Health Service Care
- Literature Review
2.1 INTRODUCTION
In 1948, the Health Minister, Aneurin Bevan, established the National Health Service (NHS), as a free, comprehensive health care service, available to the entire population. At present, the NHS can be divided into two sections: one dealing with strategy, policy and managerial issues; and the other dealing with all clinical aspects of care. The latter can be further divided into primary care (at the frontline, involving GPs, pharmacists, dentists etc), secondary care (hospital based, accessed via GP referral) and tertiary care (involving highly specialised doctors dealing with particularly difficult or rare conditions). The divisions between these sectors are becoming less distinct, with structural changes taking place within the NHS. In particular, the organisation is moving towards local decision making, breaking the barriers between primary and secondary care and enabling greater patient choice. Information on these reforms can be found in the document shifting the Balance of Power.
- History of NHS:
The fifth decade opened with widespread uneasiness about the NHS. Younger people were cynical about whether they could rely on the NHS; older ones thought that many things had been better in the past. Hospital throughput had risen and new radical treatments demanded great stamina of patients. Evidence-based medicine, clinical effectiveness and medical audit were to the fore, internationally as well as in the UK.
Before the 1990 Act a monolithic bureaucracy ran all aspects of the NHS. After the establishment of the internal market and the purchaser-provider split, 'purchasers' (health authorities and some family doctors) were given budgets to buy health care from 'providers' (acute hospitals, organisations providing care for the mentally ill, people with learning disabilities and the elderly, and ambulance services). To become a 'provider' in the internal market, health organisations became NHS trusts, independent organisations with their own management, competing with each other. The first wave of 57 NHS Trusts came into being in 1991. By 1995, all health care was provided by NHS trusts.
The last decade has seen some major changes in the structure and the working of NHS Trusts. 10 Downing Street became involved in the NHS as never before. Organisational turmoil characterised the decade, with the formation, dissolution and rearrangement of the structure and responsibilities of NHS authorities and trusts, and the appearance of a new type of body, the NHS Foundation Trust. Ultimately the organisation consisted of 10 strategic health authorities controlling primary care trusts that contracted with provider trusts, hospitals, community, mental illness and ambulance, as well as managing GPs and primary health care. In parallel new systems of financial flow, payment by results and a tariff system brought instability to the finances of the NHS.
There was a drive to increase capacity and reduce hospital waiting lists. Labour decided that while the NHS was a service provided to all without payment, provision would not necessarily be by a publicly owned infrastructure. Private sector organisations came to build and operate hospitals under PFI, and run clinical services such as Independent Treatment Centres and some NHS Walk-in Centres. "Contestability" - i.e. the introduction of competition between providers, became significant. Private practice was first discouraged and then made an important part a new and more sophisticated market wide open to the private sector.
2.3 NHS Foundation Trusts:
NHS Foundation Trusts are a new type of NHS organisation, established as independent, not for profit public benefit corporations with accountability to their local communities rather than Central Government control.
The introduction of NHS foundation trusts (often referred to as “foundation hospitals”) represents a profound change in the history of the NHS and the way in which hospital services are managed and provided. The shift of accountability from central government means that local communities and staff are being given a bigger say in managing NHS services in their area. NHS foundation trusts remain fully part of the NHS. They have been set up in law under the Health and Social Care (Community Health and Standards) Act 2003 as legally independent organisations called Public Benefit Corporations, a new kind of organisation based on mutual traditions. Their primary purpose is to provide NHS services to NHS patients according to NHS principles and standards. The public still experience healthcare according to core NHS principles - free care, based on need and not ability to pay. The first NHS foundation trusts have been up and running since 1 April 2004 with Trusts coming on-stream on that date and at regular intervals thereafter. NHS foundation trusts establish stronger connections between local hospitals and their local communities. Local communities have social ownership of their NHS foundation trust. Those living in communities served by a hospital of an NHS foundation trust will be invited to become a member. The membership community of each NHS foundation trust is made up of local people, staff, patients and their carers. To strengthen links with the local communities NHS foundation trusts also have representation from primary care trusts, local authorities and the University where the NHS foundation trust hospitals include a medical or dental school. In addition, the NHS foundation trust can designate one or more organisations as ‘partner organisations'. Members are able to stand and vote in elections for governors of the Trust. Primary care trusts, local authorities, universities and partnership organisations are all entitled to appoint a governor to the board. These governors are appointed directly by the organisation and not the trust. Governors are responsible for representing the interests of the members and partner organisations in the local health economy in the governance of the NHS foundation trust. This sort of social ownership and accountability ensures that hospital services more accurately reflect the needs and expectations of local people.
NHS foundation trusts have been set free from central Government control, manage their own budgets and are able to shape the healthcare services they provide to better reflect local needs and priorities. NHS foundation trusts have freedom to develop new solutions to long-standing problems such as staff shortages and long waits for certain treatments. NHS foundation trusts do not work in isolation. They are bound in law to work closely with other organisations in their local area. Health care planning continues to involve the whole NHS community and social care partners, but there is more freedom to develop innovative arrangements between all providers. NHS foundation trusts continue to be inspected by the Healthcare Commission to the same high standards as all other NHS hospitals.
- NHS Foundation trust core principles
NHS foundation trusts are new legal entities - Public Benefit Corporations. These are based on mutual principles giving local ownership and greater involvement of their local communities through their links with their members and their partner organisations. Local people, staff, patients and their carers are able to become members of their local NHS foundation trust. NHS foundation trusts will be different from existing NHS trusts in three important ways. They:
• have new freedom to decide locally how to deliver services;
• are accountable to local people, who will become members, governors and non-executive directors;
• are authorised and monitored by Monitor, the Independent Regulator for NHS foundation trusts. NHS foundation trusts will remain part of the NHS. They are required by law to:
• maintain high national standards for NHS services;
• deliver NHS services to NHS patients free at the point of use;
• treat patients according to need, not ability to pay;
• work in co-operation with other health and social care partners.
The primary purpose of NHS foundation trusts is to provide NHS services to NHS patients in England and this will be set out in their terms of authorisation which is determined by the Independent Regulator. NHS foundation trusts are prevented from selling off or mortgaging NHS property and resources needed to provide key NHS services.
2.3.2 Governance arrangements
NHS foundation trusts will strengthen local ownership of - and responsibility for - hospital services. Decisions will be taken by the trust with local communities for local communities. Residents in areas served by an NHS foundation trust, including patients and their carers, with an interest in the wellbeing of their local hospital will be invited to register as members of the organisation. NHS foundation trusts may also allow for people living outside of the area served by the NHS foundation trust, to become members. Members of NHS foundation trusts will not receive any special treatment as NHS patients. They will have the same access to NHS services as anyone who chooses not to become a member. All NHS foundation trust members can expect to receive regular information about their local Trust and be consulted on plans for future development.
Members will be able to vote in elections to the board of governors of the NHS foundation trust. They will also be able to stand for election as governors, and
public and patient members will be eligible to be appointed as non-executive directors on the board of directors provided that they meet the criteria. The board of governors will be responsible for representing the interests of the local community in the strategic planning and stewardship of the NHS foundation trust, and for communicating with other NHS foundation trust members. The board of governors will not be responsible for the day to day management of the organisation e.g. setting budgets, staff pay and other operational matters - that will come under the auspices of the board of directors. The board of governors will however enable local residents, staff and key stakeholders to influence decisions about spending and the development of services. The board of governors will also appoint the chair and non-executive directors of the board of directors.
It will be up to each individual NHS foundation trust to determine the detail of the arrangements for the membership and the composition of the board of governors, within certain parameters. In particular, there must be fair and transparent elections. Governance arrangements will ultimately be tailored to the individual circumstances of each trust, reflecting the range of diverse relationships with patients, the local community and other stakeholders. NHS foundation trusts will be allowed some local flexibility over the exact composition of their board of governors. However, every board must have:
• a majority of governors elected by members of the public - that is members of the public constituencies and the patient constituency, if there is one;
• at least three governors elected by staff members;
• at least one governor appointed by local primary care trusts;
• at least one governor appointed by local authorities in the area;
• at least one governor appointed from the local university if the trust's hospitals include a university medical or dental school. The Chair of the NHS foundation trust is not a governor but will preside at meetings of the Board of Governors.
2.3.3 Becoming an NHS foundation trust member
Eligibility for membership of an NHS foundation trust will be open to local residents, patients and carers and staff employed by the trust, in the terms provided in each trust's constitution. The constitution may provide additional eligibility criteria for membership and this would typically include a lower age limit, and exclusions for anyone involved in any act of violence against staff or other members of the Trust or anyone identified as a vexatious complainant. Individual NHS foundation trusts may provide for people who live outside the area to be eligible for membership. There will be no limit on the number of people who can register as members, providing they meet the eligibility criteria.
2.3.4 Monitor
The Independent Regulator, Monitor, is directly accountable to Parliament. Every NHS Foundation trust will have an authorisation - like a ‘licence' to operate- issued by Monitor. The terms of authorisation will set out the conditions under which an NHS foundation trust will operate and will cover such things as:
• a description of the health goods and services that a trust is authorised to provide;
• a list of goods and services that a trust is required to provide to the NHS in
England;
• a requirement to operate to high standards, based on the national standards for healthcare against which the Healthcare Commission will inspect;
• the circumstances in which major changes to services (for example, in response to a changing local population) need to be discussed locally and agreed by Monitor;
• a list of assets such as buildings, land or equipment that are designated as
‘protected' because they are needed to provide required NHS services;
• limits on the amount of private work an NHS foundation trust can carry out.
NHS foundation trusts will be subject to strict limits on private patient work based on the proportion of private work carried out in the year to 31st March
2003. If NHS foundations trust wishes to treat more private patients, it will need to treat more NHS patients first. This will ensure that NHS foundation
trusts continue to focus on NHS work;
• the amount of money an NHS foundation trust is allowed to borrow;
• the financial and statistical information an NHS foundation trust is required to provide.
Like all other NHS bodies, NHS foundation trusts will be inspected against national standards by the Healthcare Commission. Monitor will receive copies of inspection reports and decide whether action is needed in the event of failings. Monitor has issued a Compliance Framework which outlines the process he will use for monitoring each NHS foundation trust to ensure that they do not breach the terms of their authorisation. This is based on the fact that the main responsibility for ensuring that NHS foundation trusts comply with both their authorisation and all statutory obligations rests with the board of directors. The role of Monitor is designed to give NHS foundation trusts the freedom to deliver services to meet local needs while safeguarding the interests of NHS patients. Monitor adopts a risk based approach to regulation where the level of monitoring is based on the risk of the NHS foundation trust breaching their authorisation. In normal circumstances Monitor will have no reason to intervene in the running of an NHS foundation trust. However, if an NHS foundation trust significantly breaches the terms of its authorisation, or finds itself in difficulty, Monitor has the power to step in to resolve the breach. Monitor has a range of intervention powers, including powers to:
• issue warning notices;
• require the NHS foundation trust, its board of governors or its directors to take certain actions;
• suspend or remove members of the board of governors or the directors of the Trust. In the most serious cases, where intervention by the Independent Regulator could not resolve the breach, an NHS foundation trust could be dissolved. If this ever were to happen, the Health and Social Care (Community Health and Standards) Act 2003 provides mechanisms to ensure that NHS patients continue to receive high quality treatment.
2.3.5 Rewarding results, encouraging growth
Historically, hospital funding has been dependent on the negotiating skills of individual hospital managers in agreeing service levels in block contracts. From April 2005 a fairer, more open financial system of payments by results was introduced across the NHS.
The new financial system will:
• reimburse hospitals fairly for the services they deliver;
• reward efficiency and quality;
• ensure services are developed in line with local need;
• give patients more choice about where they are treated;
• allow funding to ‘follow' a patient if they decide to be treated in another hospital.
NHS foundation trusts enter into legally binding agreements with local Primary
Care Trusts who will buy locally relevant services for the population served by the trusts. These contracts will set out the number and type of services NHS foundation trusts will provide. If an NHS foundation trust wants to change its services, it must consult the NHS primary care trusts that pay for those services. If the services it wishes to change are classified as essential NHS services which the trust is required to provide under its terms of authorisation, then the NHS foundation trust must obtain the agreement of the Independent Regulator. Should the proposed change in services amount to a substantial development or variation in the provision of the health service then the NHS foundation trust must ensure that persons to whom those services are being or may be provided are directly or through representatives consulted. The Local Authority (Overview and Scrutiny Committee Functions) Regulations 2002 impose an obligation on local health service bodies to consult with the Overview and Scrutiny Committee on any proposal for a substantial development or variation in the provision of the health service within the committee's area that the health service bodies have under consideration.
2.3.6 Borrowing for growth, protecting NHS assets
NHS foundation trusts will have freedom to decide locally the capital investment needed in order to improve services and increase capacity. They will be able to borrow to support this investment, as long as they can afford it, without needing to seek external approval. Access to the Private Finance Initiative and to public capital for major schemes will continue. The amount they can borrow will be determined by a formula - the Prudential Code - directly linked to their ability to repay the debt from the revenue they raise. Each NHS Foundation trust will calculate their borrowing limit based on this formula. The limit for each NHS foundation trust will be set out in their authorisation and will be subject to annual review by Monitor. Against this borrowing limit, NHS foundation trusts will be allowed to raise finance to build new facilities and improve existing ones. They will be able to borrow money from the Government and from private sector lenders.
As part of the terms of authorisation issued by Monitor, NHS foundation trusts will be required to provide essential NHS goods and services including teaching and research. The property owned by the NHS foundation trust that is needed to continue to provide such ‘required' services will be designated as ‘protected' by Monitor. In this way, patients can be sure that NHS foundation trusts will continue to be able to provide the NHS services that are needed and commissioned locally. Land, buildings and other assets which are ‘protected' in this way, as part of an NHS foundation trust's authorisation, cannot be sold or leased or used as security for borrowing.
2.3.7 Pay and conditions
Like other NHS organisations NHS foundation Trusts will issue new contracts based on the new NHS pay framework Agenda for Change. As part of Agenda for Change, NHS job roles are formally assessed and put into an agreed pay band, ensuring staffs are rewarded fairly for the skills they have and the work they do. Achieving NHS foundation trust status will not affect the continuity of service of staff. Staff working in NHS foundation trusts will have full access to the NHS pension scheme and other NHS benefits. NHS foundations trusts will be able to develop a range of local initiatives. They will be encouraged to create new types of jobs, new ways of working and more flexible shift patterns to meet local needs and will have the freedom to develop innovative reward packages to retain and attract staff. Most NHS foundation trusts will use these freedoms sensitively to avoid destabilising the local health economy.
2.4 Qualifying for NHS foundation trust status
To be eligible to apply for foundation status, NHS organisations must:
• be an acute, specialist, mental health NHS Trust, or care trust (in the future foundation status may be available to other types of NHS trusts);
• hold a three or two star rating in the annual NHS performance ratings and maintain this throughout the application process;
• prove that they have strong leadership and a commitment to modernising services for the benefit of patients and local communities;
• have the support of staff and other local stakeholders for their vision for reform.
2.5 Application for NHS Foundation Trust status
The applications process for NHS foundation trust status comprises of two distinct phases:
(i) Department of Health development stage; and
(ii) Monitor authorisation stage.
Applicants in the DH stage are asked to develop an integrated business plan that sets out:
• the vision for the new organisation in a five year business plan. This must complement the local health community's vision;
• proposals for their governance arrangements (e.g. membership arrangements, size and composition of the board of governors and board of directors etc);
• the proposed human resources policy.
At the end of the development stage, the Secretary of State for Health will consider the proposal against set criteria, alongside evidence of relevant and inclusive consultation. She will then indicate whether she supports the application.
Once the Secretary of State has given her support, applicants will be asked to submit an application for an authorisation to Monitor. The final decision on whether an organisation can be established as an NHS foundation trust rests with Monitor.
We provide a professional essay writing service that thousands of our customers use as an effective way of improving their grades, improving their research and saving them lots of time.
