Free Health Essays - Current Issues in Health & Social Care.
The NHS Plan (DOH, 2000)
Requires a fundamental change in thinking, practice and delivery over the next decade (Pattison, 2001, pg7)." Critically analyse this statement and discuss the implications for physiotherapists.
The NHS Plan is a radical reform, the magnitude of which has been compared by some, to the original inception of the NHS in 1948. The cynic would see it as little more than political rhetoric and manoeuvring as a response to public disquiet. The optimistic reformer would perhaps see it as a potential for major improvement. (Moss et al 1995)
The purpose of this essay is to examine whether this Plan has produced significant change since its inception with particular relevance to the discipline of physiotherapy.
The main stated aims of the NHS Plan are to:-
Increase funding and reform
Aim to redress geographical inequalities,
Improve service standards,
Extend patient choice.
To some extent, in the context of the original question, one can produce a rather tautological argument to say that, if a fundamental change of “thinking, practice and delivery” was not necessary, then there would be no need for the Plan in the first place. I suspect that any healthcare professional who has been working in the NHS for any appreciable length of time, would consider that this question is both self-evident and almost self-answering. In this essay we shall explore the evidence to support this contention.
What is meant by change and organisational change within the NHS?
There are a number of key issues which require investigation. Perhaps the most important is the whole concept of change and the mechanisms by which change is successfully brought about. We only have to look back to the Griffiths Report in the 1980s (Griffiths Report 1983) to see that not all fundamental change in the NHS is either successful or even beneficial. (Bryant 2005)
The Government’s own assessment (Davidmann 1988) was hardly glowing. We shall consider this in a little more detail (Change management) later.
In the context of this essay, the four elements of change have been summarised in the previous section. Increased funding is promised to the extent that the March 2000 Budget settlement means that the NHS will grow by one half in cash terms and by one third in real terms in just five years. The Plan itself promises £500 million for a “performance fund” for specific areas which are identified as in particular need of assistance.
Geographical inequalities and service standards are largely dealt with in the National Service Frameworks which have been rolled out across the country (Rouse et al 2001), together with institutions such as the National Institute for Clinical Excellence which is charged with examining practices and facilities with a view to achieving national standards (NICE 2004). There is a salutary note to be sounded here as the National Institute for Clinical Excellence, although doubtless a great concept and a good idea, is already finding itself short of money to do the research necessary to justify its existence. (Shannon 2003)
Patient choice is more difficult to address because it actually means that the patient’s primary healthcare team has more choice as to where to refer the patient. (Wierzbicki et al 2001)
The NHS plan is probably best seen as part of a continuum of reform which contains a number of different elements. We have already refered to its precursor, the Griffiths report in the 1980s. Part of this continuum is the Agenda for Change (2004) which primarily looks at the pay structures within the NHS which is due to come into full force at the end of September 2005, this is together with another Government White Paper, the NHS knowledge and skills framework (2004) which is primarily aimed at recognising and rewarding specific enhancement of skills and knowledge that are relevant to professional performance. Specifically it promises £280 million over the following three years to develop specific staff skills. It includes the promise that all clinical staff will have individual Learning accounts which will be worth £150 a year. It is not yet clear whether that will have a direct impact on the field of physiotherapy.
Changing roles, role redesign, flexible working, skill mix, re-designing professional boundaries.
If one has to analyse the pre-2000 structure of the NHS, one may well conclude that it has three major problems which are not actually consistent with the structure and organisation of a 21st century provider.
a lack of national standards
old-fashioned demarcations between staff and barriers between services
a lack of clear incentives and levers to improve performance
over-centralisation and disempowered patients. (Nickols 2004)
The NHS Plan calls for change in the working practices, and indeed the actual roles, of many healthcare professionals, including physiotherapists although it has to be said that despite its great length and detail in some areas, there is actually very little detail in just how it expects these changes to come about. There is even less detail in exactly what it expects these changes to be. (Krogstad et al 2002)
It is fair to say that the “seamless interface” is a phrase which is seen frequently in the document, and as a concept it is something which appears to be progressively incorporated into modern practice (Dixon et al 2003)
Team working
One could be forgiven for concluding that team working is one of the more important new concepts that have evolved over the past decade or so. There was a time (certainly pre-NHS Plan) when working practices in the NHS were very insular. (Netten et al 1996)
Each speciality had its own “empire” and was largely self regulating. (Lee et al 2004)
One of the more significant concepts that has started to evolve with advent of the NHS plan, is that of the “seamless interface” between the various professional groups. (Rudd et al 1997)
This requires the concept of the team approach to the patient’s particular problems and has arguably been demonstrable in the primary healthcare team setting to a greater degree than in the hospital setting. (Indredavik et al 2000)
Many physiotherapists have set up links with their local primary healthcare team and take direct referrals for both clinic patients and domicillary patients. In the latter case particularly, there is almost inevitably a professional framework of liaison between the physiotherapist, the nursing team and the General Practitioner as a matter of course. (Stroke Unit Trialists' Collaboration. 1997)
Donaghy (et al 2000) point to the need to change the working practice of the physiotherapist within the NHS. They also comment on the previous prevalence of insular and “isolationist” practices and call for a smoother integration of all aspects of healthcare between all healthcare professionals. (Lee et al 2004)
One could conclude that this is apparently happening with increasing degrees of momentum. With specific regard to the role of the physiotherapist, there have been a number of recent papers that look at, and compare the differential and the integrated roles of the professionals in specific consideration of a number of common presenting complaints. One such complaint (for the sake of illustration) is low back pain. A typical patient may present directly to a physiotherapist, a nurse or his General Practice or may mention it to any other potential healthcare professional.
Assendelft (et al 2003) considers the various treatment modalities that could be available. Van Tulder (et al 2000) produces another. The actual results are not so important to the thrust of this essay as is the concept that the multidisciplinary and integrated approach is being accepted as commonplace. This concept is taken even a stage further by Underwood (et al 2002). Who considers providing basic multidisciplinary training in the management of the condition so that each member of the healthcare team can learn and benefit from the input and experience of the others. Perhaps this is actually what the thrust of the NHS Plan is all about.
Change management
The management of change is perhaps the most critical of the elements in this discussion. There is little point in having vision or ideas if you cannot successfully implement them into reality (Bennis et al 1999).
The science of the management of change is underpinned, linked and integrated by a set of concepts and principles known as General Systems Theory (GST). (Newell et al 1992). This is a hugely complex area and it is not appropriate to discuss it in any depth this particular essay. In short, and as directly applicable to our considerations here, it can be summarised as a process of “Unfreezing, Changing and Refreezing” in other words, assessing a situation changing it, and then making the changes stick. (Thompson 1992)
We can consider the reasons why the Griffiths Report (which, in some ways can be considered a precursor to the NHS Plan) failed to deliver what it promised in terms of reorganisation in the 1980s was because it was imposed rather than managed (Davidmann 1988)
There is therefore , perhaps considerable merit in Marinker’s view (Marinker M.1997) which suggests that there is a subtle and fundamental difference between compliance and concordance. He suggests that human beings generally respond better to suggestion, reason and coercion rather than direct imposition of arbitrary change.
Conclusions and discussion
To a large extent we have discussed the aspects of the various elements of change that the NHS Plan calls for under the headings above. The original premise that the plan does require a “fundamental change in thinking, practice and delivery over the next decade”, from the evidence that we have shown, is probably not in dispute. The most important and fundamental conclusion that we can come to however, is that it would appear that many of these changes are already underway. (Stevens et al 1999)
Testament to this are the plethora of other government initiatives that have been introduced both before and after the NHS Plan, some of which we have examined, together with the academic papers that are now appearing in peer reviewed journals which already espouse the concepts outlined in the Plan. (Cato 2005)
It is also clear that these apparent and proposed changes do not impact only upon the discipline of physiotherapy, but upon almost every other discipline of healthcare to a greater or lesser degree. (Haggerty et al 2003). It follows from this that these same changes will have a demonstrable (and hopefully beneficial) impact upon the delivery of patient care.
We are now five years on from the original publication of the Plan and anyone working in the NHS will certainly be aware of the pace of change that is apparent in the organisation (Berger 2001). Those of us who have been working in the NHS for long enough, will probably observe that the pace of change will not ultimately depend upon the enthusiasm of the healthcare professionals for that change, nor even on the skill of the managers who are charged with implementing that change, but it will actually eventually depend, like so many initiatives before it, on the amount of money that the Government actually makes available to implement the changes that it’s Government White Papers call for. (Beech et al 1996)
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