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National Health Service History |
A guide to the NHS
Geoffrey Rivett
Introduction
This guide provides an insight into the NHS. It was originally written to help overseas visitors but could be useful for anyone needing a quick account of the service. It relates to
Established in 1948, the object of the NHS was to provide a comprehensive health service to improve the physical and mental health of the people through the prevention, diagnosis and treatment of illness. An introductory booklet [2] said the NHS would "make all the health services available to every man, woman and child in the population, irrespective of their age or where they live, or how much money they have; and to make the total cost of the Service a charge on the national income in the same way as the Defence Services and other national necessities." This has hardly changed in 60 years.
Topics covered
Developments in medicine
Health care affects the organization of hospitals
The organizational structure of the NHS
Primary care
Secondary care, NHS trusts and foundation trusts
Primary Care Trusts
Strategic Health Authorities
Parliament and the secretary of state
Health Service Policies
NHS core principals
The NHS Plan
The private sector
National priority areas and NICE
Buildings
Staff
Money
How the money is allocated
What the money is spent on
Monitoring, inspecting and regulating the NHS
The function of the NHS is to provide medical care and the care required depends on three factors
the needs of people
the forms of care and treatment required
the money available
The superstructure of the NHS, its management finance and organization, should ideally be based on clinical matters, though since the start of the NHS other factors such as political philosophy and the economic health of the country have had a significant impact.
World-wide and in
So the NHS faces different clinical challenges. As the disease pattern has changed, so has the capacity to help. Sometimes a disease, for example diabetes, can more readily be handled outside hospital. Sometimes the movement has been from primary into secondary care. Surgery for arthritis and heart disease made these conditions appropriate for hospital. New forms of treatment spur new activities for the NHS. As treatment becomes easier, as in the case of keyhole surgery, more people come forward for care, increasing costs and activity. Historically, the introduction of anesthesia in the 19th century trebled the number of operations within a month!
Proponents of new forms of care often argue that in the long run theyey will save money. This is a fallacy. We save people from dying cheaply when young and as a result they die more expensively later on, sometimes after several previously lethal conditions have been treated. Something like half of the entire lifetime costs of an individual to the NHS are in the last month or two of life. So the introduction of new drugs, from penicillin to Aricept, has increased costs. Technology in the imaging department (e.g. MRI scanning) and in treatment (e.g. interventional radiology and angioplasty) have increases bills not just immediately but in the future as well.
Health care affects the organization of NHS hospitals
200 years ago when neither the local doctor nor the hospital could do much, the way health care was organized hardly mattered. Once anaesthesia and aseptic surgery were available, hospitals became important and by the early years of the last century the idea of a district hospital providing all usual forms of hospital care for a local population was accepted. The introduction of motor ambulances in the 1914-1918 war encouraged the transfer of serious cases and by the 1920s it was realized that some forms of treatment, for example radiotherapy for cancer, could not be provided everywhere. University and specialist hospitals were the answer. Continually increasing specialisation has accelerated this process. For example general surgeons gave up orthopaedics and uro-genital surgery. Hospitals had three surgeons, not one. Cancer was largely a matter for the surgeon but now it requires the surgeon, radiotherapist, oncologist - and the MacMillan nurse. To provide a service round the clock one needs five of each specialty, not one. Patients may have better outcomes and leave hospital sooner but the hospital staff multiplies like rabbits. Our more leisured society also affects this. Doctors, many women with family commitments, are no longer expected to work all hours of the day and night. Indeed European Work regulations embargo long hours, even were tired doctors safe doctors. If the staff is not expanded hospitals will not provide good care and other hospitals will need to take over.
Such problems have led to major changes in the organization of the hospital services in the last 30 years. Closure of hospitals does not, in fact, save much money. The patients and the costs go elsewhere. The concentration of work on fewer hospitals that are better equipped improves patient outcomes. A surgeon who specializes in a few operations on average does them better. The hospital where the surgeon works is likely to be better equipped and staffed.
Ara Darzi
The recent report [3] on health services in
The organisational structure of NHS
The organizational structure has changed repeatedly over the last 60 years, sometimes appearing to come full circle. Internationally it seems that good health services can be organized on many principles, for example insurance, central taxation, local authority management and private sector involvement. There is an international turmoil of activity as countries try to deliver that Holy Grail, comprehensive, good, accessible health care at a cost that society can and is prepared to afford. This note deals with the structure we have now.
The passing of the National Health Service Act 1946 provided the legislation for the NHS which came into being on July 5th 1948. The current framework in
Under the 1977 Act, the NHS is essentially split into two parts.
· The provision of health care in hospitals and covers services described as community health services, e.g. services provided by midwives, health visitors and clinics.
· The family health services, i.e. the services provided by family doctors, general dental practitioners, ophthalmic opticians and chemists.
Primary care services (also known as Family Health Services)
Primary care services are provided by general practitioners (GPs), dentists, pharmacists and opticians. The majority of these providers are independent contractors. There are something like 32,000 GPs in
Most GPs are paid to carry out specified duties under a national contract; this is known as the General Medical Services (GMS) contract. From April 2004 there has been a new GMS contract between the primary care trusts and either individual GPs, or partnerships or companies that include GPs. The new contract gives primary care organisations (PCOs) greater freedom to decide how to design their services to best meet local needs. The contract allowed practices to transfer responsibility for providing some services – including out-of-hours care – to their PCO. The negotiation was not the Department’s finest hour for the outcome was an substantial increase in GP pay at the same time as they gave up their out of hours commitment. Government is now trying to recoup the situation.
There is a second contract used by about half the GPs. The NHS (Primary Care) Act 1997 allowed for the establishment of Personal Medical Services (PMS). PMS creates opportunities for practices to work in different ways and to develop services that meet local need. So as well as GMS GPs there are PMS GPs and PMS salaried GPs. A PMS GP is a practitioner who has a contract with the PCT to provide the full range of general medical services (GMS) through a PMS contract. PMS contracted doctors are still independent contractors and have a patient list.
Other PMS doctors work in PMS practices and are the equivalents of assistants and salaried doctors.
It is complicated. Under the current GMS arrangements, there are:
unrestricted principal practitioners who provide the full range of general medical services and their list is not limited to any particular group of people
restricted principals are practitioners who either provide the full range of medical services but whose list is limited, or only provide maternity services and/or contraceptive services
assistants who are fully registered practitioners employed by a principal to act as an assistant
salaried doctors who are practitioners employed by an unrestricted principal (at the discretion of the PCT) under the practice staff scheme.
A GP registrar is a practitioner employed, usually for one year, for training.
Secondary care - NHS trusts
Most people reach hospital by GP referral, though accident and emergency departments, NHS Direct and other pathways are also used. Hospital services are now provided by NHS trusts. These were created in 1991 under the Conservative NHS reforms to manage and provide hospital care, mental health care and ambulance and special services. Trusts are self-governing bodies with their own board of directors. They work within a legal framework that lays down certain financial, quality and partnership requirements. There may be more than one hospital in an NHS trust. Some trusts also act as regional or national centres of expertise for more specialised care, while some are attached to universities and help to train professionals. Trusts can also provide services in the community – for example through health centres, clinics or in peoples’ homes.
Over the last ten years the quality of care has become far more of an issue that it was previously. Trusts have obligations to provide quality of care, as well as obligations to stay within their budgets and meet targets for the speed of treatment.
NHS foundation trusts
NHS foundation trusts began in April 2004. They differ in a number respects, primarily by having a Board of Governors as well as a Board of Directors, the former having the function of representing the interests of the community and of partnership organizations. They have financial freedoms, earned by a record of financial probity
There are now some 96 such trusts. NHS foundation trusts are legally independent organisations called Public Benefit Corporations. The primary purpose of foundation trusts is to provide NHS services to NHS patients. This is set out in the terms of authorisation issued by Monitor, the Independent Regulator. They are not allowed to sell off or mortgage NHS property and resources needed to provide key NHS services. Each Foundation Trust has an individual constitution designed to meet its own circumstances. There is no single formal model and it is government policy to encourage all trusts to become foundation trusts.
NHS foundation trusts are freer from central government control, manage their own budgets and shape the health care services they provide to reflect local needs and priorities. They are inspected by the Healthcare Commission to the same standards as other NHS trusts and have freedom to develop new solutions to long-standing problems such as staff shortages and long waits for certain treatments.
Although run locally, NHS foundation trusts are part of the NHS family. They continue to deliver relevant care for their population, purchased by locally based primary care trusts. They
have freedom to decide locally how to meet their obligations
are accountable to local people, who can become members and governors
are authorised and monitored by Monitor, the independent regulator for NHS foundation trusts.
· Members are able to stand and vote in elections for governors of the trust. Governors will be responsible for representing the interests of the members and partner organizations (e.g. the local authorities) in the local health economy in the governance of the trust.
Primary care trusts (PCTs)
PCTs are responsible for planning and securing health services and for improving the health of the local population and are the main route for the funding or primary and secondary care. They have an inappropriate name for while they provide and commission primary care, they also commission secondary care. There are some 150 PCTs across the country. On average they cover a population size of a quarter of a million. PCTs directly control most of the NHS budget. Often they are roughly coterminous with local authority boundaries, a good thing because the same person often needs services from both. PCTs have responsibility for assessing local health needs and providing a wide range of health care services. These include primary care services and community health services such as district nursing, health visiting and community mental health. What they cannot deliver themselves they commission from other organisations. In the main these will be acute hospital services but also include services from the voluntary and the private sectors. PCTs are also the principle NHS bodies delivering public health services as part of their health improvement function.
The accountable officer for the PCT is the chief executive, who is responsible for ensuring that the PCT carries out its functions in such a way as to ensure the proper stewardship of public money and assets. This includes responsibility for:
The propriety and regularity of the PCT’s finances
The keeping of proper accounts prudent and economical administration
Avoidance of waste and extravagance, and the efficient and effective use of all resources.
PCTs must make sure there are enough GPs to provide care for their population and that primary care services are accessible to patients. They are responsible for the provision of other health services including hospitals, dentists, mental health care, Walk-in Centres, NHS Direct, patient transport (including accident and emergency), population screening, pharmacies and opticians and for integrating health and social care so the two systems work together for patients. They are usually responsible for out of hours GP services.
Strategic health authorities (SHAs)
There are 10 strategic health authorities in
Monitor
The Secretary of State for Health
Delegates responsibility of the NHS to the Accounting Officer of the strategic health authority who is accountable both to the Secretary of State and directly to Parliament. A similar dual accountability role applies to chief executives of strategic health authorities who are responsible both to their boards and, via the accounting officer, to Parliament. The Accounting Officer is responsible for the propriety and regularity of public finances in the NHS; for the keeping of proper accounts; for prudent and economical administration; for the avoidance of waste and extravagance; and the efficient and effective use of all the resources in his charge.
Core principles
Underpinning the NHS is a set of core principles. In 1952 Bevan wrote "The essence of a satisfactory health service is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged." (In Place of Fear, a collection of essays).
Some things have been modified over the years, for example in 1948 the NHS in general owned all the capital stock from which hospital services were provided. Now it is considered more important to provide the services well irrespective of the ownership and management of the plant and personnel. The Department recently expressed the core values as follows:
A universal service for all based on clinical need, not ability to pay.
A comprehensive range of service
To shape its services around the needs and preferences of individual patients their families and their carers
To respond to different needs of different populations
To work continuously to improve quality services and to minimise errors
To support and value its staff
Public funds for healthcare will be devoted solely to NHS patients
To work together with others to ensure a seamless service for patients
To help keep people healthy and work to reduce health inequalities
To respect the confidentiality of individual patients and provide open access to information about services, treatment and performance
Published in July 2000 the NHS Plan was Labour’s ten year policy to “to deliver a health service fit for the 21st century with services designed around the needs of patients and improved health outcomes, particularly for the poorest in our society. “
The result of much consultation, its aims were
more power and information for patients
more hospitals, beds, doctors and nurses
shorter waiting times for hospital and doctor appointments
cleaner wards, better food and facilities in hospitals
improved care for older people
· tougher standards for NHS organisations and better rewards for the best trusts.
It was accompanied by the largest increase in spending that the NHS had seen in 50 years. Time has passed, much has been accomplished and, in some respects, policies have inevitably changed. The growth rate rose to over 7% a year but it is now falling to 4% growth. Sadly the increased money was spent several times over leading to a temporary financial crisis.
The NHS Plan was essentially about increasing capacity but stress was also laid upon “modernization”. This phrase included such things as altering the skill mix of the workforce so, for example, skilled nurses might take over the duties previously undertaken by junior doctors, and radiographers of experience do some things previously done by radiologists. It also involves efficiency, ensuring that patients get all their tests done at one visit and do not travel without reason, and improving the experience of patients by looking at “clinical pathways” so the right thing is done at the right time, all the time.
Subsequently patient choice became an increasingly important policy. This led to diversification of providers, for example independent treatment centres, and the introduction of payment by results.
The Private Sector
While the NHS continues to be sound to its principles, it has moved from being the provider of all NHS services to commissioning, funding, defining and monitoring some that are provided by outside organizations. In fact there is hardly an activity within the NHS that is not now provided in some places by the private sector. Hospitals built under the private finance initiative are built and operated by private consortia. Independent treatment centres offer day surgery under contract to the NHS. NHS Logistics that moves NHS supplies about is now operated by a private company. Many GPs, of course, have always been independent contractors. Even the function of commissioning services is likely to be undertaken by selected firms on behalf of PCTs.
The national priority areas
Over the years the NHS has regularly examined what is being done well and what is poorer. Historically there is a raft of statements about service improvement, for example in the 1960s mental illness and mental handicap services received much attention. (These very names are now out-dated). Hospital building has been a priority and currently computerization is high on the agenda. In the field of health care clinical priorities have changed little in recent years. The Health of the Nation (1992) [5] listed much the same priorities as the white paper ‘Saving Lives: Our Healthier Nation’ of 1999, both covering the major causes of avoidable ill-health and premature death. They include:
· cancer – to reduce the death rate in people under 75 by at least one-fifth
· coronary heart disease, stroke and related diseases – to reduce the death rate in people under 75 by at least two-fifths
· mental health – to reduce the death rate from suicide and undetermined injury by at least one-fifth.
Stress is being placed on smoking cessation, obesity and sexual health.
Key documents are regularly issued that outline what the NHS is expected to achieve. Reconfiguration of the health system and the hospital service is now one of these, and is the subject of the most recent, a report by Lord Darzi, a junior minister and a surgeon of international renown. (See above)
National standards – The National Service Frameworks (NSFs) and NICE
As the NHS has loosened up, new providers have emerged and patients have been encouraged to exercise choice, it has become essential to ensure that national standards are observed. The Healthcare Commission (see below) plays a major role in holding the ring.
A range of measures to raise quality and decrease variations in service were introduced in 1998 by A First Class Service [6]. These include National Service Frameworks. NSFs are evidence-based programmes spelling out what patients can expect to receive from the health service in a major area or disease group. They are implemented as part of trusts local delivery plans and the Healthcare Commission monitors progress. NSFs:
set national standards and define service models for a specified service or care group
put in place strategies to support implementation
establish performance measures against which progress is assessed
National Institute for Clinical Excellence (NICE)
NICE is a national body set up in 1999 as a special health authority to promote high quality of treatment and technology and the effective use of available resources in the NHS. It is the independent organisation providing national guidance on the use of specified medicines and treatments and the care and treatment of NHS patients with specified diseases. NICE tries to avoid treatment being dependent on where you live.
Currently NICE produces three types of guidance:
whether a particular medicine or treatment is recommended for use within the NHS in
the appropriate treatment and care of patients with certain specified diseases and conditions within the NHS in
Whether interventional procedures used for diagnosis or treatment are safe enough and work well enough for routine use – Interventional Procedures Guidance.
How the NHS Works
This section explains key players, their relationships and lines of accountability; how the NHS is financed; how it is planned – the priorities and targets; and commissioning. A major change in the last 15 years has been the separation, within the NHS, of those whose function is to purchase or commission health care, and those whose function is to provide it. This purchaser/provider split has been characteristic of NHS organization recently, and has opened the door for new providers, some in the private sector.
The organization of the health care system
When the NHS began there was an uneven distribution of money spent on health care with the south receiving far more than the north, and cities than the country. GPs were poorly distributed over the country. There were some over doctored areas and other under doctored ones. Much effort has gone into the correction of this, but there is still a disparity in the number, quality and accommodation of GPs in different areas. Conurbations generally do worst. Similarly there was a disparity in hospital services – here the large cities did best in terms of the number and quality of hospitals. Equity being a corner stone of the NHS – we are all tax payers - many mechanisms have been used to improve this. Under Labour, the Resource Allocation Working Party [7] started the process of moving money to the north. Most new medical schools have been placed in areas with deficient services for doctors tend to practice in the area in which they have trained.
Accountability
There has always been, and currently is, active debate about how far the NHS could be “freed from political interference”. However ultimately the NHS is funded by the taxpayer. This means it is accountable to parliament. So, currently with the exception of NHS foundation trusts it is managed by the Department of Health which is directly responsible to the Secretary of State for Health, currently Alan Johnson. Some political parties would consider changing this.
Parliament
The Parliament in
The Secretary of State for Health
The Secretary of State for Health is a member of the Cabinet and has overall responsibility for the work of the Department of Health. He works together with a group of ministers for health and the Permanent Secretary and NHS Chief Executive.
Department of Health
The Department of Health’s purpose is to support the Government to improve the health and well being of the population. It is responsible for modernising the NHS and social care as well as improving standards of public health.
The focus of its role is:
setting overall direction and leading transformation of the NHS and social care
setting national standards
securing resources and making major investment decisions to ensure that the NHS and social care have the capacity to deliver
working with key partners to ensure quality of service such as the strategic health authorities, the Healthcare Commission and the CSCI.
Special health authorities and other bodies
There are a number of special health authorities and other bodies which are either part of the NHS or closely associated with it. They include the National Institute for Clinical Excellence (NICE), the Health Protection Agency HPA) and Prescription Pricing Authority. These organisations are either accountable to the Secretary of State, or have formal agreements with the Department of Health. In general they provide national services.
Buildings
The quality of NHS premises has long lagged behind those of other countries. In recognition of this a major building programme started with Enoch Powell’s Hospital Plan (19620 [8] and has been accelerated in recent years. It affects both the hospitals and primary health care. It has been largely financed not as previously directly by the Treasury, but by the Private Finance Initiative (PFI), or public-private partnership. This has meant that NHS building costs do not fall on the normal government balance sheet, but that the NHS is essentially leasing buildings that are designed, built and operated by the private sector. While there are some advantages in using the experience of the private sector in getting hospitals built rapidly, the ultimate cost can be high and it may be difficult to change buildings as requirements change. Many trusts will be financially challenged by PFI contracts over the coming years.
Staff
The NHS is a massive employer with some 1.3 million staff in the
Because the NHS is virtually a monopoly employer, and because in spite of student fees the state pays much of the cost of educating doctors and nurses, government has always been involved in deciding the numbers in training, attempting to match training places to the likely requirements of the NHS. Only too often it has got the numbers wrong because it takes about 15 years to train a consultant and 4 years or more a nurse. Demands change over this period and changing demands require changing staff skills. Modernising Medical Careers – improving the way doctors are trained to become specialists or GPs is the latest in many attempts over the years to match training to new clinical requirements. It has run into substantial difficulties. For nursing, the Department of Health and the Nursing and Midwifery Council are both consulting on modernizing nurse education – a follow-up to Project 2000 a decade ago. The Agenda for Change, concerned with other staff groups, has probably been more concerned with pay and grading than professional development, but new clinical needs are part of that as well.
NHS Foundation Trusts generally have powers to agree such pay, terms and conditions, as they think fit for their staff. However in practice, the majority of NHS staff are employed on terms and conditions negotiated at national level between the Department of Health, trades unions and NHS employer representatives. The Department of Health has devolved future much responsibility for such negotiations to an NHS employers’ body. Consultants’ pay is still determined by an independent review body.
A major new pay system, Agenda for Change, covers almost all staff other than doctors and dentists. It is designed to ensure equal pay for work of equal value, to facilitate service re-design and to support recruitment and retention.
The NHS is funded largely through taxes levied by the Government. The total cost in
How the money is allocated
The way in which resources are allocated is constantly being refined. PCTs are allocated revenue funds directly from the Department of Health. Revenue funding is allocated on the basis of the relative needs of their populations. A weighted capitation formula is used to determine each PCT’s target share of available resources, to enable them to commission similar levels of health services for populations in similar need. The current formula has the following components:
Hospital and community health services
HIV/AIDS
GP practice infrastructure, e.g. practice staff wages, premises and equipment
general practice prescribing
GP remuneration.
The components of the formula are used to adjust each primary care trust’s “crude” population according to their relative need (age and additional need) for health care and the unavoidable geographical differences in the cost of providing healthcare (market forces factor).
The weighted capitation formula is regularly reviewed. The majority of a PCT’s funding is on the basis of a recurring allocation made at the start of the financial year. The vast majority of the revenue funding is
channelled to the front line via unified allocations. These are cash limited. The rest of the funding is for family health services and is non-cash limited
Capital funding systems are changing to one of interest bearing debt and Trusts will have a borrowing limit. Operational capital is allocated to all NHS trusts and PCTs. The funding is provided to maintain and enhance existing capital stock and fund small to medium sized developments. The allocation of operational capital to PCTs and NHS trusts is based on their level of depreciation.
How the money is divided up
Virtually all of the revenue allocation is spent on day-to-day running costs such as staff pay and drugs with some small proportion going on capital expenditure, used to purchase new equipment and buildings and to refurbish existing assets.
Where the money is spent
The health service is staff intensive and more than half the NHS More than 50% of the money is spent on acute services – medical and surgical care in hospital. 12% is spent on mental health services, 10% on services for the elderly, 5% on people with learning disabilities and 5% on maternity services. Health care for people over 65 years old accounts for around 40% of the total expenditure.
Financial duties of PCTs
The financial duties of a PCT are:
to remain within its cash limit
to maintain operational financial balance and remain within its capital and revenue resource limits to demonstrate that it achieves full cost recovery, in relation to its provider functions. This will ensure consistency and transparency in costing services throughout the NHS
to pay capital charges on its assets
to achieve a target of paying 95% of non-NHS creditors within 30 days of receipt of valid invoice.
Finance for NHS Trusts
NHS trusts get most or their income from PCTs on the basis of the care they provide. A small percentage of their income is from private health care. They also receive funding to provide training for health professionals and benefit from income-generating schemes such as shops and car parking. NHS trusts have to break even. If a trust fails to do this it may agree a recovery plan with the strategic health authority.
Changes to the flows of money
Recently there have been changes to NHS ‘financial flows’ with trusts being paid a standard national tariff for the activity they undertake in a given year on a cost per case basis. Trusts whose costs are above national averages need to make efficiencies to enable them to break-even. This system is known as payment by results (PbR) though in fact it is payment by activity. Practice based commissioning, in which contracts are set by groupings of general practitioners, is having an increasing effect as all PCTs are expected to have schemes in place. Patient Choice is increasingly enabling the patient to choose the provider at the time of referral. All these changes impact on the way funds flow around the NHS and the financial wellbeing of hospitals.
Planning within Trusts has been improved by better financial information and Trusts should now know how money is allocated to each specialty and whether it is in profit of deficit on specific specialty activities.
PCTs as the lead planners are responsible for creating local plans that describe health and service improvements in their area. These are developed using clinicians’ knowledge as well as patients’ and the public’s contributions. They incorporate the national priorities
each NHS trust is responsible for creating its own plan which shows how it will deploy its resources to deliver on both national and local priorities and fit within the plan of its PCT commissioners
The SHA's create the workforce plan as part of the local delivery plan
Strategic health authorities bring together the PCT plans into a comprehensive local delivery plan for their area
Local delivery plans identify expected progress or milestones for each priority area over the three-year period. They identify quarterly or annual milestones and in a small number of critical deliverables they may show planned progress on a month by month basis. Local delivery plans are supported by a financial strategy and plan that takes account of the changes to the financial system during the three year period and shows how resources are to be deployed and value for money achieved. The local delivery plan covers a whole strategic health authority area but is based on PCT level plans. It is a “live” document that is amended with, for example, corrective action taken if delivery goes off course and any new initiatives which are taken when the opportunities arise.
Commissioning
Commissioning involves identifying the health needs of the target population and working with providers of health services to develop a service to meet those needs. The majority of commissioning decisions are undertaken by PCTs. Contracts can range from large contracts for acute care from hospitals to small contracts with voluntary sector providers. Joint commissioning brings together the PCTs and social care services in the strategic planning and development of services. It uses resources for commissioning collaboratively to get the best outcomes for local people.
Specialised services commissioning
Better results are usually obtained for rarer conditions if the patients are concentrated in centres with particular expertise. Not every district general hospital can have an ENT or an ophthalmic service, let alone cardiac surgery and radiotherapy. Such specialised services are generally of high cost services, but with low volume use. For example services for rare cancers, are provided from a small number of centres and commissioned by PCTs working together.
Out of area treatments (OATS)
Out of area treatment arrangements cover those situations where an individual is admitted to a hospital away from home, usually as an emergency where there is no pre-arranged service level agreement in place. Funding for these ad hoc cases is built into the host PCT’s service agreement with their local hospital(s).
Monitoring, inspecting and regulating the NHS
The more that freedom is granted to local management, the more it is desirable to have an inspection and regulation system, particularly when one wishes there to be a measure of equity across the system as a whole.
The arrangements for monitoring and performance management in the NHS are that:
each organisation has its own system for monitoring service delivery and trusts certify compliance to the Healthcare Commission
PCTs hold provider organisations to account for the delivery of services which they have commissioned
with the exception of Foundation Trusts, SHAs hold all NHS organisations to account for performance
· With the exception of Foundation Trusts, the Department of Health holds the strategic health authorities to account for the performance of the NHS within their area.
In the case of Foundation Trusts Monitor is the economic regulator and has a strict compliance regime. Quality is regulated by the Healthcare Commission (to be amalgamated with other bodies as the Care Quality Commission (Ofcare) in 2009).
Strategic health authorities routinely collect data from the NHS trusts and PCTs in their sector on their performance against key Government targets. The strategic health authority tracks the trusts’ performance and monitors any lapses. For example, the number of patients who wait more than they should for an outpatient appointment; the percentage of patients who are not seen within four hours in A&E; the number of patients who are able to access a GP within 24 hours. The strategic health authority works with NHS trusts and PCTs that are not meeting the targets to improve their performance.
Membership of PCT and NHS trust boards
Boards are governing bodies of organisations; they decide the overall strategic direction of the organisation and make sure it meets its statutory financial and legal obligations. A board has a chair, executive and non-executive directors.
An NHS board has a duty to:
adopt and maintain Standing Orders (SOs)
adopt and maintain Standing Financial Instructions (SFIs)
adopt and maintain the codes of conduct, accountability and openness
decide which decisions need to be reserved for the board
agree a scheme for delegating authority from the board to directors and officers (Scheme of Delegation)
appoint an audit committee and a terms of service remuneration committee.
The only body that undertakes a full inspection of NHS organisations is the Healthcare Commission
The Healthcare Commission, established in 2002 and to cease in 2009, is the independent inspection body of the NHS. It monitors how standards that are set by the Government, through its health policies, National Service Frameworks, and clinical guidance provided by the National Institute of Clinical Excellence (NICE), are being met. It:
reviews health care organisations in the NHS every three or four years (clinical governance reviews)
investigates serious service failures
reports on key issues, such as coronary heart disease and national service frameworks
assesses and reports on performance in the NHS (star ratings)
publishes data on staff and patient surveys
jointly inspects with other bodies
manages the clinical audit programme.
register and inspect private healthcare provision
conducts NHS value for money studies
validates and publish performance assessment information and statistics on the NHS, including waiting list information
publishes performance ratings for all NHS organisations
publishes reports on the performance of NHS organisations both locally and nationally
independently scrutinise patient complaints, and
publishes an annual report to Parliament on national progress on healthcare and how resources have been used.
inspects NHS foundation trusts and report its findings to the independent regulator, recommending special measures where it has serious concerns about the quality of services provided.
The Commission is due to be integrated into a "super-regulator", the Care Quality Commission, in 2009.
Audit Commission
The Audit Commission is an independent body responsible for ensuring that public money is used economically, efficiently, and effectively. Its function is the audit of local authority and NHS bodies. It is responsible for appointing external auditors to audit financial statements and to carry out reviews of governance arrangements and performance in all local authorities, strategic health authorities, trusts and other public bodies such as the police and fire authorities. In the course of producing its national studies it may send out questionnaires to collect data and visit a sample of NHS trusts. The Audit Commission may act as auditor for Foundation Trusts.
References
1 From Cradle to Grave, 50 years of the NHS. Rivett G.C. 1998,
2 The National Health Service. 1948.
3 A Framework for Action. Lord Darzi. 2007. Healthcare for
4 The NHS Plan, A plan for investment, A plan for reform 2000, London HMSO
5 The Health of the Nation. A strategy for health in
6 A First Class Service – Quality in the new NHS. Consultation document, 1998,
7 Sharing Resources for Health in
8 National Health Service. A hospital plan for
