In this paper we are going to discuss about how the nhs is facing the different types of challenges and the various changes which are approaching. In reaction towards our concern regarding the present and possible injure of market reforms and also it provide high-quality, complete healthcare for everyone, without charge at the point of use.
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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.
Challenges faced by NHS:
During the first programme of this three-part series Gerry Robinson seems to be struggling to make sense of some of the apparent complexities that are causing stagnation and feelings of negativity throughout the hospital system. What needs to shift in order for some simple things to happen? How can patient waiting times be brought under control if everything drifts on in the way that it always has? Who is managing the system?
Although these problems seem to be specific to the hospital in which the series has been recorded, there are features that may well be generalised throughout the NHS. In his attempt to understand what is going on within this hospital in Rotherham, Gerry has discovered that there are powerful interest groups involved in running the organisation. Surgeons and anaesthetists in the operating theatres and clinical consultants in the paediatric department seem to be pitted against the managers when it comes to attempts to implement change. Initially members of these powerful groups seem keen to protect their own interests and defend the status quo.
However, it is not as simple as a battle between potentially competing interest groups. In each of these groups Gerry has identified individuals who do not conform to type. Within each group there are people prepared to use their personal energy to advocate change, and who have developed ideas for improving the system. Gerry seems to sniff them out and let them have their say. These ‘champions’ need encouragement and rewards for bringing about change. But there are also individuals who tend to block every suggestion and spread feelings of negativity.
Are the situations and complex problems that Gerry Robinson has uncovered deep within Rotherham General Hospital unique to that organisation, or are they typical of what happens throughout the NHS and within all large organisations? Obviously the individuals who were brave enough to be recorded going about their work in the bowels of the hospital are unique. But I found myself stimulated by the programme to think how similar the problems faced by the people featured in the series were to those I encounter in every corner of the NHS. In my experience of working in the NHS it does seem difficult to change things for the better.
The dead weight of routine and ‘usual practice’ can suppress innovation and squash the energy out of people of good will who are committed to finding ways of improving the system. It is too easy to say that ‘too much bureaucracy’ is the problemâ€¦ because pitfalls and reasons to revert to the way that things have always been done can come from many different quarters. It might be that powerful interests are involved, such as the doctors or other professional groupsâ€¦ but often it is just a rather general lack of motivation or imagination, or the intervention of one difficult character, that keeps things the way they have always been. Of course, in times of financial growth new services can be added to the old, but in the current climate this is impossible and any new ways of working will be in direct competition with the powerful status quo.
Although the first programme in the series does not deal with the problem of targets and financial imperatives that are imposed from higher up within the NHS, or from central government, these are real issues for people working in today’s NHS. Many units at all levels of the NHS seem mesmerised by the need to meet increasingly impossible financial targets. Managers, such as the Chief Executive of Rotherham General Hospital, Brian James, appear to be overwhelmed by pressure from above, to meet those targets, and pressure from below, attempting to respond to the concerns of people providing front-line services.
The plans aim to improve health and health services and to tackle theÂ main challenges faced by the local NHS.
By getting involved in the debate, you can help to ensure that future health services make sense clinically and make sense to local communities.
Why do things need to change?
The local NHS wants to improve the quality of the services they offer by:
- Providing modern health services that meet the highest standards of safety, effectiveness and patient experience
- Giving you more opportunities to maintain and improve their own health
- Safeguarding health services for the future.
This means that they need to make plans now that will address the challenges they will face in the future.
The main challenges they face include:
The Challenge: More people are living longer lives with long term conditions such as diabetes, dementia and cancer.
The Challenge: They are seeing rising levels of obesity, and there is still more work to do to help people to quit smoking.
The Challenge: Some new equipment and treatments need specialist staff and are very expensive. This means they can only be offered in larger district hospitals and regional specialist hospitals. However, many people live in remote and rural areas.
The Challenge: 24-hour health services need enough specialist staff to keep them running round the clock. This isn’t just a case of employing more staff – the doctors and nurses need to see enough different patients to keep their skills up to date.
The Challenge: They cannot spend more money than they receive from taxpayers. They also need to invest in improving their hospitals and other healthcare buildings.
What is being proposed?
The first part of this describes plans for the next five years. A later section sets out longer term proposals. Their plans have been developed by senior doctors and nurses working with patients and staff, and taking national quality guidelines into account. They have three main aims:
Bringing care closer to peoples’ homes for example, a wider range of services at the GP surgery
Providing sustainable and accessible hospital services
This will include:
Offering you and their carers better information and sign posting which will help you navigate their way through the health and care system
Many more of their outpatient appointments and day case operations will be provided in community settings including community hospitals and in GP premises. You will be much less likely to need to visit a major hospital for their planned care.
If you are pregnant, you will be able to receive more of their ante-natal care and give birth in local midwifery units, using the main consultant
service if you need this additional support. Direct access to midwives will help you to plan their pregnancy as early as possible.
Giving you more support to improve their own health, designed aroundÂ their needs and circumstances.
Some the biggest challenges they face are in Accident and Emergency, surgery (particularly emergency surgery) and children’s services. In order to keep these important services in Shropshire, Telford and Wrekin they need to consider some changes to ensure that they continue to meet high standards of clinical quality. These are explained in more detail below.
Â Why are changes to A&E and Surgery needed?
Â In order to provide 24-htheir emergency services, they need to ensure that there is a rota of suitably-trained clinical staff available around the clock to provide their care. They face challenges in Shropshire, Telford and Wrekin because:
The Challenge: Shrewsbury and Telford are relatively small hospitals, based on patient numbers. This makes it hard for them to carry on providing certain services because:
Doctors and other clinical staff need to see enough different patients toÂ give them wide experience of different illnesses and treatments. This is
particularly important for doctors in training, as it makes sure that they develop the skills and knowledge they will need when they are fully qualified.
Since their hospitals are small, trainee doctors do not necessarily seeÂ enough different patients and complex cases. This means that the hospitals risk losing their accreditation to train doctors. Trainee doctors are a vital part of the clinical staff of their hospitals. Without them it is difficult or impossible to provide 24-htheir patient services. Some people have suggested that 24-htheir rotas could be maintained using other
doctors. However, it is difficult to attract doctors to the area if they will
not see a wide range of patients – and particularly if they won’t be involved in training junior doctors.
The European Working Time Directive places limits on the number of hours that doctors and other clinical staff can work. This means thatÂ more staff are needed to provide a 24-htheir service.
Specialist services often need expensive equipment or specially trained staff. It is more difficult to provide these specialist services locally when staff and resources are spread across two hospital sites.
The Challenge: Surgeons are becoming more “specialist”. This means that their knowledge and skills focus on a particular part of the body. They provide very high standards of clinical care in this area, but they are less experienced in other parts of the body. This makes it much harder to provide all the types of expertise at all times at both hospitals for a seriously ill patient who needs an operation.
What changes to A&E and surgery are proposed?
Over the next five years they will need to make changes to the way that A&E and Surgery services are provided between the Princess Royal Hospital
(PRH) and the Royal Shrewsbury Hospital (RSH).
The main proposals are:
Keeping 24 htheir A&E units at both hospitals, in Telford and in Shrewsbury.
Continuing planned surgical operations – inpatients and day cases –
at both hospitals in most specialties. Some specialties will need to focus on one site (e.g. urology). The majority of operations are plannedÂ perations, so most operations will continue to take place at both hospitals.
Continuing outpatient clinics and diagnostic tests at both hospitals.
Concentrating 24-htheir emergency / acute operations, carried out on very seriously ill and injured patients, at one of the two hospitals. This hospital would also have the A&E unit for the most seriously ill and
injured patients (although there will continue to be a 24-htheir A&E unit
at both hospitals).
Why are changes to Children’s Services needed?
Â Children with very serious illnesses already need to be treated inÂ regional children’s hospitals, such as Birmingham. Local specialist children’s services provide care for children who suddenly become ill, or live at home with a long term illness. They face challenges in Shropshire, Telford and Wrekin because:
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The Challenge: Where possible, children’s services should be provided at home or as close to home as possible. This helps children toÂ maintain their independence, and helps parents to plan their children’s care alongside other commitments..
The Challenge: As with A&E and surgery, children’s services risk losing
accreditation to train doctors, which would make it very unlikely they could continue. The European Working Time Directive also means more staff are needed to provide a 24-htheir service.
What changes are proposed?
Over the next five years they will need to make changes to the way that Children’s Services are provided between their two main hospitals and in the community.
The main proposals are:
Developing a new Hospital at Home service across Shropshire, Telford and Wrekin. This is a nurse-led service, supporting children at home. It would provide care when children come out of hospital, but also reduce the need for admission to hospital in the first place.
Strengthening children’s assessment units at both hospitals. These would be the ‘front door’ for all sick children at bth hospitals. They would provide tests, are and treatment for routine and emergency issues.
Once these new services have been established, then children’s inpatient hospital beds would be concentrated at either the PRH or the RSH.
Steps Approaching By the NHS To overcome Challenges:
Â So these are the following ways which are following by the NHS to overcoming its challenges.
The NHS Institute is a lean organisation and works in a focused way on what are called their ‘priority programmes’. These six programmes are agreed with the Department of Health and aligned with current targets.
The Patient Safety programme looks at developing the skills needed by staff to improve patient safety. With partners, we’ll be running a national campaign on patient safety, identifying processes and systems so that doctors and nurses make patient safety a priority in their jobs.
Their No Delays priority programme is focused on helping NHS trusts in England achieve the Department of Health’s objective of reducing delays in the health service – the 18-week patient pathway by December 2008.
The Care Outside Hospital priority programme is helping the government achieve its vision of shifting care closer to home. The programme looks at how the shift in care can be made by trusts – systematically, quickly and efficiently.
Â Their Delivering Quality and Value programme comes from the philosophy that well-delivered care should be right for the patient first time – and therefore should also ultimately be the cheapest and most efficient care.
Â The Building Capability programme looks at developing leadership, new skills and capabilities that will be needed at individual, team, organisation and system level.
Â Their final area comes in the form of the National Innovation Centre, which helps to develop individual’s ideas for innovation through the maze of regulation and the development process.
Â We’re not working alone in any of this. All these programmes are highly integrated with those working within the NHS – both clinicians and managers. Their experience is integral to many of the products, tools and processes that they develop. Their NHS partners, including so many chief executives and senior managers in the NHS, often lead the way in much of the development of their work since their knowledge is so vital.
Â This integration with the NHS is represented through various networks. They work closely with the ten SHA’s through a link director who spends some time working with us. They also have relationships with chief executives of both provider organisations and of PCTs.
Â Their Practice Partner Network is made up of various types of NHS organisations – 38 in total – who volunteer to test and help develop products from the NHS Institute. They are a sounding board, constantly providing them with feedback on what we’re doing therefore helping them keep what we’re doing in line with the real challenges out there.
From the above we can analyse that the NHS began in an environment of conflicting ideologies and this state endures. Supply induces demand, yet resources in the NHS are finite. In primary care we looked at attempts at cost containment through marketization and at improving efficiency via pay for performance. With secondary care we discussed difficulties in using hard and soft approaches to exploit efficiency savings through industrialisation. We also observe that the various challenges faced by the nhs and the steps followed by the nhs to overcome the challenges.
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