Can the NHS cope in future?

Four potential pressures are likely to determine whether the NHS will be able to cope in future: the change in population structure, changes in level of morbidity, introduction of new technologies, and increasing expectations of patients and NHS providers. New technology and changes in expectations are likely to have the biggest effect and are also the most difficult to quantify. Nevertheless, these pressures are to some extent amenable to control. If the growth in funding continues as it has in the past there is no convincing evidence that the NHS will not continue to cope.     

Arbitration agreements and your malpractice coverage

With new legislation and favorable case law developments, many providers of health care services are turning to binding arbitration agreements as a partial solution to the medical malpractice crisis. Existing data indicate tremendous advantages can be gained from the use of such agreements, if they are carefully drawn to comply with new law, tailored to the particular situation in which they will be used and coupled with appropriate procedures to secure the intended benefits. Arbitration is not a substitute for insurance, but if a provider has taken the calculated risk of forgoing insurance he should not be without a carefully drawn binding arbitration agreement.     

Why Britain is reorganizing its national health service--yet again

The Labour government's 1997 plans for Britain's National Health Service (NHS) have been presented as a reaction to the reforms introduced by its Conservative predecessor in 1991. But to a large extent they build on the Conservative legacy. The centerpiece of the Labour reform--managed care organizations based on groups of primary care physicians--is based on the Conservative experiment with general practitioner fund holding. Welcomed when published, Labour's plans may arouse opposition in implementation, for they imply greater central control and threaten medical autonomy. If the political costs are to be contained, Labour may have to choose between increasing spending on the NHS or making concessions to the medical profession--and quite possibly have to do both.     

Dispute Review Boards: Elements of a Convincing Recommendation

This paper will discuss the dispute review board (DRB) process and in particular the settlement recommendation and the elements thereof that may induce contractual parties to resolve their conflict. The recommendation is a document issued after the contractual parties bring a dispute to the DRB panel that they have failed to resolve. To lay the foundation for the issuance of a recommendation, the DRB process will be briefly discussed. Also discussed is the groundwork the panel itself must lay to gain the parties trust prior to the issuance of any recommendation. Given the importance of the recommendation as a linchpin of the DRB process, it is surprising to note the dearth of literature regarding it. This paper will help to partially fill that void.     

Clinical governance

Clinical governance has marked a significant shift towards involving clinicians in the assurances of both quality and accountability in healthcare delivery. The White Paper (Department of Health (DoH), 1997) stated that: 'The Government will require every NHS trust to embrace the concept of clinical governance, so that quality is at the core, both of their responsibilities as organizations, and of each of their staff as individual professionals.' In order to achieve this the Government will bring forward legislation to give NHS trusts a new duty for maintaining quality care. Under these arrangements, chief executives will carry ultimate responsibility for assuring the quality of the services provided by their NHS trust, just as they are already accountable for the proper use of resources. In 'A First Class Service Quality in the NHS' (DoH, 1998), clinical governance is defined as 'a framework through which NHS organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish'. The principles of clinical governance apply to all those who provide or manage patient care services in the NHS. It requires staff to work in partnerships, breaking down boundaries by providing integrated care within health and social care teams (Wilson, 1996), and between practitioners and managers and between the NHS, patients and the public.     

Planning flexible learning to match the needs of consumers: a national survey

The injection of market forces into the National Health Service (NHS) has led to nurse education being viewed as a commodity which educational institutions supply and NHS employers purchase. Conscious of the costs of paying for courses within this new consumer culture, NHS trusts and other health service employers are increasingly looking for cost-effective flexible training to educate their workforce quickly and efficiently. Parallel to this is the accelerated demand for continuing professional development (CPD) brought about by the inception of the UKCC's Post-Registration Education and Practice Project (PREPP). Both registered and enrolled nurses are finding they need professional updating and skills and thus increased access to courses. The increased demand for education and training brought about by these changes cannot be met through traditional methods alone, requiring educational institutions to re-appraise their methods of delivery and introduce more flexible approaches to learning. There is every evidence that this is now the case with open learning, distance learning and flexible approaches to learning ever growing in popularity as providers of nurse education recognize the benefits such approaches offer. The emphasis is on meeting the diverse needs of the health care employers and individuals by providing education that is flexible, learner-centred and customer focused. This paper presents the findings of a national survey to ascertain how providers of flexible education plan educational programmes to meet the needs of their customers. Based on data collected from 120 educational institutions within the higher education, health and social care and private sectors, it highlights: the ways in which flexible learning programmes and courses are delivered; what aspects of flexibility are considered important when designing programmes to meet the needs of prospective customers; and what approaches are used to assess demand for flexible education. The study stresses the need for providers of flexible education to take into account the dual perspectives of those who have a stake in the flexibility of nurse education; NHS employers as funders of students and individual healthcare professionals themselves.     

Experienced anesthetists show better reaction to central gas supply dropout--an anesthesia simulator study

The reform process underway within the Italian National Health System is aimed at making decision makers responsible for appropriate and efficient resource utilisation and at ensuring quality of care, eliminating conflict between fairness, quality and cost control. The risk for the quality of the services provided entailed by resource rationalisation is avoidable and controllable. This article explains how the Italian NHS has managed the reform process assuring quality improvement, and describes the policy and the tools adopted. As well as involving all players and the system as a whole in constant improvement, the Italian NHS's policy in pursuing quality of care is based on the adoption of a wide range of measures: measurement of health care and of clinical outcomes, systematic data collection, team work and protocols. The tools adopted, currently under implementation, to support quality control are: an integrated system of indicators for measuring efficiency and quality of NHS structures (demand and accessibility indicators, resource related indicators, activity indicators and result indicators); compulsory accreditation as a prerequisite for health care providers; a system to monitor and control the effects of the new prospective payment system; clinical guidelines (each related to a specific clinical problem); a menu of services (Carta dei Servizi) released by all NHS accredited service providers with full information and warranties regarding the services provided and their quality.     

Does publishing the parameters that trigger review of Medicare claims change provider behavior? Results of the parameter release study

In April 1989, the Health Care Financing Administration stopped publishing the parameters that trigger review of Medicare claims because they thought that knowledge of the parameters would permit providers to schedule visits to avoid review. In this article, the authors report the results of an experimental study where previously unrevealed parameters were revealed to some providers of Medicare services and not to others. The authors find little evidence to suggest that providers schedule procedures to avoid review when they know the parameters. There is some evidence, however, that providers may be responding to the release of the parameters in other ways.     

'Health law 2000': the legal system and the changing health care market

The failure of national health reform confirmed in many ways the conservative nature of the American legal system. Legislatures, regulatory agencies, and courts usually find themselves in a reactive posture, responding to groups and individuals aggrieved by changing circumstances. The rapid transformation of the U.S. health care system through managed care presents an extreme example of this phenomenon, involving billions of dollars, millions of lives, and thousands of existing laws. Over the next few years the legal system will face a host of difficult issues deriving from the integration of health care financing and delivery, and the consolidation of fragmented providers into large corporations and contractual networks. What emerges may be neither logical nor consistent but no doubt will reflect the intricate interplay of societal and individual interests in health care.     

Paradoxes of GP fundholding: contracting for community health services in the British National Health Service

The expansion of GP fundholding (GPFH) is central to the British government's attempt to maintain the revolution under way in the National Health Service (NHS). Evaluations of the NHS reforms have portrayed GPFH as an important mechanism for competition, and GPFH's bargaining power is reported to have secured significant changes in health service provision. However, these developments have been acknowledged to be less applicable in relation to community health services (CHS) than acute hospital services. On the basis of case studies of the process of contracting for CHS, GPFHs are shown to display ambivalent and sometimes contradictory views which have to be related to broader policy developments in general practice and primary care. Although this paper focuses on the British situation, many of the issues raised by reforms in primary and community health services have implications for developments in other Western health care systems.     

Incentive effects of workers' compensation

Economic theory and evidence indicate that workers, employers, and healthcare personnel respond to the incentives built into state workers' compensation systems. Although empirical studies cannot provide precise estimates of the quantitative effects resulting from specific policy changes, research is useful in evaluating the qualitative effects of alternative policies. Studies show that workers' compensation claims are higher the more generous the level of benefits, the shorter the waiting period, and the more readily available is information on benefits to workers. States that decrease real benefit levels and lengthen the period required before workers are compensated for lost earnings can constrain future growth in workers' compensation costs, while continuing to provide partial compensation for workers with the most serious injuries. The most difficult problem facing policymakers is to design and implement reforms that take into account what are often the incompatible incentives of workers, employers, and medical care providers.     

Animal and human listeriosis: a shared problem?

There are some interesting paradoxes in the relationship between local government and the National Health Service (NHS). Local government is responsible for a range of major services, many of which relate to health broadly defined. The NHS provides many services which are often popularly thought to be part of local government (and, indeed, in many countries are). Local government prides itself on its 'localness'; the NHS, with its services delivered in a very local fashion for the most part, cannot quite decide whether it is a national service or a local one. Yet these two major agencies of governance and public service provision often seem unable to work very well together. In the interests of good government, both agencies need to work together where their interests coincide or abut one another. Differences of perspective, priority, culture and style need to be recognized but resolved. Opportunities for joint working need to be grasped and the experience built on. The paper looks at a series of issues and opportunities which bring local government and the NHS together. They create an incentive to improve working relationships; at the same time they suggest an agenda of future possibilities.     

Nursing in the NHS: the executive nurse director

The advent of trusts within the NHS brought a new dimension to the role of nurses in management, in that each trust must appoint an executive nurse director to sit on the trust board. The function and potential function of this role is, I believe, pivotal to the development of clinical services within the NHS.     

Different approaches to the tasks of educating and training information systems professionals, within the National Health Service (UK)

In 1994, La Sainte Union College of Higher Education (LSU) developed an MSc in Health Informatics course, in conjunction with Southampton University NHS Trust (SUHT). The original part-time, 1 day per week mode of delivery has since been broadened to include a distance leaning route and recently a block release mode, by which students combine usage of the distance learning materials with attendance in College for an intensive 2-day taught element. Because the course was designed in close co-operation with a major teaching hospital, it has always been 'market led' to meet the needs both of the individual students and of the organisations that they work for. At the same time, students acquire a quality-assured qualification from a premier UK university, a qualification that holds credence outside the National Health Service (NHS). At the same time as LSU and SUHT were developing the MSc in Health Informatics, the UK NHS Training Division (NHSTD) started to promote a professional qualification for health service professionals. the so-called 'Statement of Recognition' (SoR). In contrast to the academic format of an MSc, the SoR was not a formal course, but a combination of modules designed to help candidates demonstrate their competence and achievement at work by portfolio evidence. This approach has national standing throughout the UK in a set of qualifications known as NVQs (National Vocational Qualifications). The NHSTD, through its successor, the Institute of Health Care Development (IHCD), has further refined this competency based model, culminating in the launch in 1996 of the Diploma and Advanced Diploma in Information and Technology (Health). Professionals within the area of Information Management and Technology (IM&T) in the NHS now have the alternatives of an academic or a competency route to achieve their goals. This paper traces the development of and the relationship between, these two approaches to the educational and training of healthcare professionals. It will illustrate the shift from Information Technology (IT) to Information Management skills, which is a pre-requisite to satisfy the changing needs of information users. It will also consider how a single Master's course can lead to a range of courses which meet the needs of professionals at various levels. Finally, it makes some recommendations for future developments of the programmes, suggestions which may have some relevance outside of the UK.     

Effects of prior contractual experiences on self-control in children.

Studied the relationship between adult-child contractual interactions and children's self-control. Ss were 95 8-12 yr old girls who performed an arm-extension exercise and a monotonous letter-crossing task. Overall results suggest the utility of a model relating contractual agreements to self-control, although the locus of effects is not completely clear. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

In vivo perfusion measurements in the human placenta using echo planar imaging at 0.5 T

This paper alerts practitioners and administrators in correctional healthcare settings to a variety of issues of concern when advising or negotiating with state or county governments on the provision of managed behavioral healthcare. The participation of the mental health practitioner or administrator involved in determining the quality and appropriateness of behavioral managed care contractual services is an essential component of an overall healthcare service in a correctional setting. Several crucial elements are outlined relative to correctional settings, including the interface between custody and treatment providers, crisis intervention for incoming detainees or inmates, and provision of services for longer term "no parole" inmates in correctional settings. A number of considerations are reviewed, including (1) staffing, (2) drug formularies, (3) levels of service, and (4) "hidden costs," that may influence contractual negotiations as well as service provision by managed behavioral healthcare companies in correctional settings.     

Where should health services go: local authorities versus the NHS?

The Association of Metropolitan Authorities has recently proposed that responsibility for the NHS should pass from health authorities to local authorities. One of the fiercest debates at the outset of the NHS was whether the hospitals should be run by local authorities. In the end the minister for health, Aneurin Bevan, decided against local democracy and in favour of a national health service. His arguments included the fact that equality of treatment could not be guaranteed if facilities varied with local finances and that even the largest authorities were not big enough to pool risks and expertise. All these arguments still apply today, and the recent changes in community care provide an insight into how a market model of local authority control might work. The changes have been accompanied by a shift from public to private sector provision and the introduction of charges for services that the NHS once provided free. As important, the willingness and ability of local authorities to raise extra revenue from local taxes and charges affect the service they can provide, so leading to inequalities of provision. Local authorities have yet to make the case that they can preserve the fundamental principles and benefits of the NHS, including its reliance on central taxation and unified funding formulas.     

Does a fixed-dollar premium contribution lower spending?

In a multiple-option health benefits program, the employer's premium contribution determines the incentives facing employees and participating health plans. Advocates of managed contribution argue that a fixed-dollar contribution policy will result in lower health spending by encouraging cost-conscious choices by employees and price competition among plans. The University of California (UC), which adopted a fixed-dollar contribution policy in 1994, provides a useful case study for assessing this claim. This DataWatch documents the effect of this policy on health maintenance organization (HMO) premiums and per employee health spending in the UC health benefits program.     

Shared governance as a way to involve staff in decision-making

Increasing the involvement of clinicians in decision-making is a key part of recent NHS policy. One model designed to increase involvement is shared governance. This article describes the approach to shared governance developed at Kettering General Hospital. Ongoing evaluation of the scheme suggests benefits in terms of personal and professional development for those involved.     

Managed care in a new key: Britain's strategies for the 1990s

The new Labour government in Britain has issued three variations of a White Paper that outline significant changes in how the world's largest managed care health system will be run. All three emphasize systemwide criteria for quality, effectiveness, and health gain, which in turn imply redressing past inequalities in funding and service. One, the Scottish Paper, eliminates Thatcher's internal market and returns to a simple organizational structure centering on the health boards. The other two propose combining primary care practices into purchasing groups, a daunting task that will spawn many new problems and expenses as it recreates the internal market.