Chair: Helen Groom, GP
Ron Singer, salaried GP, outlined concerns about:
* poor communication between patient and professional carers, and between professional carers and relatives
* Intensive Care being a nightmare for relatives
* insensitivity of conducting investigations on trolleys in corridors = an uncaring environment; doctors disputing treatment over patient's bed
* parents with children often having to wait too long at GP surgery.
He welcomed most of the NHS Plan and other recent initiatives for primary care (NHS Direct, NHS On-line, Walk-in Centre, Pharmacists as first-line advisers, reorganisation of general practice) but expressed concerns about adequacy of finance, shortage of trained staff and implementation. Organisation of out-of-hours care through NHS Direct generally welcome, but need for short-cuts where client knows whom they want to contact. Dangers of higher rents for PFI premises, payable from revenue. NICE a brilliant idea but dodging issues of affordability - rationing must be more explicit.
John Lipetz, former NHS manager, said that the NHS Plan had great potential to improve the delivery of health services. Account had to be taken of the size and complexity of the NHS to ensure managers and clinicians could deliver health outcomes effectively and in an accountable way. The DoH and NHSE had distinctive roles, the former to set strategy, priorities and standards and to hold to account, the latter to deliver an effective service to high quality professional standards using best management practice.
Challenge is how to ensure effective management responsive to local needs within such a huge organisation. The common experience in the NHS of top-down management, driven by financial `bottom line' pressures is not the way. The key is genuine valuing of staff through team working, involvement and a bottom up approach. Workforce planning should be instituted across all functions to ensure that the right people with appropriate skills are available when needed. Staff training and development should be extended across all disciplines. NHS should have own staff college to lead this work rather than rely on training bought in from expensive conference providers. The Labour health team should be prepared to listen and to work out in consultation with organisations such as ours how best this management and organisational change can be achieved to meet the objectives of the NHS plan.
Peter Fisher, consultant, described need for good and immediate communications between professionals (compulsory use/delegation of bleep to PA) to enable GPs and consultants to be effectively available to each other to discuss patients. Written communications should be speedy (importance of medical secretaries as PAs). Inadequate communication with patients often due to lack of time to talk properly (staffing & funding implications), but patients and relatives need to know how to get information, discuss prognosis - through information booklets, national information; should be a mandatory duty of management.
For the Patients Forum/PALS system to be successful both patients and NHS staff would need to approach it in a spirit of cooperation, not confrontation. There would need to be a coordinating body, equivalent to ACHCEW
Discussion: how to make the NHS democratic, accountable and capable of delivering complex outcomes. Effect of clinical governance; influence of citizens/patients on outcomes; complaints procedures.
Points raised in discussion are grouped under headings agreed by participants as the main issues
VALUING THE WORKFORCE
* humanise the NHS
* pressures on clinicians/consultants must be recognised; burn-out common after 10 years, however enthusiastically they start. Consultants are under extra pressure due to cuts in junior doctors' hours.
* Managers should nurture not exploit junior staff; staff should feel valued; build on experience of small units with recognition of value of cleaner to clinician
* management by consent (e.g. police operate the law, with the consent of the people)
* Trust boards should play a role in improving staff relations/ethos
* NHS is highly complex at local and national levels. NHS culture should be changed to bottom-up
NEED FOR CONSISTENCY
* need to judge success by outcomes which tackle inequalities
* make use of bleepers mandatory: corporate management currently incapable of enforcing participation by clinicians, e.g. to ensure rapid contact e.g. between GP and consultant on urgent cases.
* need for national norm for ratio of consultants to population - currently consultants + Trust have too much discretion about how many consultants to employ/not employ leading to manipulation of waiting lists/private practice
* concern at role of Royal Colleges and Post-Graduate Deans in criteria for hospital/unit size (government hides behind guidelines) - with no accountability. Effect on mergers.
* Scotland has `managed clinical networks' v. English `hub & spoke' model.
* need for national service standards: central diktat + local flexibility
* importance of organisational structures
* need for changes in regulatory framework - GMC/UKCC often do not even check registration
* use of PFI is affecting planning - bed numbers being determined by what can be afforded; harmful to strategic planning. Secrecy/lack of detail during consultation process
* telemedicine seen as threat by some consultants (e.g. dermatologists)
CAREER STRUCTURES
* need for career structure for professionals, e.g. MLSOs, Medical Secretaries (promotion to PA) so as to recruit and retain essential ancillary staff
* need for strong union representation (patient advocacy groups not aware of most staffing issues)
* concerns about skill mix - who is doing the nursing/are some nursing functions neglected - feeding, washing by relatives (cf Africa)
CLINICAL GOVERNANCE - VALUING COMPLAINTS
* role of honest criticism from bottom-up / whistleblowing to alert management to problems. Legacy from `internal market' philosophy includes clamp on honesty - managers (particularly Chief Executive) still too focused on `bottom line'.
* legacy of consultant top-down culture - but sea change being driven by clinical governance agenda.
* staff and public should be able to agree reports upwards. Accountability leads to democracy. Currently there is disincentive to take messages upwards; fear of making complaints. Need culture of learning from mistakes, not hiding them
* need to address inequalities in care - what happens if effective and ineffective trusts are merged (danger of levelling down). Potential dangers on morale of red/yellow/green status. Emphasis needs to be on putting weaknesses right. Welcome for role of Commission for Health Improvement, providing critical support not punitive OFSTED-style reports.
ACCOUNTABILITY - SPOTLIGHT FROM OUTSIDE
* Importance of audit - currently too many bodies come up with standards; need simplification - one central auditing mechanism (this would take some stress off staff, and increase democratic accountability)
* Tools for auditing mental health care in the community lie within Health of the Nation outcomes.
* role of CRE : Human Rights Act, Freedom of Information - potential legal framework for patients
* what will be the impact of evidence-based culture? What patients want, or what they need? Where is the public input?
* what is the responsibility of the public to be `accountable' - ie will the means to pay for what is needed, through taxation, or agree what is to be cut
COMMUNICATIONS
* importance of quality of care, and understanding role of communication with patients/public - and at all levels
* Keep patients well informed
* advocacy for (very ill) patients - power of attorney for care providers
* communication with immigrant communities - role of CRE in monitoring interpretation + technical know-how
Workshop1 Participation
Workshop 2 Local democratic accountability
Workshop 3 Two sorts of accountability