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Once again an NHS trust is highlighted as having poor, if not dangerous, care. See this item in the London Telegraph.

Tacoma Narrows Bridge collapsing, captured in ...

Catastrophic System Failure [Tacoma Narrows Bridge collapsing, captured in 16 mm Kodachrome motion picture film. The view looks west. (Photo credit: Wikipedia)]

Are the problems a result of design flaws in the way the NHS organises itself to deliver care? Some basic elements of the UK’s NHS that are relevant to the argument I’m going to make:

  1. consultants/specialists have contracts of employment and clinical duties are agreed annually in “job plans” in use since 1991
  2. doctors, once qualified, and registed with the GMC, the professional regulator, are immediately employable in the NHS; their authority to act rests on this
  3. performance improvement and clinical professional development is still work in progress in the NHS despite GMC efforts over the years
  4. junior doctors in training rarely fail and marginal clinical performance is not recognised as such
  5. the Royal Colleges act on behalf of the interests of doctors, not in the public interest as that is the job of the General Medical Council, though they no doubt would argue otherwise.

One starting point is that CQC (Care Quality Commission) inspection may identify the problems, but hospital doctors, other clinicians (nurses, OT, etc.), managers and the board have a collective duty to clinical quality. CQC is not a system of accreditation, and so failing hospitals continue to be protected from the consequences of their actions. The only options are bureaucratic and invariably political (merge the hospital with another, shut the hospital), but this does not solve the problem of failed oversight and management. There is good evidence that hospital quality control systems are weak and rigourous quantitative methods are still needed. I have separately argued that hospitals need in-house operations management capabilites to model clinical care systems, for instance — exemplary hospitals providing high quality care use data-driven analytics in improving clinical work flow and patient outcomes. The Francis report is what I would say is a ‘team hug’ approach recognising individual and cultural factors. I’ll also take a starting point that job plans are not working to uphold standards of care. Putting all this together, we might conclude that we have either the failure of hospital management systems, or the absence of the right type of control system.

My suggested solution is that the NHS should introduce a system called “privileges”, by which appointments/employment and clinical work are subject to prior agreement and degrees of supervisory quality control and oversight. This is an evidence-informed quality control system:

  1. The responsibility of clinical quality rests primarily with the hospital, not the NHS as such, and hospitals need to put in place quality systems that check the quality of clinical work. The quality of clinical work is the responsibility of the hospital Board, as advised by the Medical Director
  2. Medical job plans of NHS employment should include explicit use of privileges or contracts should include privilege as the fundamental determinant with respect to the scope of practice in these job plans.
  3. Appointments to a hospital’s medical staff would require a review of credentials, training, fellowships, previous work undertaken by a medical committee with a recommendation to the Medical Director (and then to the Board, which would be the body granting privileges).
  4. The privileges system would introduce a system of control over what clinical work the individual doctor is recognised as qualified to do (say knee surgery but not hand surgery)
  5. Changes in what a doctor has privileges to do would require the doctor to produce evidence of specific training to establish their ability in the required area.
  6. All new medical appointments, regardless of their total time practising since being licensed, would be supervised in their first 6 months to a year, by a senior colleague acting on behalf of the hospital. At the end of this probationary period, privileges would be confirmed.
  7. Privileges are not forever, but are reviewed for substantive changes on an ongoing basis, and fundamentally reviewed every so many years.

I like the idea because I’ve worked in a system that used privileges, where I’ve seen how it acted to improve clinical quality and worked to the benefit of the doctors themselves. It brings order and structure to clincal work within the hospital by better aligning case mix with skill mix. New hospital appointments would be supervised, while monthly notices kept all clinical staff, importantly nurses on the wards and in the operating theatres, up to date to changes in privileges (who had an area added, or dropped).

Interestingly, the private hospitals in the UK use a system akin to privileges to decide whom to appoint to their medical staff, but it lacks substantive quality criteria or credentialling apart from the requirement of having an NHS appointment!

Some additional potential benefits:

  1. It would create a level clinical playing field between the public and private systems, now that the private or independent sector is becoming more important and perhaps better integrated into the care system in the UK;
  2. Thinking of the future, the privileges system would decouple to some extent doctors’ employment and the work they do. This might increase the likelihood that new ways of organising clinical services in the community, for instance, might become more common.
  3. Patients would have clear evidence that quality and clinical work are connected.

I acknowledge that much is done to create a quality environment within the publicly-funded NHS, and this is not ignored in my comments, which in no way need undermine efforts at team working, or cost control. Job Plans in NHS contracts do not discuss clinical focus in detail and actually spend more space on dealing with private practice and academic appointments than on direct patient care; in essence, they are only workload management plans. However, as employment contracts, they focus on the dimensions of employment (e.g. car allowances, maternity leave and employer responsibilities such as providing the necessary tools for the work to be done).

In my view, the problems have a genesis in these aspects of the system that taken together do not produce the desired outcomes when there are problems, and may actually mask poor quality care. Considering a system like privileges may serve to focus attention on what is really important.

Additional Notes

There are types of privileges: admitting, surgical, courtesy.

Hospitals can add conditions to privileges such as living nearby so the doctor can get to the hospital quickly in an emergency.

Hospitals would revoke or suspend privileges where there is evidence of danger to patients, unethical conduct, and disruptive of hospital operations (that last one’s tricky).

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Some New Thoughts on Education are needed

The new Government’s plans to scrap SHAs by 2012 in an effort to slash NHS administration costs will have ‘major ramifications’ for the future of GP training, and could see budgets cut, warns the GMC. From the GP Bulletin, Pulse, 1 June 2010.

As Mark Twain said, rumors of his death, etc. the issue is overstated as always.  Fear replaces optimism as vested interests worry that they won’t be getting their education funding. But what was it doing with the SHAs in the first place? The creation of some form of market in health professions education, tied in some way to supply management does not in the end ensure a steady and flexible supply of health professions, any more than a similar system would ensure a reliable supply of geologists or accountants. The higher education system fails to evolve in response to the funding, as it is quite separate from the students or the continuing professional development needs of practising professionals.

It is good, though, to know that some see merit in this change as it will, in the end, clarify the purchaser/provider issues and redefine the necessary oversight of the health system. GPs and other health professions, though, do need to be assured that funding is in place to ensure that the programmes they need are properly funded, and accessible in ways that meet their requirements. It is, perhaps, no surprise that the revalidation argument fell at the final hurdle on the issue of a doctor’s time to do revalidation (having had some involvement in this issue in the past, I had calculated the full-time equivalents required to run the system, as well as the time it would take just to read the documents involved — but no one it seems had actually tried to read the paperwork, conduct the required activities with an eye to a clock!).

In the end, the simplest solution is to put the funding in the hands of both the students seeking the study a health profession, and in the hands of either the self-employed GP or their employer (the hospital) to decide what to do. With a level playing field on the provider side, this would ensure that the free-ride enjoyed by the private sector ended, and that all providers were properly responsible for both professional development generally, and CPD in particular. One benefit would be improved accountability by the higher education institutions that have come to monopolise this area, regardless of the quality of their offerings or not.

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