The Chief Executive of the NHS, Sir David Nicholson, wrote to all the NHS Trusts yesterday to explain more about how the NHS in England will be changing over the next three years. His letter includes a timetable for the changes.
These changes are focussed on improving outcomes, on improving the quality of NHS care — care which currently results in a accelerating avalanche of complaints from patients and from the relatives of deceased ex-patients.
From page 4 of the letter :
…it is critical that we do not lose sight of what that system is designed to achieve…to drive improvements in health outcomes.
Outcomes were the subject of my last post: Outcomes
The trouble with the present system of complaints in the NHS is that most of the complaints are absorbed by the bureaucracy. Although they often improve matters for the individual patients who complain, they don’t so often change the NHS for the better. They don’t improve outcomes generally. The Government has plans to remedy this.
From the Health and Social Care Bill 2011 combined impact assessments (page 90):
…there is a lack of exchange of information: on some occasions views from patients are not sought, not shared appropriately, or do not influence behaviour of some health and care professionals. In particular,…there are no ways of ensuring those views lead to changes that better meet patient/public need.
In a report published a few days ago, the Parliamentary and Healthcare Ombudsman highlighted ten dreadful cases in which the NHS had failed elderly patients: Care and compassion?
What they have in common is their experience of suffering unnecessary pain, indignity and distress while in the care of the NHS…
It is incomprehensible that the Ombudsman needs to hold the NHS to account for the most fundamental aspects of care: clean and comfortable surroundings, assistance with eating if needed, drinking water available and the ability to call someone who will respond.
This is the tip of an iceberg. It’s not that the Ombudsman investigated all of the 152,000 formal complaints a year made against the NHS and found only ten that were worth mentioning. The Ombudsman only investigates a tiny fraction of the complaints that are made.
Many of the NHS’s failures don’t result in any complaint at all, and many more are talked away with an apology or an excuse about funding. Only a few thousand a year ever reach the Ombudsman, and of those only a very few can be investigated. So ten cases of serious failings are an indication of widespread problems.
In mental health, although IAPT is resulting in some improvement, too many NHS staff still think it’s OK to play amateur psychotherapist while only being qualified as something else. Too many of those who are actually qualified as psychotherapists only have academic theories to show for it, so that they struggle with basic practical skills. A focus on outcomes will change this culture of failure.
Government plans will make patients central in driving the NHS to improve its outcomes. From Sir David Nicholson’s letter again:
In order to make these improvements a reality,…empower patients by expanding access to information, extending the range and nature of patient choice, and designing clinical services to suit patient needs.
Some of the old theories about healthcare have been shown to be wrong.
Regulation of healthcare professionals was meant to ensure that the public could rely on them, but regulation of doctors and nurses has not protected patients from neglect. Instead, it has led to a false sense of security in which sub-standard care continues unchecked in more than a few places. So Government plans no longer include wasting more money on central bureaucratic regulation schemes.
From the Department of Health command paper Enabling Excellence (page 8):
…an end to the assumption that national statutory action should be the first resort in dealing with risks arising from professional activities or concerns that happen locally.
…the risks posed by individual failings are often most effectively and quickly mitigated by timely local action and effective leadership by senior health and social care professionals.
NHS managers were meant to be professionals who would do a better job of managing the NHS than doctors could, but instead they spent more and more of the money on themselves, on other managers, and on management consultants. So layers and layers of managers are being removed, and in future, senior NHS managers will face penalties when there are serious failures of patient care.
From Enabling Excellence again (page 18):
The Government recognises the strong public, patient and professional concern about instances where senior managers who have let people down appear to have avoided significant consequences for their actions and that a stronger assurance mechanism is needed.
The old theory about complaints was that they would mostly be resolved locally. The Ombudsman was meant to be a last resort in a very few complex cases. Instead, the whole complaints system is creaking under the strain of so many complaints, and the Ombudsman is completely snowed under. This is happening because complaints are being dealt with only by the NHS bureaucracy itself, and the bureaucracy resists change.
So Government plans include making it easier to resolve complaints locally in a way that leads to real improvements in care. Supervision of both health care and social care will be in the hands of local councils, which will oversee the work of both the NHS and social services (building on their existing Health Overview and Scrutiny Committees).
From the Health and Social Care Bill 2011 combined impact assessments again (page 92):
Each local authority will have to establish a health and wellbeing board covering health, public health and adult social care. The board will…ensure that feedback from patients and service users can be reflected…
Ordinary people — patients, carers, relatives — will be able to contribute to their local council’s supervisory role through a new, independent, local organization known as HealthWatch, which will be created by each council for this purpose (building on the Local Involvement Networks that already exist).
From the Health and Social Care Bill 2011 itself, 167(3)(1), amending the Local Government and Public Involvement in Health Act 2007:
There is to be a body known as a Local Healthwatch organisation for the area of each local authority…
Choice and control
In cases where the NHS is failing to provide adequate care, patients will have two options. One is to exercise choice by getting care from somewhere else. The other is to exercise control by complaining about the failing service.
No one can make choices without knowing what’s available. Information is essential. Previously, information was provided by the NHS itself. PALS in every NHS region was meant to provide this service.
But PALS is not independent. So PALS will be replaced with an independent information service run by the local council. It might actually be the same people, sitting at the same desks, but they’ll have new freedom to help patients make realistic choices from their new position outside the NHS management structure.
Exercising control over the NHS by making complaints is not easy. At present an advocacy service, ICAS, helps patients to make complaints. It’s a national service, so it’s independent of the local NHS.
But although ICAS is independent, it too rarely gets into the details of what needs to be changed locally to improve NHS care. So ICAS will be replaced with a complaints advocacy service run by the local council. The council might choose to appoint one of the old ICAS providers to do the work, and again it might be the same people sitting at the same desks, but they’ll have new incentive to help patients improve local standards of NHS care.
Local councils will be able to integrate information, advocacy and supervision of healthcare and social care in a single service operated by their local HealthWatch if they feel that’s best.
Although all this seems quite complex, it’s not revolutionary. Rather, it’s a subtle shift of power away from central government and towards local councils and individual patients.
GPs and the NHS Trusts that deliver healthcare remain pretty much as they are. The behind-the-scenes NHS primary care trusts and health authorities, which mainly had management roles and didn’t provide much actual healthcare, will disappear. The money saved by getting rid of those managers will be available within the NHS for patient care.
GPs will control the NHS’s local budget indirectly through consortia, which will give local GPs a huge say collectively in how NHS money is spent, without making individual GPs responsible for decisions about funding.
Information about the choices available to patients will become independent of the NHS.
Help with making complaints will become a local service, remaining independent of the NHS.
The NHS, along with social services, will be supervised by local people and by the local council through their HealthWatch.
HealthWatch and the council will be able to make change happen locally when standards of NHS care are inadequate. The NHS bureaucracy will not be able to stonewall them the way they can individual complainants in the current system. It won’t take a national scandal to force change as it does now.
This is a plan that will virtually put the Ombudsman out of a job, if it works. As things are now, she can only point at the tip of the iceberg in order to warn everyone when there’s danger. In future, effective independent local advocacy services should make it much easier for patients to make real choices about their own care and to make complaints that result in real change.