I think that commissioners of services need to be much tougher when monitoring services being delivered by outside bodies. For example, my organisation delivers transport getting patients to and from hospital. It was only we flagged to the commissioner that we were carrying a high number of patients to a hospital in the west Midlands from gloucestershire that the commissioner relised that the consultant was having all the patients travelling to him rather than the consultant carrying out clinics in gloucestershire as per his contract. The ambulance service who we sub contracted did not flag this to the commissioner.
Our focus has to be on Effectiveness and Efficiency, but the step-change required from Archie Cochrane's day is introduce new ways of monitoring effectiveness and efficiency throughout the system as part of routine day-to-day care, not just in RCTs and occasional surveys. Once we link data on activity and case-mix with outcomes and experience, we will have most of what is needed to monitor performance.
The problem with the NHS (and conventional medicine) is that the treatments do not work to cure the patient. They just make him addicted to the drug, which keeps the NHS staff and Big Pharma in business. CAM is an alternative health service which works (othrwise it would go out of business) The 2 services should be merged by integration, as the Prince of Wales has been advocating. CAM is much more cost effective in curing the patient, and has no side effects, and no deaths by medicine (see garynull.com)
Quality and productivity improvements are not mutually exclusive terms. Should all NHS boards not have confidence that all the care pathways they deliver to their patients have been recently reviewed against best practice both for the standard of clinical intervention, minimisation of patient inconvenience (i.e correct bundling of diagnostics and pre-admission procedures) and efficiency of admin and clinical process. If all our organisations had the level of clinical and managerial engagement necessary to deliver this then the improvements in productivity we must deliver can be achieved as a by-product of good quality care.
The NHS needs to have a serious discussion with itself about what it is there to do and what it is not there to do, less could well be more in a financially constrained environment. Whatever it does do should be of the highest quality and clearly link to a paradigm that embraces a holistic, effective community/preventation based approach to intervention. I fear many current NHS practices are reactionary and disempowering, which is not totally surprising given the high level of dependence on illness models as opposed to good health models.
As a medical manager, I am involved heavily in both making operational management decisions and experiencing these amongst a clinical peer group. There is an urgent need to provide the NHS workforce as a whole with those tools that will bring about, in some cases, radical changes to services while improving their effectiveness and acceptability. Currently, there are varying degrees of good intentions and great ideas but a lack of the practical skills needed to redesign services efficiently and collaboratively at the coal face.
Community based midwifery care has been shown to respond to parents needs, provides higher quality care and is cheaper. What is the King's Fund doing to promote and encourage implementation of that?
Maternity services are a key theme for The King's Fund and so we have several stands of work in this area. In 2008, the Fund published the findings of it's Maternity Inquiry; Safer Births: Everybody's business makes practical recommendations in seven key areas: teamworking, staffing, training, guidance and information relevant to safety, the role of trust boards, and the role of national bodies concerned with safety and maternity services. We have now establshed a Safer Births network of 12 maternity services across England who will work together to imporve the quality, safety and value of maternity care in their areas. The King's Fund also expects to undertake further work in this area in due course including reseach into effective and efficient staffing models for maternity services.