From 1989 to the present, various policies for the NHS have been followed by both the Conservative and New Labour governments. These policies have included, the provision of increased money and the improvement of the management efficiency. In the first of these policies the increase of money has been adhered to, however this increase in expenditure has not been sufficient to cope with the ever increasing population. In 1991,there was a period of immense change and new challenges within the health service.
NHS reforms have effected the way in the NHS operates, reforms are leading to a gradual improvements in the quality of care, responsiveness to individuals and even better value for money, from the growing NHS budget. The introduction of competitive tendering for contracts has stimulated a new focus on the quality of care patients are receiving. As the standard of management is often reflected within the quality of service this shall be the viewpoint of this work.
After years of the Thatcher governments attempt to cut back public spending her successor John Major sought to instil a more positive approach to public services with the introduction of a Citizens Charter, this was later followed by the Patients Charter. Within the NHS patterns have not followed any specific trend, however the NHS had the idea of re-organisation to increase efficiency, by changing the structure as soon as anything goes wrong, this often missed the real problems.
The current structure seems to be more specific and compact, starting with the removal of the health authorities. This in itself reduced costs and allowed the NHS to become much more efficient and strive to producing a quality service. Maxwell,(1991,p181-182) argued this point in respect of quality of service this a feature of general management and that all employees are responsible for quality.
The initiation of the concept of quality management can be traced to two American management scientists Deming and Juran, Deming’s management theory, the “System of Profound Knowledge,” to determine whether the managerial leadership properties of this theory represent a paradigm shift in current management leadership theory.
Deming has been labelled “The Father Of Quality”, yet his message encompasses leadership principles for all fields of study and all types of organisations. Deming was the person whose teachings in Japan from 1950 onwards, largely initiated a transformation in Japanese business, resulting in what we understand today as the “Japanese Industrial Miracle”.
But what do we comprehend by this word ‘quality’ indeed the some interpretations of the word can conjure different definitions within each person, quality is a grey area with no cut and dry definitions, quality might be described as more a philosophy than a theory. Quality concerns itself with value judgements and opinions that are negotiable, but cannot be said to be either right or wrong. To bring a definition to this word and its use in conjunction with this work quality will be defined simply as meeting the customers requirements, or to cite Deming “Quality is the totality of features and characteristics of a product or service that bear on its ability to satisfy or implied need”
As the NHS services can defiantly be defined as not paralleling physical goods the creation of the service quality concept was cultivated virtually from scratch. This service quality evolution was based upon the idea of that what customers perceive as quality is important. This point leads to the reasons of change within the NHS, customer satisfaction and economic profitability are linked to the product and service quality. The higher standard of quality results in the greater satisfaction. Oakland (1993) suggests that the motivation for change is triggered by one or more of the following points:-
· Demanding customers
· Greenfield Venture
· Restart situation
In the NHS the motivation was the more likely reason coupled with the increased competition which arrived when the government introduced trusts and dived the purchasers and provider roles. These roles ensure formal contracts between each party. This competitive environment had the effect of forcing the individual trusts to strive to improve quality and introduce to quality systems.
Within the quality management concept four stages exist, Inspection, Quality Control, Quality Assurance and Total Quality Management. If we look at the last of these concepts, Quality Management, it considers the organisation as the whole in that it covers improving quality in every department not just those who are directly involved in the service.
The principles of this concept requires a fundamental change in the outlook and culture of any organisation, therefore having decided on a quality management approach, an organisation must then formulate a strategy for implementation, total quality requires a top down approach , beginning with senior management. The role of the NHS executive is defined as:- “the NHS offers good quality services, sound financial control, high standards of probity, and value for money; that information and costing/pricing systems are improved across the NHS;. (The role of the NHS Executive, Crown Publication, 1997)
Quality Assurance can be defined as Morgan & Everett, (1990,p23-36) state a system of activities that assure that the production of a defined service is akin to a set and agreed standards. This system is applicable to the NHS organisation rather than methods like inspection and quality control systems. This is because the prevention rather than detection characteristics lends itself better to the ‘hands on’ nature of the NHS. In 1997 the government introduced The new National Performance Framework which as fig 1 shows the drive to become a more efficient and cost effective and quality organisation.
Areas Aspects of performance
1. Health improvement The overall health of populations, reflecting social and environmental factors and individual behaviour as well as care provided by the NHS and other agencies
2. Fair access The fairness of the provision of services in relation to need on various dimensions:- geographical- socio-economic- demographic (age, ethnicity, sex)- care groups (eg. people with learning difficulties)
3. Effective delivery of appropriate healthcare The extent to which services are:- clinically effective (interventions or care packages are evidence-based)- appropriate to need- timely- in line with agreed standards- provided according to best practice service organisation- delivered by appropriately trained and educated staff
4. Efficiency The extent to which the NHS provides efficient services, including:- cost per unit of care/outcome- productivity of capital estate- labour productivity
5. Patient/carer experience The patient/carer perceptions on the delivery of services including:- responsiveness to individual needs and preferences- the skill, care and continuity of service provision- patient involvement, good information and choice- waiting times and accessibility- the physical environment; the organisation and courtesy of administrative arrangements
6. Health outcomes of NHS care NHS success in using its resources to:- reduce levels of risk factors- reduce levels of disease, impairment and complications of treatment- improve quality of life for patients and carers- reduce premature deaths
Source: The rationale for adopting a new approach to assessing NHS performance, Department of Health, Crown. 1998
The quality drive within the NHS is aimed at delivering new quality standards through life long leaning to meet new challenges. This life long learning will ensure that that staff have the necessary skills to meet the quality requirements required. Although the bureaucratic structure of the NHS will be streamlined a professional self regulating is to empower clinicians to introduce standards of quality. But we must ask is, if a organisation is self regulating, will this lead to a bureaucratic system that was so dominant within public bodies? As mentioned before the governments intention to set standards and monitor such standards.
It must be remembers that within the NHS quality is not a new phoneme. There has always been concern for quality provision of health care. Whilst this new quality drive is far more extensive an co-ordinated than before, there have been previous initiatives. Up until the 1980’s there were two main players in the maintenance of good quality service, the professional groupings and the health authorities. Quality management offers staff at each level an active role in the pursuit of quality, this is with respect of the emphasis on employee involvement. The two most important pieces of literature concerned with quality to date were both produced in the 1980’s. They are the Grithiths Report (1983) and the governments White Paper “Working For Patients” (1983).
The Grithiths Team Report(1983) considered that the management structure of the NHS was inadequate. They also concluded that not enough attention was being paid to the users of the service, and that their views should be sought more and incorporated more in decisions.
As a result of the Grithiths report, District Health Authorities (DHA)replaced the old Health Authorities and General Managers were appointed, many of whom were drafted in from the private sector. In response to this report the British Medical Association argued that the concept of non-medical chief executives, This seems to be promoting the professional retention of management functions.
In the white paper “Working for Patients”(1988), this put forward a number of proposals directly aimed at improving efficiency and quality. Morgan & Everett (1990) state that most significant proposal of this report was to open the NHS to competition by the creation of the internal markets in the form of the purchaser/provider split. This meant rather to rely on a monopoly supplier of services as before the DHA were able to ‘shop around’ for the best quality service provider. The criteria which the purchaser uses to make their choice is based on a culmination of cost, volume and quality. Contracts are provided by all service provider departments and the purchaser makes choice based on who sells their service the best.
However issues of quality were dealt with on a rather ad hoc basis. The professional groupings concerned themselves with local peer review meetings and the case review meetings. These were attempts to develop the skills and the knowledge of staff. Some of these groupings also published good practice guides, policies and standards. These however tended to be minimum standards. The problems with minimum standards are that they tend to be worked down to and are a blockage to good quality.
However the success of any quality related issues depended on the success of the providers of health care and how well they communicated desirable levels of quality and equally as important achievable levels of quality to them. If the quality of information passed up to the health authority was of poor quality, inappropriate and unachievable standards were produced and distributed by the health authorities.
Individuals will measure performance in comparison with another service they have had some experience of in the past, for instance the service received at one hospital to that in another. This is a difficult comparison to judge as many people only go to one hospital or trust. To those people who use the service on a regular basis will be able to make a choice of this service by comparing the service against the service received on prior visits. So some people will measure the quality of service by how quickly they are seen.
To help in the measurement of service provided by the NHS there is set in place the national standard of performance of every major service offered within the NHS, this lists waiting times in out patients to waiting times for operations. The local and national charter standards are measured every quarter and this is the trusts main method of measuring performance.
To measure quality has improved apart from the above mentioned method is the use of SAS Audits and other techniques. The results obtained from the measuring the standards of the Patients Charter are published in the league tables. The NHS performance tables show how the trusts, hospitals, health authorities, GPs and ambulance services have been performing.
In each table the total of all the hospitals within one trust are combined into the tables. To ensure accuracy, the audit commission has considered the way that the organisation in the NHS are keeping their records and how the figures have been collected. It is not the case that statistics can be manipulated by the interpretation of the collection methods, if a patient attending an emergency unit is seen within ten minutes but not dealt with medically within 4 hours the earlier figure can be taken as the response time to the situation.
In conclusion to this work I would re-instate various points raised. There has been over many years significant changes which are designed to improve performance within the NHS. Evidence exists that the NHS has worked to achieve good quality management, this is reflected within the quality of service, Although within this work it has not been possible to delve into the depths of NHS management structure points to be raised from this work and with the quality perception of the NHS relate to the a monitoring system which can be seen by the individual as independent. To measure the efficiency of the NHS all departments must be taken into account in the production of league tables, it is not a matter of defining quality on the basis of statistics.
Cole, G.A 1993, 4th ed. Management Theory and Practice, DP Publications, London
Maxwell,R 1991, The National Health Service, Policy Journals, Berks
Oakland ,S.J 1993, Total Quality Management, Butterworth, Oxford
Owen, D 1988, Our NHS, Pan, London
Riseborough & Walter. 1988, Management in Health Care, Butterworth, London
The role of the NHS Executive, Crown Publication, 1997)
The rationale for adopting a new approach to assessing NHS performance, Department of Health, Crown. 1998
The Patient’s Charter. 1995, Crown. London
Grithiths Report 1983
“Working For Patients” Crown