Guide to the NHS NHS Medical Directorate

A Junior Doctor’s Guide to the NHS

Dr Layla McCay Dr Sarah Jonas Guide to the NHS Guide to the NHS Foreword

Postgraduate doctors in training are fundamental to the success of the Contents NHS. They are the backbone of medical services and, more importantly, they hold the key to the future of our NHS. Chapter Page 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 else’s responsibility. Foreword 3 Over the years I began to appreciate that this perception was misguided. If Introduction 4 I really cared about how well patients were treated then I had a moral and NHS structure 5 professional responsibility to understand the system in which I practised. Parliament 6 Junior doctors who work closely with patients and alongside other ! Department of Health (DH) 7 members of staff on the shop floor 24 hours a day have penetrating insight into how things really Doctors holding senior roles in the DH 8 work – where the frustrations and inefficiencies lie, where the safety threats lurk and how quality of Arm’s Length Bodies 8 clinical care can be improved. Strategic Health Authorities (SHAs) 9 But junior doctors often feel undervalued by their organisation. They are often seen as birds of Primary Care Trusts (PCTs) 10 passage and this can make them feel disenfranchised from the NHS as a whole. This feeling Trusts and Foundation Trusts 11 discourages them from engaging enthusiastically with others to change the way NHS organisations New providers 12 work and deliver services. This saddens me, as they are often the most informed and enthusiastic Regulating the health service 12 and have the most innovative ideas about how the NHS could be improved for the benefit of staff and patients alike. Complaints and litigation 13 Commissioning 14 I want junior doctors to play a bigger role in improving the NHS. Throughout my career I wanted World Class Commissioning 15 my patients to have the best possible quality of care. I could see some of the problems, but I didn’t NHS finance 16 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 NHS strategy: policy into practice 18 happens when clinicians, managers, policy makers, and all sorts of people who are expert in the NHS Next Stage Review: High Quality Care for All 19 different aspects of healthcare have the will to work together to achieve the same goal or vision. (“The Darzi Review”) Quality in the NHS 20 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 National Institute for Health and Clinical Excellence (NICE) 22 the system properly from the beginning, I would have avoided a great deal of trial and error, as well Clinical governance 23 as frustration. This is why I want you to have this guide. IT in the NHS 24 The health system in Scotland 25 Junior doctors have sometimes felt at the mercy of ‘management’ or ‘policy’. Let’s change that. Instead I invite you to be part of it. By all means use this guide for general interest, to answer The health system in Wales 26 interview questions, to understand policies, buzzwords and ‘management speak’. Use it to immerse The health system in Northern Ireland 27 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 tomorrow’s clinical leaders.

! Professor Sir Bruce Keogh NHS Medical Director

3 Guide to the NHS Guide to the NHS Introduction NHS structure

This is a simplified diagram giving an overview of the NHS structure in England. 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, NHS providers 1 Department of reforms often mean that the structure has changed. If you are going for an interview, have a Health particular reason for needing to understand, want an update/refresher, or just think it might Other provider be useful to know how your organisation actually works (or are embarrassed that you don’t), organisations Regulatory 10 Strategic Health you have several options. You could comb the internet. You could look at some of the dense 2 tomes that are published. You could talk to people. Or you could let us do it all for you and bodies Authorities summarise it into what you need to know. Independent contractors 3 152 Primary We hope you find A Junior Doctor’s Guide to the NHS helpful. Commissioners Care Trusts 5.b Monitor

Dr Layla McCay ST3 doctor working on secondment with Professor Sir Bruce Keogh in the Medical Directorate, Primary Care Community health Acute Mental Ambulance Commercial NHS Department of Health. Services: services (e.g. hospital health Trusts providers Foundation GP practices, dental district nursing, Trusts Trusts & voluntary Trusts 4 practices, community health visiting etc) organisations Dr Sarah Jonas pharmacies, ST5 doctor working on secondment with Professor Sir Bruce Keogh in the Medical Directorate, optometrists etc Department of Health.

June 2009 5.a Care Quality Commission

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 Foun- dation 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 can’t promise that some of it won’t change.

4 5 Guide to the NHS Guide to the NHS Parliament Department of Health (DH)

Parliament is responsible for approving legislation and forming the framework in which The Department of Health (DH) is a n Leading health and wellbeing on behalf the health service operates. Parliament also holds the Department of Health to account government department, headed by the of the government – working with other for their spending of taxpayers’ money and operation of the National Health Service. Secretary of State for Health. It is based in government departments, third and private This accountability is supported by the National Audit Office, which audits the accounts London and Leeds, with 9 regional Public sectors, and international partners. of all government departments and reports to Parliament on the economy, efficiency and Health teams, and is accountable to the effectiveness on their use of public funds. public through Parliament. The DH does not n Accounting to parliament and the public directly deliver health or social care services – answering parliamentary questions and How health laws are made How Parliament holds the to the public; it works with delivery partners, communicating to the public via the media, (not all laws go through every stage): Department of Health to account: including the NHS, local government and letters, visits and speeches. Arm’s Length Bodies. Consultation Questions to the Secretary of State for Three people are responsible for managing papers on Health The DH’s goals are twofold: the DH: proposed These questions can be both written and n Green Paper Attainment of better health, wellbeing, change oral in both Houses of Parliament care and value for the country Chief Medical Officer Proposal for n Provision of leadership for the NHS, social Government’s chief adviser on medical change of Parliamentary select committees, care, and public health issues and public health. such as: law n Health Select Committee White Paper The DH does this in the following ways: NHS Chief Executive n Public Accounts Committee Pre-legislative Government’s chief adviser on NHS issues, n Public Administration Committee scrutiny often n Setting direction for the NHS, adult and leader of the NHS. by Select social care, and public health – policy, Committee These committees scrutinise aspects of Debate of Draft Bill strategy, legislation, resource allocation, and the work at the Department of Health via a Permanent Secretary the Bill in NHS operating framework. Parliament series of enquiries questioning Senior civil servant responsible for leadership (House of witnesses on specific topics of interest, e.g. and management of the DH, ensuring that Commons and patient safety, alcohol, top-up fees etc. n Supporting delivery of care – performance it operates efficiently and coherently as a Lords): final Bill Bill Bill given monitoring, managerial leadership, building department of state in support of ministers. to be agreed by Royal Asent capacity and capability, and ensuring value both houses These sessions are open to the public so by the Queen for money. becomes an you can go along to see them in action, Act and thus or submit evidence: http://www.parlia- DH Law ment.uk/parliamentary_committees/ Act health_committee.cfm

Chief Medical Officer NHS Chief Executive Permanent Secretary

Health ministers provide political leadership to the Department of Health Finance and operations The prime minister appoints them and agrees their portfolios Research and NHS Medical Directorate Commercial development Policy and strategy – overall strategic responsibility for the work of the Department. Commissioning and Workforce Secretary of State Health system management Minister of State for Health Services – responsibilities include NHS policy and strategy, finance, improvement Social care, local government and care and protection system management and regulation, commissioning and departmental management. NHS finance, Chief Nursing Officer partnerships Minister of State for Public Health – responsibilities include public health, health protection, performance and Regional public operations Communications emergency preparedness, health inequalities, health improvement programmes, medicines health groups Chief Information Officer and pharmaceuticals, research and development. Equality and human rights Minister of State for Care Services – responsibilities include social care, mental health, prison/offender health, third sector, carers, equality and human rights. Government Adviser on Inequalities

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. Email DH: [email protected] Write to the Secretary of State for Health, Email the CMO: [email protected] Department of Health, Richmond House, 79 Whitehall, London, SW1A 2NS

6 7 Guide to the NHS Guide to the NHS

Doctors holding senior roles in the DH Strategic Health Authorities (SHAs) Strategic Health Authorities (SHAs) manage the NHS locally. They occupy the middle tier A number of doctors provide advice to the Associate NHS Medical Director between the Department of Health and local Trusts and PCTs. DH and to Ministers. Like civil servants, their Supports the Medical Director in his roles. roles are not political and they do not change There are 10 Strategic Health Authorities in England. with Governments. Director General of Research and

Development North Chief Medical Officer (CMO) Responsible for establishing the NHS East The role of the UK Government’s principal as an international centre for research medical adviser dates back to Victorian excellence and commissioning research to North West times. The CMO provides independent underpin policy and practice in health and advice to the Secretary of State for Health, healthcare, by running the National Institute Yorkshire and other Health Ministers, Ministers of other for Health Research and the Policy Research the Humber Government departments and the Prime Programme. Minister. Responsibilities include developing National Policy policies and programmes to reduce health Director of Medical Education inequalities and to protect and improve the Responsible for the full range of medical health of the public and reviewing policy education, including Modernising Medical SHAs East Midlands in new, changing and contentious areas of Careers (MMC), and reports directly to the health. Over the years the CMO has shown NHS Medical Director. West Midlands East of England a particular interest in improving safety and quality of care in the NHS. Health Improvement and Protection Trusts & PCTs The Directors of Immunisation, Emergency NHS Medical Director South Preparedness and Pandemic Influenza Pre Central London This new position commenced in November specific clinical areas such as cancer, heart 2007. This is an operational role with disease, stroke, diabetes, renal disease, South East Coast responsibility for clinical quality, safety and trauma, transplantation, mental health, and South West strategy; this includes the medicines supply maternal and child health. chain into the UK, including policy relating to drugs, pharmacy and the pharmaceutical Regional Directors of Public Health industry. The role has oversight of funding Responsible for providing regional and work programmes of NICE, the NPSA leadership, vision, advice, advocacy and (National Patient Safety Agency), and implementation. Strategic Health Authorities are responsible for: Medical Education England. The occupant is also Deputy CMO. n Developing strategic plans for improving n Offering services to Trusts where pooling health services in their region of regional resources is helpful n Ensuring local health services are acces- n Managing corporate affairs for the region, in- sible, of a high quality and performing well cluding strategic direction and communication n Increasing the capacity and capability of n Holding all NHS organisations (except local health services so they can provide NHS Foundation Trusts) to account for more and higher quality services performance n Ensuring national priorities and policies Arm’s Length Bodies — for example, programmes for improving cancer services — are explained and inte- These have a role in the process of national government, but are not part of government grated into local health service plans departments. They operate at arm’s length from ministers. They are sponsored by government departments and derive all or part of their funding from their sponsor departments. Find out more about each SHA here: http://www.nhs.uk/ServiceDirectories/Pages/StrategicHealthAuthorityListing.aspx 8 9 Guide to the NHS Guide to the NHS Primary Care Trusts (PCTs) Trusts and Foundation Trusts NHS Trusts provide healthcare services that have been commissioned by PCTs and practice- Primary Care Trusts (PCTs) are the key Direct provision of services based commissioners. Trusts generally concentrate on one work area: acute care, mental health, organisations responsible for ensuring there PCTs can directly provide services to pa- learning disability, community or ambulance. All Trusts have a legal duty to break even, financially is a comprehensive range of health services tients, for instance community services. earn a specific return on capital and meet minimum quality standards. for the local population. Governance Since 2004, Trusts have been able to apply to change their status in the NHS to NHS Foundation Functions of the PCT: PCTs hold service providers to account Trusts. As of 1st May 2009 there were 120 NHS Foundation Trusts in the UK. The Department via contracts. They can ask regulators to of Health wants as many trusts as possible to become NHS Foundation Trusts in the next few Public health care intervene if the providers are not meeting years. PCTs work to improve the health and well- expected standards. being of their local population by assessing How do NHS Foundation Trusts Special kinds of Trusts needs and working directly with other local PCTs are held to account by the relevant partners (e.g. local authorities, children’s differ from NHS Trusts? Care Trusts exist as partnerships SHA. The PCT board is accountable to the n services and housing services) to provide Must meet financial requirements to become one between health and social relevant SHA board. n Independent from SHA/DH control services to meet these needs. care, delivering both services in n Regulated by Monitor who reports directly to tandem. Parliament Commissioning and contracting PCTs deliver services to the population via: n Increased financial obligations to maintain services Children’s Trusts were introduced surplus by the Children’s Act of 2004; PCTs control the vast majority of the NHS n Acute Trusts they are not necessarily one budget and are responsible for commission- n Mental Health Trusts Freedoms include: organisation in the same way, ing the healthcare services for their area. n Ambulance Trusts n Keep receipts from capital sales as other trusts but exist to help They commission services (including acute n GP practices n Decide how to meet national targets rather than co-ordinate children’s services care, primary care and mental health care) n Dental practices being performance-managed in an area through a partnership for the whole of their population, with a n Community pharmacies n Borrow money under strict conditions between health, social care and view to improving their population’s health. n Optical practices n Set terms and conditions for staff locally education. All services are NHS-funded but may be n Community hospitals provided by voluntary or independent sector n And more organisations as well as by NHS organisa- Trust Board tions. (The process of commissioning is Find our more about your PCT here: http:// Functions: described on pages 14 and 15.) www.nhs.uk/ServiceDirectories/Pages/ n Sets strategic direction, define objectives and agree plans PrimaryCareTrustListing.aspx 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

Boards are typically composed of 11 members: 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 trust’s website: http://www.nhs.uk/ServiceDirectories/Pages/AcuteTrustListing.aspx

10 11 Guide to the NHS Guide to the NHS New providers Complaints and litigation In the UK, there have always been healthcare treat patients within the NHS. The second phase providers other than the NHS; however, of Treatment Centres has been historically these providers have mainly provided more integrated within the current NHS facilities, care to those who either had private insurance or and has increased contractual obligations to Top 10 NHS NHS complaints paid directly and there was very little provision quality. Any future procurement of this kind of complaints Go through Patient Advice of NHS care. service is likely to be taken forward locally. n Safety/effectiveness Talk directly to the person First steps Liaison Service (PALS) – Since 1997 many other providers have entered of clinical practice involved. informal can help with resolution the NHS market. n Poor communication/ or refer to complaints 2. Third sector manager (all NHS bodies This includes voluntary groups and charitable lack of information Contact primary care must have one) The new providers can be divided into three organisations, co-operatives, Trusts, community n Poor response to a practitioner / NHS Local groups: interest groups and foundations, working for complaint organisation in writing or resolution orally with written record instance in the mental health and substance n Patient’s experience The NHS Constitution states 1. Private sector misuse sectors. These groups are often able to of care that people should receive a timely and appropriate This sector is managed and owned by private bridge the gap between care sectors. n Clinical treatment Independent Complaints Other options response companies. It has been established in the n Delay or cancellation and Advocacy Service secondary care market as a provider to insurance 3. Social enterprise of appointment (ICAS) provide free advice companies, but increasingly provides NHS and assistance for making Independent professional Social enterprises are organisations that are run n Attitude of staff complaints advice, independent review, services, either through free choice (e.g. elective along business lines, but where any profits are n Lack of access to Parliamentary and mediation care) or through winning contracts to provide Health Service reinvested into the community or into service personal records specific services via commissioning. Ombudsman developments. Encouraging social enterprise in n Access to services The first phase of Independent Sector Treatment health and social care is a key part of the and waiting times Legally can use this step at Centres was created to increase the capacity to patient-led reforms. n Independent of NHS and any stage, but usually when Lack of carer/relative government other steps have been involvement exhausted Regulating the health service The NHS has a number of different regulators Audit Commission for different purposes. The main ones are listed The Commission audits NHS Trusts, PCTs and below. SHAs to review the quality of their financial NHS Litigation Authority (NHSLA) of Health. If the NHS body no longer exists, systems. It also publishes independent reports A Special Health Authority within the NHS, the relevant SHA occasionally becomes the Regulators of NHS organisations which highlight risks and good practice to responsible for handling negligence claims legal defendant. improve the quality of financial management Care Quality Commission (including employee negligence) made in the health service and, working with CQC, The Care Quality Commission replaced the against member NHS bodies in England Risk Pooling Scheme for Trusts Healthcare Commission, Mental Health Act undertakes national value for money studies. Visit through the following schemes (membership (RPST) Commission, and the Commission for Social http://www.audit-commission.gov.uk is voluntary): has 2 schemes, the Liabilities to Third Parties Care Inspection in April 2009. Its role is to regulate the quality of both health and adult social care in Regulators of treatment Scheme (LTPS), which covers falls, bullying, England as an independent regulator. Visit http:// Medicines and Healthcare Regulatory Agency Clinical Negligence Scheme for stress, defamation, injury, and the Property www.cqc.org.uk This Agency monitors the safety of new Trusts (CNST) Expenses Scheme (PES), which covers theft medications and products and licences new covers clinical negligence claims relating and damages. Monitor medicinal products. to incidents occurring after April 1995. If This body assesses Trusts applying for Foundation Visit http://www.mhra.gov.uk a claim is made, the NHS body remains The NHSLA has risk management Trust status to ensure they are legally constituted, the legal defendant but the NHSLA takes programmes to raise standards and financially sound and well-governed. The regulator Regulation of professionals responsibility for handling the claim and minimise negligence claims. Adherence to ensures that, once authorised, NHS Foundation Individual professionals within the NHS are also meeting the costs. the programme results in reduction in cost of Trusts continue to meet the terms of their licence. regulated, through the professional regulatory contributions; 96% of negligence claims are Monitor reports directly to Parliament. Visit http:// bodies, such as the General Medical Council, Existing Liabilities Scheme (ELS) settled out of court by the NHSLA. www.monitor-nhsft.gov.uk the Nursing and Midwifery Council, the Health covers clinical negligence claims relating Professions Council, the General Dental Council, to an incident that occurred before April the General Optical Council, and the General 1995. Funded centrally by the Department 12 Osteopathic Council. 13 Guide to the NHS Guide to the NHS Commissioning World Class Commissioning Commissioning is the process Commissioning occurs: of determining: n mainly at PCT level n the health needs of the population n Improving commissioning is key at PCT group, SHA, or national level to WCC aims to deliver: n the resources available provide for very rare conditions to improving quality of care. World n how to organise service provision Class Commissioning (WCC) is a statement of intent for how the NHS Better health and wellbeing for all Review will secure (from locally available n People will live longer, healthier lives Access service resources) maximum improvement n Health inequalities will be dramatically reduced pop. provision in locally prioritised health and Better care for all needs n Evidence-based, high-quality services wellbeing outcomes. Decide n People will have choice and control over priorities services PCTs will become World Class Better value for all Patient Commissioners by developing feedback n Investment decisions will be made in an 11 organisational competencies. informed and considered way Design services They will be assessed against strategies and service n PCTs will work with others to optimise care these competencies by an annual commissioning-assurance Performance process. management Shaping supply Competencies 6. Prioritise investment Develop outcome-focused strategic priori- Clinical ties and investment plans. decisions Manage 1. Locally lead the NHS demand Actively steer the local health agenda as 7. Stimulate the market leaders of the local NHS. Improve the patient’s experience of NHS services and outcomes of care by using PCTs are responsible for buying services from services to their patients, so that services bet- 2. Work with community partners investment choices to influence service local providers. The first step in this process ter represent patients’ preferences. Practices Identify the wider determinants of health, design and increase choice. is a Joint Strategic Needs Assessment to can group together but the PCT retains the and develop solutions together with key determine the healthcare needs of the local legal responsibility. Practices can use 70% partners. population. of the savings made for reinvestment for new 8. Promote improvement and innovation services or more equipment for existing ones. 3. Engage with the public and with Specify required quality and outcomes, and What is... a Joint Strategic Needs patients What about... SHA and national base commissioning on results. Assessment (JSNA)? Build local trust, actively seeking the views This is a process conducted in partnership by commissioning? of patients, carers, and the public. local government, PCTs and the local com- For services serving populations of greater 9. Secure procurement skills munity to identify areas for priority action to than a million people, there is a small amount Facilitate good working relationships with improve local health and wellbeing through of commissioning for specialist services at the 4. Collaborate with clinicians providers, with clear agreements. Local Area Agreements. The JSNA has been a SHA level (through regional specialist commis- Strengthen clinical leadership and engage- ment throughout all stages of commission- statutory requirement since 1st April 2008 and sioning groups) and at the national level ( the 10. Manage the local health system helps commissioners to specify outcomes that National Commissioning Group). This grouping ing. Ensure delivery of the highest possible help providers shape services to address local of commissioning allows PCTs to pool the risk quality of service and value for money. needs. of unlikely but expensive treatments. 5. Manage knowledge and assess needs 11. Make sound financial investments What is... practice-based commis- Base commissioning decisions on sound Ensure commissioning decisions are sus- sioning? evidence of specific present and future local tainable and improve outcomes. This reform gives individual GPs and practice needs. nurses more say in how the NHS provides

14 15 Guide to the NHS Guide to the NHS

Money flow and Funding Parliament NHS finance accountability Accountability Where does the money for the NHS they will deliver for the money; these agreements come from? are called Public Service Agreements (PSAs). They set out specific targets and aims towards DH The budget for the NHS in 2008/9 was £96 which the DH will work. billion and will rise to about £110 billion in 2010/11. Future spending predictions Given the size and importance of health SHAs Arm’s length bodies Most money comes from general taxation and spending, the Treasury commissioned a report (including Monitor) National Insurance (NHS portion) receipts. A by Derek Wanless to look at future trends for small proportion comes from other sources, healthcare and how spending would change. such as: PCTs NHS Trusts n Treatment charges (including prescriptions) The Wanless report (2002)* concluded that costs n Dental charges would be driven up; the main cause would not n Charges for road traffic and personal injury be an aging population but patients demanding victims (money claimed from insurers) more choice and higher quality services. NHS Foundation n Overseas visitors Trusts n Capital receipts He recommended that improving spending on IT and communication would be key, as would changes in skill-mix and ways of working, How does the Government decide On what areas of health do we currently how much to spend? and that the role of primary care needed enhancing. spend money? 3% Spending limits for Government Departments 4% for the three years from 2008/09 to 2010/11 *Securing our future: taking a long-term view. 4% were the outcome of the Comprehensive Final Report. April 2002 4% Spending Review (CSR) announced by Treasury General & acute care in October 2007. Spending Reviews are usually Mental illness run every two years. NHS finance sources Community health 12% 0.2% As part of the CSR the DH enters into a set of Learning difficulties agreements with the Treasury regarding what 2.6% 18.4% Other contracts 59% 2007 PSA Targets 2.6% A&E Maternity 14% n Increase life expectancy to 78.6 years for men and 82.5 years for women

n Reduce gap in life expectancy by at least 10% by 2010

n Reduce smoking rates to 21% by 2010

n Maximum wait of 18 weeks from GP referral to the start of hospital treatment by 76.2% Dec 2008 General taxation National insurance n Sustain progress on reducing the number of MRSA blood stream infections achieved Capital receipts Charges & misc n Reduce the number of C.difficile infections by 30% by March 2011 Trust interest receipts & loan repayments 16 17 Guide to the NHS Guide to the NHS NHS strategy: policy into practice NHS Next Stage Review: The DH creates, maintains, adapts and How is policy implemented at High Quality Care for All (“The Darzi Review”) integrates policy on public health, social national level? care and the NHS to provide a clear What: A report on the way forward for the When: The regional visions were pub- national framework within which service Public Service Agreement (PSA) development can take place locally. NHS on its 60th Anniversary lished in May and June 2008 (July 2007 Every 2 years the Department of Health in London). High Quality Care for All was draws up a PSA with the Treasury, Why: To carry out a wide-ranging review published in June 2008. Why is policy needed? describing what it aims to provide with its of the NHS to achieve a properly resourced Policy is the translation of government’s allocated resources; thus the Government NHS that is clinically-led, patient-centred Where: High Quality Care for All is avail- political priorities and principles into ensures that increased resources lead to and locally accountable, and to consider able on the Department of Health website programmes and courses of action to reform. deliver desired change (Modern policy- the case for a new NHS constitution http://www.dh.gov.uk/en/publication- making, National Audit Office, November (www.dh.gov.uk/nhsconstitution). sandstatistics/publications/publication- DH Strategic Framework spolicyandguidance/DH_085825 2001).Policy develops in response to rising This is the translation of the PSA into a expectations, changes in population, framework for implementation to allow Commissioned by: the Prime Minister, developments in medicine and the Chancellor of the Exchequer and Secretary The regional visions are available on SHA organisations to plan change. It shows websites and on the Department of Health need to tackle quality (including safety, how the high-level objectives of DH mesh of State for Health. effectiveness, patient experience, access website with the wider Government performance http://www.dh.gov.uk/en/Publication- and value for money). framework. Commissioned: Lord Ara Darzi, a practicing colorectal surgeon, and Minister sandstatistics/Publications/Publication- sPolicyAndGuidance/DH_085400 How is policy need identified? NHS Operating Framework (Parliamentary Under-Secretary of State). There is a wide variety of methods of The Operating Framework is published Aims of the report: identifying policy need, including evidence- annually by the NHS Chief Executive and How: A year-long review of the NHS was based analysis of current problems, carried out, led by nearly 2,000 clinicians sets out the priorities for the NHS over the n To ensure that improving quality is the response to things going wrong, public and engaging 65,000 healthcare staff, next year and the strategies for addressing organising principle of the NHS inquiries, alerts raised by pressure groups them. social-care staff, patients and members of and media campaigns, financial restraints, the public. and reaction to political pressure. n To improve patient care, including pro- How is policy implemented at local viding high-quality, joined-up services for level? The 2,000 clinicians were part of 8 clinical Where does policy come from? those suffering long-term or life-threatening Local Delivery Plans (LDPs) – LDPs are local pathway groups (maternity and newborn Policy is developed by civil servants conditions translations of the DH Strategic Framework. care, children’s health, planned care, mental in consultation with stakeholders (the They cover SHA areas and form the basis health, staying healthy, long-term condi- individuals and groups affected by the n To ensure that primary and secondary of the relationship between DH and SHAs. tions, acute care and end-of-life care) in strategy and policy proposals, including providers integrate more accessible and NHS planning takes place locally, within the each of the 10 SHAs. They looked at the healthcare staff), pressure groups, experts, convenient care national framework. evidence available and engaged widely to academics, lobbyists and politicians. produce a vision for the future. The groups n To establish for the next decade of the Ministers make final policy decisions. also considered the barriers to delivering PCTs develop strategic commissioning NHS a vision based less on central direction these visions. These barriers were ad- plans to deliver the improvements in and more on patient control, choice and dressed in High Quality Care for All, an outcomes that they have identified their local accountability. population needs. enabling report designed to support local delivery of the regional clinical visions.

18 19 Guide to the NHS Guide to the NHS

Quality in the NHS Clinical leadership Safeguarding quality High quality care means that care is safe, effective, and provides the best possible patient expe- There are clinical leaders throughout the NHS. Care Quality Commission (CQC) rience. The quality of care is determined by each individual interaction you and your colleagues High Quality Care for All built on this and The CQC is the new health and adult social have with patients. Lord Darzi’s NHS Next Stage Review report described a framework for introduced the following groups: care regulator. It will register providers of enabling local quality improvement in the NHS. health and adult social care to provide National Quality Board: This board will assurance that they meet essential levels of provide strategic oversight and leadership safety and quality, and will use its enforcement Bring Publish Recognise on quality in the NHS. It is chaired by the powers to address failings. Measure Clinical Safeguard clarity to quality and reward Stay ahead quality leadership quality NHS Chief Executive and has memabers quality performance quality representing national and statutory bodies. Staying ahead n NICE n Metrics – n Quality n PCT contracts, n Practice-based n CQC n Learning from It will: Innovation is the successful implementation Quality local, national, Accounts including commissioning, registration Never Events Standards international n NHS CQUIN payment service line n Professional n CQC Special of new ideas. A number of policies support n NHS n PROMs Choices framework reporting, social regulation Reviews n Advise the Secretary of State on priorities innovation. Evidence (patient- n CQC n Best practice enterprise n SHA duty to for quality standards (set by NICE) and The Health Innovation Council champions reported periodic tariffs n SHA Medical innovate oversee the development of quality indicators outcome review n Clinical Directors & n Innovation innovation for the NHS and helps develop measures) n International Excellence clinical advisory funds & prizes n Submit an annual report on the state of innovation proposals. n Clinical measures Awards groups n Academic quality in England (internationally comparable) Best Practice Tariffs enable the NHS to pay dashboards n Quality and n Quality Health Science Outcomes Observatories Centres prices that reflect the cost of best practice Framework n National n Health SHA Medical Directors: Responsible for rather than the average cost. (QOF) Quality Board Innovation & overseeing implementation of local clinical SHAs have a new legal duty to promote n Accreditation n National Education visions and for providing medical leadership to Clinical Directors Clusters innovation funds. SHA Regional Innovation NHS organisations in their area. Funds will identify, grow and diffuse innovation through funding and prizes. Bringing clarity to quality effectiveness, and patient experience) and Quality Observatories: A “Quality Health Innovation and Education Clusters Clinicians reported that there was too much further work over the next few years is needed Observatory” will be established in every SHA bring together the talents of different sectors guidance – that it was too difficult to find the to develop new indicators. These will include to help develop local indicators, enable local for education and learning and run joint most up-to-date guidance and to know what PROMs (patient-reported outcome measures). benchmarking, and support front-line staff to innovation programmes reflecting local needs. was required and what was good practice. innovate and improve their services. Academic Health Science Centres bring In response, the role of NICE was expanded Publishing quality performance together a small number of health and to set quality standards, which will distil the All registered healthcare providers working academic partners to focus on world class range of guidance available into a short set of for, or on behalf of, the NHS will be required research, teaching and patient care. Their key markers of high-quality care in a particular by law to publish Quality Accounts for the purpose is to promote the application of new clinical area. NICE will also manage public. These will be reports on the quality of discoveries in the NHS and around the world. NHS Evidence, a new online portal to access services they provide (safety, experience and quality-assured evidence and practice at outcomes). http://www.evidence.nhs.uk. NICE will continue to evaluate drugs (more quickly on The Care Quality Commission will publish key drugs) and other health interventions for an independent assessment of provider and clinical- and cost-effectiveness. commissioner performance using nationally agreed indicators of quality. The CQC will also Measuring quality carry out general reviews and investigations of High-performing teams not only have good issues of interest to the public and will submit clinical leadership, but are also defined by their an annual report to Parliament. willingness to measure their own performance and use this information to continuously Recognising and rewarding quality improve. To support front-line teams to select The CQUIN (Commissioning for Quality and indicators and benchmark themselves against Innovation) Payment Framework will make a others, a Menu of Assured Quality Measures small percentage of hospital funding conditional will be published, pulling together indicators on quality of care. Schemes will be agreed from existing sources. Existing commonly locally between providers and commissioners. used indicators do not give full coverage of The Quality and Outcomes Framework (QOF) all pathways and all aspects of quality (safety, already rewards quality in primary care. 20 21 Guide to the NHS Guide to the NHS

National Institute for Health and Clinical Clinical governance Excellence (NICE) “The system through NICE was established in 1999. It is an independent NHS organisation responsible for provid- Clinical which NHS organisations ing national guidance on promoting good health and preventing and treating ill health. Its work audit are accountable for focuses on three areas: Clinical continuously monitoring n Public health – Guidance for those working in the NHS, the local authorities and the wider Openess effectivness and improving the quality public and voluntary sector on the promotion of good health and the prevention of ill health. n Health technologies – Guidance on the use of new and existing medicines, treatments and of their care and services and safeguarding high procedures within the NHS. Clinical n Clinical practice – Guidance on the appropriate treatment and care of people with specific governance standards of care and diseases and conditions within the NHS. services.” Education Risk and training management What is NICE and who develops NICE will be responsible for NHS Evidence, Scally G and Donaldson LJ. Looking forward: Clinical the guidance? where anyone will be able to access clinical and non-clinical evidence and best practice, governance and the drive for Research with clear descriptions of high quality care and quality improvement in the new NICE guidance is developed by independent and how to deliver it. This will support commis- NHS in England. BMJ 1998; 317: advisory groups composed of health profes- development sioning the most clinically and cost-effective 61-65 sionals, NHS staff, patients, carers, and the diagnostics, treatments and procedures. public. The NICE Board and senior manage- ment team set strategic direction and oversee The new NHS Constitution will set out the Risk management delivery and oversee financial issues and Clinical audit right of all patients to receive interventions There are three areas of risk: ensure corporate governance. The review of clinical practice positively appraised by NICE when clinically against defined national standards 1) Risk to patients (patient safety) appropriate, helping to minimise perceptions is a cyclical process in which care 2) Risk to staff (infection, radiation) How will NICE develop following of a “postcode lottery” of access to care. 3) Risks to the organisation (financial, the Darzi review? is continuously measured, improved and re-measured, thereby enabling poor quality, legal, reputational, staff For more information about NICE, visit continuous improvement. employment) Following the Next Stage Review (2008) the role http://www.nice.org.uk of NICE will be expanded to set and approve Clinical effectiveness These are all managed by identifying independent national quality standards. The To explore NHS Evidence, visit possible risks and developing National Quality Board will advise Ministers on The measure of how well a particular http://www.evidence.nhs.uk solutions before the event, and the priorities for NICE’s clinical standard setting. intervention works in practice. This having a mechanism for learning NICE will also provide guidance on significant is obviously important in clinical new drugs within a few months of their launch. practice but can be further enhanced where things went wrong. by measuring appropriateness and value for money. In the NHS NICE Research and development takes on the role of assessing the Good practice is continuously clinical and cost effectiveness of evolving in response to research treatments in a systematic way for evidence; however, there is often a the whole NHS. long delay between research findings being known and implementation in clinical settings. Tools (such as the Aligning audit critical appraisal of papers) have with the Trust’s developed in this area, but there is current priorities still a need for improvement. can help lead to changes in policy and practice 22 23 Guide to the NHS Guide to the NHS IT in the NHS The health system in Scotland

NHS Connecting for Health (NHS CFH) The National Programme for IT in the NHS supports information technology (IT) systems underpins the modernisation of the NHS. Differences between the Scottish and There are 8 Special Health Boards: Scottish for the NHS in England. It works with both It helps the NHS to meet patients’ growing English NHS (Scottish population: 5 Ambulance Service, NHS 24, State Hospitals local NHS organisations and suppliers in expectations about choice, convenience, million) Board for Scotland, NHS Health Scotland, introducing new IT systems and services to quality and responsiveness. It also supports NHS Quality Improvement Scotland, NHS improve the way health information is stored complex modern care, where treatment The devolved parliament is respon- Education for Scotland, National Waiting and shared. is delivered by a team of healthcare staff sible for NHSScotland (since 1999) Times Centre Board, and NHS National based in different buildings or organisations Parliamentary Committees involved in Services Scotland. Specifically, NHS CFH is responsible for: across primary and secondary care, or out in NHSScotland: n New IT systems and services – together the community. The complexity of this care n Health and Sport Committee: health policy, Financed by the Scottish Executive known as the National Programme for IT requires information to be shared effectively public health, and community care (via UK Parliament); no internal (NPfIT) — computer systems support this function. n Finance Committee: public expenditure market n Existing business-critical national NHS IT n Public Audit Committee: considers reports NHSScotland is funded by general taxation systems (originally delivered by the former Responsibility for implementing NPfIT produced by the Audit General for Scotland, and National Insurance through the UK NHS Information Authority), and systems and services at local level lies with including reports on NHS expenditure Government, which allocates public money n Legislative and digital policy advice on SHAs. to the Scottish Government for distribution information systems for the NHS. Scottish Executive Health and within its departments. NHSScotland has Wellbeing Directorates (SEHD) rejected market-based reforms and there is is responsible for NHSScotland currently no role for internal market within policy Scottish healthcare. Core programmes within the NPfIT: The head of SEHD is also the chief executive of NHSScotland and is accountable to SIGN, not NICE n N3 – the secure broadband National Network for the NHS the Scottish Parliament. SEHD develops The Scottish Intercollegiate Guidelines strategies, implements policy, and holds Network (SIGN) improves quality by n NHS Care Records Service (NHS CRS) – a secure service linking patient information the NHS to account for its performance. reducing variation in practice and outcome electronically, with detailed records shared locally between NHS organisations caring Scotland’s CMO is the Scottish Government’s by publishing national clinical guidelines. for the patient and Summary Care Records available across England to support emer- medical adviser, with responsibility for The Scottish Medicines Consortium (SMC) gency and out-of-hours care clinical effectiveness, quality assurance, develops advice on new drugs for the NHS in accreditation and research. Scotland. Scotland adopts NICE guidelines n Picture Archiving Communications Systems (PACS) – digital x-rays and scans for for interventional procedures and some faster diagnosis NHS Boards, not Trusts technology appraisals. (since 2004) n NHSmail – the only email and directory service endorsed by the BMA and RCN for NHSScotland abolished Trusts in favour of Managed Clinical Networks to the secure transfer of patient information integrated boards, responsible for protecting integrate health and social care and improving health, delivering hospital NHSScotland works through ‘managed n Choose and Book – electronic booking service, enabling the patient to choose the and community services, developing a clinical networks’ to integrate systems of time, date and place of their first outpatient appointment local health plan, allocating resources, and care for specific conditions. performance management. n Electronic Prescription Service (EPS) – enabling prescription messages to be sent electronically from prescriber to dispenser There are 14 area Health Boards. In each area, an NHS Board oversees the NHS n Support for GP IT – including GP Systems of Choice (GPSoC), electronic patient locally. Within each Board, Community record transfer between GP practices (GP2GP) and QMAS (GP payment system) Health Partnerships manage primary and community services. More information is available at http://www.connectingforhealth.nhs.uk

24 25 Guide to the NHS Guide to the NHS The health system in Wales The health system in Northern Ireland

DHSSPS was created as part of the Northern Differences between the Welsh and English Fewer Trusts than LHBs Differences between the Northern Irish and English NHS Ireland Executive and is responsible for NHS (Welsh population: 2.9 million) There are 14 NHS trusts, providing services (Northern Irish population: 1.7 million) health and social care, public health, and mainly commissioned by LHBs. The Welsh National Assembly is public safety. The Permanent Secretary of The Northern Ireland Assembly DHSSPS is also Chief Executive of the HSC responsible for NHS Wales (since Health Commission Wales pays for is responsible for healthcare in system. 1999) national services The Assembly can pass secondary This is an executive commissioning body for Northern Ireland Devolved powers were returned to the Reforms are underway to legislation, but not primary legislation. specialist and tertiary services throughout Northern Ireland Assembly in 2007. The restructure the HSC system Assembly committees involved in NHS Wales. In April 2007, 19 HSS Trusts were merged Wales: Assembly can pass both primary and to create six Health and Social Care Trusts. n Health and Social Services Committee: secondary legislation. Community Health Councils (CHCs) They have responsibility for delivering the full develop policy, scrutinise legislation, and hold NHS Wales to account by the range of health and social care. advise on budget allocation Assembly committees involved with Health, public By 1 April 2009 the following was due to be n Audit Committee: public expenditure Social Services and Public Safety: There are 19 of these statutory lay n Health and Social Services Committee: established: organisations, which work to improve the n A single Regional Health and Social Health and Social Care Department advise and assist the Minister for Health, quality of local healthcare. Social Services and Public Safety. The Care Board (RHSCB), responsible for sits within the Welsh Assembly committee undertakes a scrutiny, policy commissioning, performance management/ Government Financed by the National Assembly development and consultation role with improvement and financial management. Established in 2004, this department advises for Wales (via UK Parliament) respect to the Department of Health, Social n A Regional Agency for Public Health and the Assembly on health and social care The Assembly Government allocates Services and Public Safety and plays a key Social Well-being (RAPHSW), responsible policy and strategy, contributes to legislation, resources each year to LHBs and Health role in the consideration and development of for health protection, health improvement manages health and social care delivery, Commission Wales to pay for the costs legislation. and addressing existing health inequalities. and is responsible for funding NHS Wales. of hospital treatments provided by NHS n Public Accounts Committee: consider n A Regional Business Support Organisation The head of department is Chief Executive trusts and other independent healthcare and reports on accounts laid before the (RBSO), responsible for supporting the of NHS Wales; three regional offices act as providers. Assembly. health and social care sector. local agents. n a Patient and Client Council (PCC), NICE and National Service The Department of Health, Social providing a strong voice for patients, clients Local Health Boards (LHBs), not Frameworks are used Services and Public Safety and carers. SHAs NICE provides clinical guidelines, (DHSSPS) is responsible for health, Wales has 22 LHBs which receive 75% of the technology appraisals and interventional NHS budget and work with local authorities, social services and public safety procedure guidance for NHS Wales. The The NHS in Northern Ireland is called Health including housing and education, to deliver a Welsh Assembly works with DH to deliver a public health strategy. and Social Care (HSC) and it provides common quality agenda. integrated health and social care services. It has retained the commissioner–provider split.

26 27 Guide to the NHS

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