In an unprecedented public statement, 500 senior doctors have warned that the NHS cannot meet rising expectations and that the time has come to consider a new way to deliver healthcare in Britain.
The doctors all work in the NHS and are committed to its values of universal and equitable access to health care. Many also work in the private sector. They have formed a new non-party group Doctors for Reform with the aim of starting a national debate on healthcare reform.
The group has released a new ICM poll on attitudes of the public to the NHS. 69 per cent of the public agree that "the NHS was the right idea when it was introduced in the 1940s, but Britain has changed and we need a different healthcare system now".
The group advocates considering the social insurance systems that deliver higher standards of medical care in Switzerland, France and Germany. It opposes the US approach to funding health care.
The Government's focus on improvements to the NHS includes radical new initiatives such as giving patients the right to choose where they will be treated out of a range of hospitals from December 2005. The consequences for private medical insurers and private hospital groups are analysed in an article for health insurance magazine COVER in October 2003 by CareHealth director Dominic Leahy.
Tony Blair announced in a speech on 23rd January 2003 that from the summer NHS patients in London who have waited six months for an operation for most elective surgery (hip, knee, hernia and cataract operations) will be offered an operation at an alternative hospital. This will be either an NHS or a private hospital. This option will be extended nationwide from summer 2004. At this point no details of the scheme are available on the Department of Health website.
A similar scheme has been operating for patients throughout England waiting more than six months for cardiac operations - they have the choice over which alternative hospital will treat them. In practice most patients making use of the scheme are treated in NHS hospitals but a small number have been treated at private hospitals. An NHS document giving details is available here - note that this is a PDF file, requiring Adobe Acrobat.
In order to reduce some of the overlap between CHI and the NCSC, a new body has been set up during 2003, called the Commission for Healthcare Audit and Inspection. CHAI will incorporate the following functions:
CHAI will inspect the NHS and private health sector and will review the quality of patient care and how well the NHS is using its funds. New CHAI will be independent of both government and the NHS and will produce an annual report direct to parliament. CHAI is likely to start work in the first half of 2004, but in the meantime, CHI and NCSC continue to develop separately.
The NCSC has announced that it is extending its role to regulate Nurses Agencies, Residential Family Centres and Domiciliary Care Services, with effect from 1 April 2003. See the following press release.
In April 2002, the NCSC took over the regulation of independent hospitals from local authorities and health authorities. In the past, private hospitals were regulated as nursing homes, with emphasis on their premises and facilities rather than on the quality of treatment received. The Commission is also responsible for the regulation of other areas of private health care, including care homes, children's homes and adoption agencies. The Commission will regulate private hospitals against national minimum standards set by the Secretary of State for Health, with priority given to safeguards and quality assurance for patients, particularly in relation to the clinical quality of services.
This watchdog is responsible for inspecting around 40,000 establishments in England, including some 300 independent hospitals and 1,500 private clinics. (Separate bodies have been set up for Wales and Scotland). As far as hospitals are concerned, it has devolved its responsibilities to the Commission for Health Improvement (CHI) which regulates both NHS hospitals, and the treatment of NHS patients in private hospitals.
An advantage of the new structure is that, for the first time, there is now a single national body to which patients and relatives can complain.
On 17th January 2002 Health Secretary Alan Milburn published the Government's response to the report by Professor Sir Ian Kennedy on the Public Inquiry into the Bristol Royal Infirmary, following the high rates of death among children being operated on for heart conditions.
The response includes many important measures designed to open up the closed culture of the NHS and provide patients with more information and greater involvement. Two of the most important are:
The new council, which will be at arm's length from the Government, will bring together the proliferation of bodies working to improve standards in the NHS - the National Institute for Clinical Excellence, the Commission for Health Improvement, the National Clinical Assessment Authority and the National Patient Safety Agency. It will also strengthen links with the Social Services Inspectorate, the National Care Standards Commission (which has responsibility for monitoring standards in private hospitals), the Audit Commission, the NHS Modernisation Agency and patient involvement groups.
A year later, there is no indication when either measure will come into force, and indeed the formation of CHAI will probably supervene.
The Government's press release is now available, as is an executive summary.
See also our articles on Improving standards in private health and the National Care Standards Commission.
A variety of initiatives have been launched by the Government aiming to bring about improvements in the quality of medical care. Many of these focus on the NHS, although they are likely to have an impact on the independent sector also. The NHS is itself a major provider of private medical care.
A main theme in these initiatives is to apply "clinical governance" procedures to the NHS. This term means the adoption of systematic processes to monitor and improve clinical quality, requiring that health care organisations collect information on their performance and measure this against external standards. A related theme is to ensure that medical procedures carried out by doctors are "evidence based", that is they are in accordance with approaches which reputable research shows to be most effective.
Two new bodies have been established to help implement this policy.
The National Institute for Clinical Excellence (NICE) was established in April 1999 to develop national service frameworks which specify how particular treatments should be delivered. NICE will help collect and publicise information on what forms of treatment are most effective. The aim is to prevent people in certain hospitals or parts of the country receiving less effective treatment because these hospitals or doctors are using out-of-date or discredited procedures.
In order to ensure that health care organisations are following the principles which have been laid down for clinical governance, a new inspectorate, the Commission for Health Improvement (CHI) was established in 2000, broadly on the model of Ofsted, which inspects schools. The intention is that CHI will review hospitals every four years, and so far it has published about 175 reviews, and is conducting around 12 per month. Over the last year, it has extended its remit from acute hospitals to Ambulance Trusts and Primary Care Trusts. In addition, it has conducted eleven investigations in response to "serious service failures".
Online summaries and complete reports in PDF format are available on the CHI reports page.
A list of the reviews currently in progress is available by clicking here.
Research carried out by the King's Fund indicates that all health care organisations are struggling to work out what Clinical Governance means in practice, and how to incorporate it into their existing management procedures without incurring significant extra time or cost. There is also a clear conflict between the trust and openness needed for effective Clinical Governance and the requirement to identify areas of poor performance, which will take considerable time to resolve.
CHI will also endorse a national review of hospital doctors, which will compare each doctor's performance with that of their peers. This information will be shared with hospitals but will not be made public. Broader comparative league tables will be published.
The activities of NICE and CHI do not apply directly to private hospitals, but the majority of consultants who work in private hospitals also work within the NHS, and are therefore affected.
The new bodies are still in the early stages of their work. They are not currently producing information which would help potential patients assess individual hospitals or doctors. However, the move to establishing independent monitoring of quality standards and publishing some comparative information can only improve the medical care received by patients on both NHS and independent hospitals. Once information begins to be collected, through processes paid for by the public, it becomes increasingly difficult to justify withholding it from the public.
During an inquest into the death of Laura Touche, who died at the Portland Hospital in 1999 shortly after a Caesarian operation, the Portland Hospital in London was severely criticised for lack of basic care. See this BBC news report for details.
On 25 November 2001, the Sunday Times published an article entitled Save as you go for private healthcare recommending the CareHealth website as a way to obtain independent information on paying for your own private medical treatment (self-pay). The article compares the merits of using insurance company medical schemes with paying for your own treatment. It also discusses the options available for savings and for obtaining the lowest price for treatment when you need it.
WPA has recently launched a new policy, Self-Pay Protect, targeted at people ready to follow the self-pay approach. The plan provides reimbursement of hospital charges (and follow-up out patient consultations for a further 90 days) at one of three levels: 30%, 50% or 75%. Even at the 75% level, premiums are significantly lower than for conventional medical insurance cover. Subscribers need to make arrangements with a hospital themselves - and may be able to obtain lower rates than insurance companies receive. Diagnostic tests and consultations prior to entering hospital are not covered.
Unlike high excess policies (eg. WPA's own XS health policy) this approach does not provide a definite cap on medical expenses.
For more information click here.