally, we have witnessed the establishment of the Commission for Patient and Public Involvement (DH 2003) resulting in the creation of Patient and Public User Involvement Fora. Similarly, the development of the Overview and Scrutiny Committees for Health (HMSO 2002) with the sole purpose of seeking and representing public opinion on the quality of healthcare. Between 2008 and 2009, further reforms have been introduced surrounding patient and public involvement. We have seen the demise of Patient and Public Involvement Fora and the introduction of Local Involvement Networks (LINks; DH 2008a) which embraces a joined up approach to patient, client, carer and/or user involvement within health and social care and local government. The aim of LINks as defined by the DH (2008a, p. 1) is
to give citizens a stronger voice in how their health and social care services are delivered. Run by local individuals and groups and independently supported – the role of LINks is to find out what people want, monitor local services and to use their powers to hold them to account.
In addition, other contributing factors such as changes in health policy, demographic changes, increased patient dependency, changes in healthcare delivery systems, trends towards greater access to healthcare information, advances in health technology, increased media coverage of health care and rising numbers of complaints going to litigation have influenced the need for a unified approach to providing and assuring clinical quality via clinical governance (Mc Neil 1998). These will now be debated in further detail under three broad headings and associated subheadings (Fig. 1.1).
Political
Political drivers for governance should be viewed with both a capital and a small ‘p’. The capital ‘P’ refers to those drivers resulting directly from government and policy. The small ‘p’ relates to organisation and personal factors that influence change and policy decision-making at a local level, a view held by Jarrold (2005)
Fig. 1.1 The drivers of clinical governance.
politics with a small p makes the world go round. Getting things done, seeking support, building alliances, compromising – that’s all politics, and inescapable and natural. (p. 35)
The challenge for healthcare professionals is translating policy into practice and keeping up-to-date with changes in healthcare policy.
Changes in health policy
In brief, the NHS was established in 1948 following the passing of the National Health Services Act 1946 which committed the government at the time to financially funding the health service ‘which rested on the principles of collectivism, comprehensiveness, equality and universality’ (Allsop 1986, p. 12. The politicians at the time thought that by addressing the healthcare needs of the public, this would subsequently reduce the amount of money required to maintain the NHS. The assumption being that disease could be controlled. However, this was not the case. The NHS activity spiralled, resulting in uncontrollable year-on-year expenditures to meet the rise in public demand for healthcare. In an attempt to manage this trend, the government introduced the principles of general management into the NHS (Griffiths Report 1983). The philosophy of general management was concerned with developing efficiency and effectiveness of services. The rationale behind this report was to provide services that addressed healthcare needs (effectiveness) within optimal resource allocation (efficiency). It recommended
that general managers should be appointed at all levels in the NHS to provide leadership, introduce a continual search for change and cost improvement, motivate staff and develop a more dynamic management approach. (Ham 1986, p. 33)
Key organisational processes identified as missing in the report.
Absence of this general management support means that there is no driving force seeking and accepting direct and personal responsibility for developing management plans, securing their implementation and monitoring actual achievement. It means that the process of devolution of responsibility, including discharging responsibility to units, is far too slow. (Griffiths Report 1983, p. 12)
This approach, whilst noble at the time, was concerned with organisational, managerial and financial aspects of the NHS, to the detriment of other important issues such as clinical quality. This style of management further evolved with the introduction of the White Paper Working for Patients (1989), culminating in the development of a ‘market forces’ approach to the organisation and delivery of the healthcare services by the creation of a purchaser and provider spilt. Health authorities and general practitioner fund holders were allocated resources (finances) to purchase care for their local population at the best price. It appears that the purchaser/provider split ‘did nothing more than engender a lack of strategic coordination between healthcare agencies, as they were encouraged to meet their own financial agendas rather than work in partnership’ (Wilkinson 1999, p. 86) or in the maintenance and development of clinical quality. These imbalances led to the introduction of the White Papers The New NHS Modern and Dependable (DH 1997) and Quality in the New NHS (DH 1998) putting clinical quality on par with organisational, managerial and financial aspects of health care via ‘clinical governance’. A framework ‘which is viewed positively by many healthcare professionals as an ambitious shift of focus by the current government in moving away from finance to quality’ (McSherry & Haddock 1999, p. 114). This approach to providing healthcare services places a statutory duty to match moral responsibilities and harmonises managers and clinicians responsibilities/duties more closely in assuring clinical and non-clinical quality. The impact of these reforms (DH 1989, 1997, 1998a) has enhanced public awareness and expectations for NHS as it places a strong emphasis on achieving clinical quality through restructuring and changing of services.
The DH continued drive for quality improvement through governance and PPI has seen further initiatives introduced by National Health Service Foundation Trusts (DH 2009a), which are ‘a new type of NHS organization, established as independent, not-for-profit public benefit corporations with accountability to their local communities rather than Central Government control ... [NHS Foundation Trust] give more power and a greater voice to their local communities and front line staff over the delivery and development of local healthcare. NHS Foundation Trusts have members drawn from patients, the public and staff and are governed by a Board of Governors comprising people elected from and by the membership base’ (DH 2009a, p. 1). Creating a patient-led NHS (2005) focused on building the NHS capability and capacity for excellence. Commissioning a patient-led NHS (DH 2005) builds on creating a patient-led NHS by emphasising the importance of efficient and effective commissioning of high quality care. World Class Commissioning (DH 2008a) focused a much needed attention on assuring that commissioning of services reflects the unique needs of each local population whilst seeking to embed a consistent set of performance indicators and patient-related outcomes that demonstrate improvement and comparability of services received across the NHS in England. These recent initiatives seek to increase efficiency and effectiveness and greater PPI at a local level which again have been further consolidated through the publication of High Quality Care for All (DH 2008a) commonly known as the Darzi Report. The essence of the report is as follows:
Of an NHS that gives patients and the public more information and choice, works in partnership and has quality of care at its heart – quality defined as clinically effective, personal and safe. It will see the NHS deliver high quality care for all users of services in all aspects, not just some. (DH 2008a, p. 8)
Overall, the emphasis of recent government policy (DH 2005, 2008a) has been about increasing the quality of care through seeking out, listening too and responding too the public, health professionals and users of the service(s) by establishing robust systems and processes which demonstrate enhanced patient safety, patient, public and professional involvement, and quality improvement. Furthermore, there is an expectation that has a result of recent reform, patient experience will be improved through having patient-related outcomes that highlights the overall efficiency and effectiveness service.
The impact of organisational change on the provision and delivery of healthcare
With the increases in the numbers of patients admitted with multiple needs, healthcare organisations have had to change the pattern of care delivery in order to accommodate these growing needs, leading to the development of acute medical and surgical assessment units, pre-operative assessment units, multiple needs and rehabilitation units, acute mental health assessment units. Latterly, we have witnessed a rise in the development of services dedicated to maintain individuals in the community, such as Mental Health Crisis Intervention Teams (DH 2001) and the management of patients with long-term conditions, for example diabetes and chronic obstructive pulmonary disease, Fast Response Teams (FRT) such as those jointly provided by Health and Social Care in Harrogate. FRT are designed ‘to prevent avoidable hospital admissions, facilitate early discharge and provide out of hours skilled nursing care, thus enabling service users to maintain an optimum level of independence within their own home or care setting’ (Care Services Improvement Partnership (Care Services Improvement Partnership Health and Social Care Change Agent Team 2009, p. 1)). This style of service provision is about maximising the use of acute and community beds by encouraging collaborative working between primary and secondary care in the management and maintenance of the patient in the most appropriate setting. For example, in the shared care approach to the management of patients who have diabetes, where the care is shared between the general practitioner and consultant endocrinologist with the backing of the diabetic team (diabetes nurse specialist, dietitian, podiatrist, ophthalmologist and pharmacist). Initiatives such as hospital-at-home schemes (where possible maintaining the patient in their own home) are beginning to be developed along with public and private sector partnerships (acute illness is managed in hospital, and rehabilitation is continued in private nursing home until the patient is ready for discharge).
The driving force behind these innovations could be attributed to the following. The reduction in junior doctors’ hours (DH 1998b) and the possible effects of the European working time directive (DH 2004), culminating in the development of nurse practitioners particularly in highly busy areas such as acute medical admissions and accident and emergency departments. This concept was reinforced recently by the introduction of nurse consultants and therapists (McSherry & Johnson 2005) and by the national education and competence framework for advanced critical care practitioners (DH 2008b) in order to accommodate the increasing demands for healthcare owing to the increase in the life expectancy of people with greater healthcare needs. These changes to healthcare delivery are directed towards enhancing the quality of care and in raising public confidence.
Public
The public has contributed significantly towards the introduction of clinical governance and the ongoing development through direct and indirect ways. These vary in nature from rising expectation to changes in demography.
Rising patient and public expectations and involvement
The Patient’s Charter (1992) Raising the Standards was distributed to all householders in the United Kingdom (UK) detailing the patients’ and carers’ rights of healthcare. The main principles behind this charter were that of informing and empowering the patients and this led to patients being viewed as consumers of healthcare. As consumers, they are entitled to certain rights and standards of care. These standards included the right to be registered with a general practitioner, to have a named consultant and qualified nurse as an in-patient along with the right to be seen within 30 minutes of any specified appointment time with a healthcare practitioner. The Patient’s Charter reinforced the aims of Citizen’s Charter (DH 1993) by empowering the individual to become actively involved in the delivery of health services by the granting of certain rights. This style of healthcare delivery was unique, as previously, patients tended to be seen as passive recipients of often-paternalistic methods (the ‘doctor knows best’) of providing care. The benefits of these charters have been variable, by the fact that some individuals (both the public and healthcare professionals) are unaware of how they can be used to promote raised standards. Alternatively, many patients/carers are much more aware and informed of certain rights to treatments and healthcare interventions. In general, the majority of healthcare professionals have taken up and accepted the challenges posed by these charters in improving the delivery and organisation of healthcare. This can be evidenced by reviewing outpatient waiting time results, hospital league tables and the introduction of the named qualified nurse within inpatient settings. It could be argued that the Patient’s Charter has led to a public that are more questioning about their rights and expectations of healthcare: What is the problem? How will the condition be treated? What are the alternatives? What are the potential risks and benefits of all treatment options? These are genuine concerns for the public that need addressing.
While raising awareness and expectations of healthcare services has had a benefit, a limitation of the Patient’s Charter is that it has also created a demand which at times has been difficult to satisfy for healthcare trusts. For example, to have a named qualified nurse assess, plan, implement and evaluate care from admission to discharge was impractical and overestimated. Similarly, it is sometimes difficult for a consultant to see all his or her outpatient attendees personally on every visit. The consequence of raising expectations, which are not achievable, results in dissatisfaction with services and higher incidents of complaints. The principles behind the charters are plausible providing the services are resourced sufficiently. Furthermore, the publication of waiting times and league tables has highlighted inequalities in the provision of health care by demonstrating good and poor performers of services. For example, access to services for day case surgery could be variable according to region or demographic status of the local population and geography.
League tables alone do not provide the public with the background information of the local community health trends or the availability of healthcare services for individual trusts, hence the disparity of service provision between trusts. It could be the case that it may be inappropriate to perform day case surgery for hernia repairs in a hospital situated in a rural area with a large elderly population because accessibility of services and appropriateness of the surgery to the patients’ needs. This is more evident in society today with an ever increasing elderly population with multi-complex physical, social and psychological needs, placing yet further demands on the health service, making the Patient’s Charter standards more difficult to achieve.
Since the introduction of clinical governance through the White Paper (DH 1997) we have seen a dramatic shift from limited PPI to an almost statutory requirement. NHS organisations are systematically required to involve the patients and users in making decisions about the development, provision and experience of the services they have accessed. The Patient and Public Fora (DH 2003) and PALS were two national examples of the government’s commitment to improving services for the patients and the public. A key development of PPI has the replacement of Patient and Public Fora with the establishment of LINks in each local authority to actively seek the engagement of patient, public and service users in health and social care. Another imitative exemplifying the government’s commitment to patient involvement is the establishment of the NHS Choices Website (NHS 2009) providing accessible information about where patients may receive care and treatment. The choices initiative offers patients the opportunity of choosing where they may wish to have their inpatient investigations, procedures and treatments. Recently the Health Act (2009) highlighted the importance of patient, public and professional involvement by describing the framework for how the NHS Constitution (DH 2009b) designed to
set out the principles and values of the NHS, It also sets out in one place the rights and responsibilities of patients and staff, and the NHS pledges to patients and staff.
A key outcome of these changes by the government’s health polices is seeking to place the patient(s) and service users at the heart of service development, delivery and evaluation. User, patient and professional involvement is critical in a modern consumerist society in ensuring that local services are truly representative and reflective of patient and public needs of that population. This is important in light of changes in demography and dependency.
Demographic changes
Public health policy and findings from national surveys reiterate the government’s publication of the Health of the Nation (DH 1991) document, which highlighted that life expectancy (National Statistics 2004), would increase for all along with changes in the patterns of mortality and morbidity, for example, an increased prevalence of diabetes and obesity (Press Association 2005). As a consequence of these demographic changes together with changes in morbidity patterns, the NHS needs to provide more acute, continuing care and primary care services for an increasing elderly population and to take into account the changes in the patterns of disease and illness associated with societal change. In an attempt to reduce healthcare demands, the Health of the Nation document set targets for reducing morbidity (disease and disability trends) by concentrating upon health promotion and disease prevention. For example, the reduction of strokes by the active management of high blood pressure (hypertension) and the reduction of deaths attributed to coronary heart disease by promoting healthy eating, exercise and, where necessary, the prescription of ‘statins’ (cholesterol lowering drugs; DH 2000b). The general population changes indicate there has and will continue to be a large increase in the numbers of people living to and beyond sixty-five, seventy-five and eighty-five. Longevity seems to be on the increase for all DH (1991), reinforcing the growing trends of high-dependency patients. Longevity is not the only demographic challenge facing the future NHS; we have seen widening inequalities in health, wealth and disease. There is growing public health concern about obesity, sexual health, drug-and alcohol-related problems, all which will lead to greater demands on the health service and its employees.
Lack of public confidence in healthcare provision due to media coverage of poor clinical practices
The media continues to play a major role in increasing patients’ and carers’ awareness of the NHS and social care through the publication of clinical successes and failures in the organisations, for example The Bristol case (The Royal Bristol Infirmary Inquiry 2001) and the Shipman Inquiry (The Shipman Inquiry 2005). The Bristol case related to consultant paediatric cardiac surgeons who were found to have a death-rate for paediatric heart surgery significantly higher than the national average. This only became known as a result of whistle blowing (Lancet 1998). The Shipman case involved a general practitioner in Hyde, Manchester, who was found to have murdered hundreds of his patients mainly by injecting them with an overdose of class A drugs such as morphine and diamorphine. The focus on health and social care failings continues to attract growing media attention. The publication of Care Quality Commission (CQC) ‘Review of the involvement and action taken by health bodies in relation to the case of Baby P’ (CQC 2009) details failings of child protection agencies across health and social care. Similarly, the Healthcare Commission Report ‘Investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust’ (HCC 2007) highlighted inadequacies with healthcare-associated infection policies and procedures and governance arrangements resulting in increased mortality figures.
The continued impact of these major failings and others has resulted in a lack of public confidence in the health service with a rise in the numbers of complaints proceeding to litigation (Wilson & Tingle 1999).
