Management in Health Care - Essay Example

Management in Health Care Virtually all health care systems face the same problem with regards to allocation of the limited resources available in order to service a growing number of service users that want the services offered, now this poses as a challenge since it is an almost impossible task to provide identical services to everyone given the limited supply (Sabik & Reidar 2008). Prioritizing patient care continues to be a political dilemma, addressing the problem is necessary in order to provide for a just rationing of the already scarce health care resource. The problems now facing the health care industry stemmed over the last few decades from the increasing cost of health care which may be due to an ageing population and a more health conscious society. Included in the concerns raised was also what seemed to be a lessening quality of care being delivered by the health care industry (Donabedian, Wheeler & Wysezewianski 1982, p.975) In 1991, the NHS internal market adeptly replaced resource allocation owing on areas that needs capitation funding, it can be surmised that funds follows the user to the point of service. Per person payments are seen as a cost-containment tactic in the sense that they are able to provide organizations with an enticement to withhold care regardless of its necessity to the patient (Price, Pollack & Shaol 1999 p.1891) however, these per person payments - fixed amounts of cash that provide themselves to co-payments and customer purchases in the private sector - this scheme thereby facilitates the replacement of public funding to private funding by way of private insurance and service user charges, while also providing for private services for public services. These types of capitation structures or models are also supported and advocated by the World Bank (http://www.worldbank.org/nor/class/module1/sec7i.hbm 7i). In the UK, the decentralization of capitation expenditure to family-physician fund holders has allowed for the replacement of private health insurance and user charges for some publicly funded care good examples are pharmaceuticals/ medications and elective surgery (Kerrison & Corney 1998), while also allowing for the transfer of public funds into the private sectors like elective surgery, private outpatient treatment centers, podiatry, physical therapy, and capital infrastructures. In April 1999 the introduction of the primary-care groups and primary care trusts accelerated the process (Pollock 1998). Primary care groups were given the choice to expand private health insurance and user chargers or copayments when their National Health Service per-person budgets are limited, and they will be given more leverage to utilise the private sector. An example of a copayment system is about to be tested in the United Kingdom under the department of employment and education. The said department is going to provide a UK£10,000 “individual learning account” to school-leavers to compensate for education after age 18 years, as well as apprenticeship costs in the public or the private sector (National Youth Agency 1999). Service delivery changes in creation of corporations In the UK, the National Health Service body has been re-instituted on private sector contour, or corporatized, by the obligation of business accounting practices. For instance, the sole constitutional duties of National Health Service provider trusts which are the hospital and community services are financial and not health-care duties; The National Health Service bodies must get by after having collected some proceeds for their vendors, in this instance, the government, that corresponds to a 6% return on capital investment. A similar practice will be relevant to primary-care trusts as well, which will also be tasked to conduct themselves commercially as if they have share holders. This resource bookkeeping, which is shortly to be introduced throughout all UK public services, makes public and private sectors seem interchangeable. Resource accounting is a requirement for public-private partnerships. Public-private partnerships It will be of note that the UK government is currently outsourcing labour-intensive services and investment-intensive infrastructure development through what is called a public-private partnerships (or private finance initiative in the National Health Service). The privatisation of public funds has been accomplished by almost eliminating new public funding for capital projects such as hospital refurbishment (Gaffney et al 1999) through the introduction of direct government financial support to the private sector and through formation of proceeds that can be abstracted to the private sector as leasing income. These policies are happening to a greater or lesser degree in all UK public services and are being widely imitated in other developed countries (Price, Pollock & Shaol 1999). The rationing agenda About three decades ago, rationing of health care was never an issue, until of late however; the cost of healthcare has become a foremost focus of public policy. As the society in general and the government in particular look for ways to control the healthcare costing, we are becoming more and more of the value of economic trade-offs concerned with healthcare decisions. Allocation of specific resources for one service means lesser resource left for further services; resources allocated for one patient will mean lesser resource availability for the next patient and lesser even for the one after that. The importance of correct rationing cannot simply be disregarded, and that it is becoming more visible publicly unambiguous at every level of the healthcare system although in some sections it may be conducted implicitly and inadequately discussed. Healthcare resources are preset while healthcare resources needs are not, it may be realise that allocating available resources are actually rationing decisions. In this sense one may realize that rationing of resources implies that not all will receive the service they need, want and desire secondary to cost cutting. Becoming aware of rationing must be encouraged among medical practitioners, Ubel and Goold (1997) stated three conditions that must be met in order to realise rationing. The first is that physicians have control over the use of the valuable service, the second having withheld, withdrawn or failed to offer a service that will be medically beneficial to the patient and lastly these medical practitioners act to promote someone else’s interests other than their patients including the physician themselves or other physician, the hospital or organization they work for or even the society in general by conserving the available healthcare resource for other patients. Rationing is a technique of distributing scarce resources. Bureaucrats like the orderliness of rationing because it eases the problem of administering healthcare budgets. Academics enjoy the celebrity of fathering new theories of healthcare rationing with or without technicalities attached. Many governments would like to ration health care for financial reasons, but hesitate to do so overtly for fear of electoral repercussions. The majority of physicians, carers and other providers as well as patients are guarded in their view of rationing (Cook & Giacommi 1999). Priorities should be set in all the healthcare system in whatever level of costing and regardless of the financing methods employed. The choices that have to be made and these choice do vary in between systems but one must realize that the priority setting is generalized, although priority setting is not exactly rationing, it forms a part of the process of rationing just as breaking is part of the driving process. It must be understood that priorities can be placed without rationing but rationing cannot take place without priority setting regardless of the criteria used for the setting. Although the greater the pressure to cost cut, the likelihood that the quality of care will suffer is inevitable, in the sense that it will be neglected or downgraded in order to adapt to the cost cutting schemes. There seems to be a rising discontent with patients not getting enough care although this might be construed as anecdotal as by statistical substantiation. In the US an opinion survey of ‘non-institutionalised adults’ in 1998 provided an edge for traditional insurance coverage over the managed care on all available criteria but the differences were not large enough to denounce managed care altogether. The lack of convincing evidence or a proven link between cost containment and awful outcomes are the primary reasons for classification of the present problems as grey areas. It might be derived that not all the problems of healthcare can be faulted to cost cutting and rationing alone but also to a weak and negligent healthcare management. Vast differences in the performance of providers and outcomes for patients are common when comparing the results from different location with the same healthcare system employed. While rationing can be blamed for a part of the phenomenon witnessed, an actual cause and effect correlation remains to be unsubstantiated. At the national provincial and state levels, policy states that investments in tertiary care hospitals are to be weighed against investments in other healthcare and social services including primary care, education and transportation. For example, the UK has a relatively small healthcare budget (approximately 6 percent of its gross national product in 1992) and allocates only 1–2 percent of hospital budgets to intensive care. This is in contrast to the USA, where 15 percent of gross national product is spent on healthcare and 20 percent of this is spent on intensive care (Chalfin & Fein 1994). At the level of healthcare administration, decisions must be made about where to locate ICUs geographically among communities. Autonomy is reflected in the current trend toward healthcare planning in concert with patients' values and preferences. The advance commands movement demonstrate rationing according to the principle of autonomy. Patients determine their own level of care, and medical practitioners use these articulated wishes to direct capital toward or away from a specified patient. Given cost control pressures, the standard of autonomy can be most effortlessly upheld if everyone had rather modest requirements. However, in the extreme, autonomy requires that even profligate wishes be esteemed and met. Patient autonomy can thus be at odds with physicians' essential to benefit the patient, as in the case of requests for unproven or useless behaviour. Autonomy can also be at odds with the physicians' mandate to do no injury, as in the case of wishes for assisted suicide. Ethical principles have been previously applied to such complex issues as informed consent, brain death, organ transplantation, organ donation, resuscitation, and the administration, withholding and withdrawal of life support. The significance of ethical dilemmas as they relate to rationing serious care has been captured in several consensus declaration and position papers on futility, triaging, and the distribution of medical assets. Although rationing according to necessitate tends to be professionally easy and publicly satisfactory, this approach can run counter to service principles when one very needy patient consumes an unbalanced amount of healthcare resources. The traditional 'rule of rescue' when life is threatened represents the naissance spirit of intensive care medicine. However, directing ICU possessions where they are needed most may not maximize the probability of individual patient benefit. All who triage have been faced with a choice of whether to give the last ICU bed to a patient who appears most in need (the most ill patient) versus a patient who is most likely to benefit from treatment (not always the most ill). A survey of the Society of Critical Care Medicine suggested that critical care providers were not inclined to make choices about distributing limited resources on the basis of who might benefit most (Society of Critical Care Medicine 1994). Maxwell’s Framework of Quality Access Patients are not disadvantaged in their access to services through constraints such as expanse, waiting times, design of structures or verbal communication barriers. Equity Each service has identical claim to the resources obtainable and is distributed proportionately between the diverse groups of patients using it. Relevance to need The kinds of service provided reflect health needs and requests and the amount of service made available is representative of those requirements. Social acceptability The services provided gratify the realistic expectations of patients in a way that is publicly acceptable to them and does not disagree with their social values. Efficiency The service uses the available resources favourably and is cost effectual and suitably staffed with the staff amply trained as well. Effectiveness Appropriate care is specified, the service construct the intended or desired results and patients show and report favourable results from the facility. The principles enunciated by Maxwell (1992) of equity and access may well be threatened if empowerment is interpreted to mean compliance in a request for further treatment which the pertinent professionals estimated to have a higher likelihood of failure. Dissimilarity needs to be drawn between empowerment at a collective level, ensuring that organization are in position for the patient’s voice to be heard and empowerment at an personal level, arguing for particular forms of intervention for oneself or one’s relatives. Adequate admission to healthcare is a basic human right closely related to the preservation and fortification of human dignity. The health care system of this country needs genuine reform. A national health program that guarantees universal access to complete care while containing costs and diminishing administrative meddling in the practice of medicine. We need a national health program that allows patients free choice of providers and physicians’ free choice of practice background. We need a national health program that provides widespread coverage regardless of age, sex, race, income, sexual orientation, or any other factor. Care Homes Review: Eleanor Palmer Trust Home The Eleanor Palmer Trust Home is a plush purpose-built home set in the leafier part of the London Borough of Barnet. The trust is a contribution set up to help the people of Barnet and the care home tends to take populace only within the borough. The manager is also eager to encourage discussion – particularly among residents – about how the home is run. The home is provided with a healthy budget and is second to none, including training budgets. The staff is dedicated; some staying for seventeen years and that is not a common occurrence. The home’s manager tries to keep channel of communication open with family of existing residents and those that simply want to see what care homes offer for their loved ones. Even without an appointment, people searching for a nice home can always come to the trust home. Life in Eleanor Palmer Trust Home  There are plenty of activities in Eleanor Palmer. Hanging on every wall are residents’ art which also facilitate as a reference point for people walking around the open halls and corridors. Each year the home also commemorates the Eleanor Palmer Trust Day in honour of its benefactor who left a trust for the people of Barnet on her death bed 450 years ago. During the day, staff dress up in period outfits and families and the locals join the festivities. Harmony home Harmony Home is a large, extended Georgian house located in Sutton Bridge,the home boasts of seventeen bedrooms, 12 singles and 5 doubles, of which 9 are en suite. Each bedroom is roomy and amply furnished, although residents are more than welcome to bring their own furniture. Since manager Mala Chandrapalan acquired management at Harmony, the home has made significant improvements. This has been recognised by the regulator. In its most recent CSCI inspection – carried out in January 2008 – Harmony was awarded a two-star quality rating, which translates as providing ‘good’ quality care. All seven categories assessed by CSCI were rated either ‘good’ or ‘adequate’. In the January report, CSCI noted that “significant improvements” have been made since it was taken over – and since its previous examination in August 2007 – with residents’ care needs now fully and suitably met, many areas in the home refurbished and managerial systems modernized. A room at Harmony is in the low to mid price range, costing between £350-£448 per week. Harmony home was deteriorating – it was under staffed, failing fire regulations and CSCI was so worried that it had banned the home from taking in new residents. Since then an estimated £100,000 was spent on renovations and equipment to bring Harmony Home up to standard. While the manager has made physical changes to Harmony Home, changes were made with the traditions within it. The existing team of carers has been substituted, caring practices have been renovated and the new staff has had ample training. Life at Harmony Home Harmony has three lounges, each with a different emphasis; one for music, another for TV and the other for reading or studying. There is also an activities programme, which comprise a visiting organist and regular church services on Sundays. The home also has its own minibus with wheelchair access, so excursions are becoming a standard feature. One may note that even as the two care homes provide care for the elderly significant differences can be noted. Eleanor Palmer has noted a consistent good quality rating while Harmony runs only as adequate. A difference maybe mismanagement of the part of Harmony while its management changed, significant changes were made and they are slowly crawling their way up the CSCI quality standard measurement, while Eleanor Palmer managers continued it aim for service quality. The two care homes reviewed services the elderly, one may note that an elderly can choose Harmony despite its lesser rating if it meets their needs of lower rates and a more quieter and sedentary life in the care home, while more active service users may choose to stay in the Eleanor Palmer home if they wish to be more active and prefer the more active environment rather than the sedentary ones that Harmony offers, that is if they can afford the higher price range. In this sense, one may note that a service user may choose one home over the other depending on their needs and desires during the time they enter the home or what they perceive they wish their retired life become, making either home more adequate for their needs. According to Martin & Yuan (2003) quality should always consider the service users and providers. In the health and social care service quality can be construed by the service users in the concept of how they receive the care, how they are treated during the delivery of the service and the outcomes of the services acquired (Martin & Yuan 2003 p.178). But one might also realize that quality means a variety of things to a variety of people. Quality for one individual may not mean quality for another, but quality must be realized as being able to meet the consumer’s ultimate requirement. The National Minimum Standards for Care Homes for Older People center on attainable outcomes for service users - that is, the impact on the individual of the amenities and services of the residence. The standards are clustered under various cluster of key features but this paper focus on the first six standards explained as follows. Choice of home (Standards 1-6) Each home must create a statement of purpose and other informational papers like a service user’s guide that will set out its aims and objectives clearly, the range of services available at the home and the terms and conditions on which it does so in its contract of occupancy with residents, so that potential clients/residents can make an knowledgeable choice if the home is right for the needs of the particular individual. Copies of the most recent inspection should also be provided for perusal of potential residents. While it is not expected that every home offers the same amount of the services and lifestyles, it is important to provide a variety of choices should they decide to move into the specified care home, by requiring the care homes to provide an open source of services they offer, leaving choice to chance is solved. There cannot be any room for doubt on either parties, and a range of choices across the care home sector can be sustained. Modernising Social Services called for standards that center on the major areas that most influence the value of life experienced by service users, as well as physical standards. The consultation development for growing the standards, and recent research, verify the significance of this stresses on results for service users. Fitness for purpose. The regulatory powers provided by the CSA are designed to ensure that care home managers, staff and premises are ‘fit for their purpose’ Comprehensiveness. Life in a care home is made up of a variety of services and facilities which may be of greater or lesser importance to different service users Meeting assessed needs. In applying the standards, inspectors will look for substantiation that care homes meet up evaluated needs of service users and that individuals’ altering needs go on being met. Quality services. The Government’s modernising agenda, including the new regulatory framework, intend to make certain greater assurance of quality services are provided rather than having to live with second best. Quality workforce. Proficient, well-trained managers and staff are crucial to accomplish good quality care for service users. The National Training Organisation for social care (TOPSS) is burgeoning a national occupational standards for care staff, including training competencies and establishment programmes. Conclusion While many stakeholders such as clinicians, patients, the public, and administrators, should have a voice in health-care rationing at the policy level, engaging all relevant parties in a meaningful manner is difficult. To what extent clinicians and other stakeholders take a leadership role in the dialogue in such settings is inconsistent. Rationing issues are ideally influenced by inter -disciplinary input from diverse perspectives outside of healthcare professions such as epidemiology, economics, ethics, philosophy, law and political science. Discussion about health resource allocation should not take place only in classrooms and boardrooms. Increasingly, are called upon to balance their role as patient advocate and health resource manager for society. Although this can create a sense of conflict for us, we are most likely to become aware of our daily rationing decisions if we make them in light of both responsibilities. Whether autonomy, utility and equity (or any other principles for that matter) are consciously considered when we ration is unclear. For years, supporter of a government-run healthcare system have argued that all health care should be free at the point of utilization and that it is unwarranted (and perhaps also unwise) to ask people to compare the value of health care with the cost of getting it. But if health care were made absolutely costless, the system that provides it would collapse into chaos. Understanding resource allocation in any sector of healthcare begins with knowing what goes on today. How do we currently balance patient self-determination with fiscally responsible care? What are the socio-cultural determinants of such decisions? Are we able to recognize the inferred personal beliefs and population values that motivate our rationing decisions? How are we influenced by personal incentives when caring for critically ill patients under conditions of resource constraints? Is life support withdrawn sooner from declining patients when resources are in short supply than when they are not? Investigating the formerly silent problem of rationing is fundamental to understanding the performance of medicine as we approach the next millennium. Modern health service research agendas will find such lines of inquiry enlightening and highly relevant to healthcare policy. If health care is rationed by bureaucracies, the tendency is to discriminate in favor of higher-income patients, and in favor of the young, thereby contradicting the sworn advocacy of medical practitioners to care for all the sick and not choose who to care for. The sophisticated, the wealthy, and the powerful almost always find their way to the head of rationing lines, whereas markets empower individuals, bureaucracies empower special interests. However, not only are resources are being traded off, but principles are being traded off as well. Given the imperative to contain healthcare costs, healthcare professionals are frequently faced with tensions between three principles and to obey the cost cutting scheme it is typical that one has to compromise one of the principles in the service of another. Until a few years ago, most health policy analysts did not believe in health care rationing. Their goal was to lower all financial barriers through public and private insurance and to meet any and all needs. Today, almost everyone recognizes that rationing is essential. In an ideal system, rationing would be by patient choice wherever possible. The system would be organized so that people would have the funds necessary to purchase health care through medical savings and reimbursements from insurers. But the power of choice would be in the hands of the patients, not the bureaucrats. References Chalfin DB & Fein AM (1994), Critical care medicine in managed competition and a managed care environment. New Horizons 1994, vol. 2, pp. 275-282. Cook D & Giacommi M 1999, The sound of silence: Rationing resource for critically ill patients, Critical Care, vol. 3, pp. R1-R3 Donabedian A, Wheeler J, & Wysewianski L 1982, Quality, cost and health: An integrative model, Medical Care, vol. 20, no. 10, pp. 975-992. Gaffney D, Pollock AM, Price D, & Shaoul J 1999, NHS capital expenditure and the private finance initiative: expansion or contraction? British Medical Journal, vol. 319, pp. 48 – 51 . Kerrison S & Corney R 1998, Private provision of “outreach” clinics to fund holding general practices in England, Journal for Health Service Policy Research, vol. 3, pp. 20-22. Maxwell, RJ 1992, Dimensions of quality revisited: from thought to action, Quality in Health Care, vol. 1, pp.171-7. National Youth Agency 1999, Parliamentary Policy: National Youth Agency - youth policy update, October, pp. 5-6. Price D, Pollock A & Shaol V 1999, How the World Trade Organization is shaping domestick policies in health care, Lancet, vol. 354, pp. 1889-1892. Pollock A 1998, Snowed under. Managing Care, November, pp. 6–7. Sabik, L & Reidar L 2008, Priority setting in health care: Lessons from the experiences of eight countries, International Journal for Equity in Health, vol. 7, no. 4. Available from Society of Critical Care Medicine 1994, Attitudes of critical care medicine professionals concerning distribution of intensives care resources, Critical Care Medicine, vol. 22, pp. 358-362. Ubel P & Goold S 1997, Recognizing bedside rationing: clear cases and tough calls, Annals of Internal Medicine, vol. 126, pp. 74-80. Read More