General Management at the Various Levels in the NHS - Example

Running Head: PUBLIC SECTOR HEALTHCARE Public Sector Healthcare [Name Of Student] [Name Of Institution] INTRODUCTION The Griffiths Report, which was accepted and implemented by the government in 1983, was highly critical of the NHS management at all, levels. It identified the failure of management as the central problem of the NHS (Mitchell & Vousden, 1985). In this respect, it criticized 'consensus management', mentioning the lack of a clearly defined general management function throughout the NHS. By general management, it meant the responsibility drawn together in one person, at different levels of the organizations, for planning, implementing and control of performance. The report also found a lack of identifiable individuals who would accept personal responsibility for real continuous assessment of performance against such measures as level of service, quality, budget control, cost improvement, productivity, and motivating and rewarding staff (Bowman, 1986, p. 40). The report recommended the establishment of general management at the various levels in the NHS. General management implied a single individual who would deal with strategic management. The general managers were expected to stimulate initiative, urgency and vitality, and to bring about a constant change for improvement and cost reduction, and to secure proper motivation of staff (Bowman, 1986, p. 41). They were also responsible for policy execution, service efficiency and effectiveness, the improvement of health service performance and, not least, a greater awareness of customer needs and preferences (Barnard & Harrison, 1986, p. 1216). AIM OF THE PAPER In this paper I will compare UK and an Asian country (China) and discuss the extent to which public sector performance management has improved the delivery of public service of healthcare. BACKGROUND The development of effective models of community care in the UK has been slow and patchy and the current preoccupation with shortages of beds and `over occupancy' in acute admission wards can be directly related to the failure to develop community alternatives such as supervised housing, work and employment schemes, intensive community support teams, etc. Without such services, it is entirely predictable that those who have the most severe and disabling conditions will accumulate in hospital, or will rotate ever more rapidly in the `revolving door' of acute admission, premature discharge to inadequate support in the community, relapse and re-admission. Such is the fate of many people with severe fitness troubles nationally. Given the relatively small room for manoeuvre in health budgets (because of the high contribution of inpatient costs) Health Authorities and Trust managers have thus been caught between the proverbial `rock and a hard place' and there has been little incentive to develop specialist services for people with fitness troubles. Perhaps the new White Paper (Department of Health, 2004b) will help redefine this relationship between primary care and specialist health services and assure more equitable (and effective) forms of `targeting': we will have to wait and see. DISCUSSION A culture of `blame' has also grown up which is fundamentally antithetical to the development of new services. This has been fuelled by well-publicised cases of `untoward incidents' in which members of the public have suffered death or injury apparently at the hands of people with serious health problems (mostly schizophrenia). The public inquiries, which have inevitably followed under the terms of the Guidance note (Department of Health, 2003b) have led to a widespread loss of confidence that anything can be done to salvage' community care' and that, from a policy point of view, it has demonstrably failed. Many professionals now seem to share this bleak conclusion. These are not exactly the most promising conditions for the development of innovative community services. What constitutes quality is a difficult question for health care providers because quality has many dimensions. A brief review of the health care literature shows the problematic nature of the definition of quality in the Chinan sector. The biggest dilemma that they face is of over-population and less circulation of resources to meet the needs of the growing population. For instance, Dopson and Cabbay (1987) indicated that quality spans four broad areas: consumerism, professional and technical standards, establishing a suitable balance of service, and ensuring value for money. These dimensions of quality are partly derived from the work of Maxwell (1984) and Shaw (1986a, b) who see these as integral aspects of quality. Others see quality in UK healthcare as the appropriateness and effectiveness of the clinical care delivered to patients, and the manner in which this care is delivered (NHS –National Health Service Management Bulletin, 1986, p. 2). Seen from this perspective, efficient technical care delivered without compassion, courtesy or regard for the patient's wishes is unlikely to satisfy most people's criteria for quality. Robinson and Strong (1987,p. 11), building on Vuori's (1982) and Maxwell's (1984) views on quality, add the concept of humanity. Humanity here implies the provision and delivery of health care that is sensitive to the complexity of individual needs, including human dignity. Sloan (2002,p. 65) provides a discussion of the difficulty in defining health care quality, mentioning that consumers tend to emphasize responsiveness, symptom relief and courtesy, funders are concerned about efficiency, while providers value technical skills and desired outcome. Searstone (2001) argues that due to the lack of agreement on the definition of quality, some writers on the topic prefer to use such measures as 'fitness for purpose', 'conformance to specification' or 'satisfying customer needs'. Searstone (2001,p. 249) cites some internationally agreed definition of quality as: The totality of features and characteristics of a product or service that bear on its ability to satisfy stated or implied needs. The adaptation of this definition of quality to health care in China has two different sides, either stated or implied, which affect quality management in an organization: that is, the what and how. The 'what' deals with the quality and efficiency of treatment and the 'how' the administration of care, contact with nurses, premises, hygiene and so on. According to Giles and Williams (2001,p. 29) the 'what to do' implies using quality management to satisfy internal and external customers (patients and staff). It also includes regular measurement of customer satisfaction and the implementation of plans for improvement and monitoring. This implies cross-functional cooperation to deliver what the customer wants. On the how-to-do-it, managers motivating and empowering all employees in the organization achieve quality management. Thus, senior management sets priorities and initial goals and allocates responsibility. Resource needs and senior management supports required are determined. This has been so far effectively followed in the UK healthcare but in China we see traces of paperwork indicating change, but on practical level, no change is witnessed. Senior management provides the agreed resources (people, money, training, machines, etc). Measurable goals are set to ensure that everyone's work and priorities, which have been clearly defined, fit in with the organization's priorities. Again, progress is thus monitored regularly according to an agreed timetable, extra resources are allocated if necessary, and attainments are swiftly rewarded (Giles & Williams, 2001, p. 29). Kogure goes on to give three functions of quality assurance. He argues that quality assurance should contain some customer-oriented activities as well as ordinary quality control activities. The deliverer of the service should carry out activities to ensure quality and take responsibility for assuring quality to meet customers' requirements while at the same time carrying out discrete, customer-oriented activities to provide circumstances where customers can obtain services with confidence. According to this perspective, if we analyze UK healthcare, quality assurance provides three fundamental functions, namely securing quality, ascertaining quality and verifying quality. The first involves an in-built quality process, the second involves such issues as inspection, quality audits and survey of customer satisfaction, and the third involves activities that tell customers about securing and ascertaining quality. Examples are the issuing of certificates, systems to prevent recurrences such as projects undertaken by quality circles, and preventions in advance as well as dealing with customers' complaints and compensation. In the health care setting, MacDonald and McCoy (1987) suggest that quality assurance is the method for assuring that a quality product is continuously delivered. Specifically, MacDonald and McCoy (1987,p. 24) define quality assurance as: The process of assuring the consumer a specific degree of excellence of a product or service through continuous measurement and evaluation, using established criteria and standards, for the purpose of improving the product or service . . . In a health care context, it is accomplished by developing and implementing both hospital and departmental standard of practice. Collard and Sivyer suggest that total quality management, which they define as, should back a quality assurance system: A cost-effective system for integrating the continuous quality improvement efforts of people at all levels in an organization to deliver products and services that ensure customer satisfaction. They admit that this definition, while imperfect, conveys the idea that total quality management goes beyond the functions of quality assurance, which emphasizes the prevention of deficiencies. Thus, although total quality management is not a technical system, it fosters a sense of quality consciousness, awareness, motivation, understanding and commitment of employees at all levels. In this respect, total quality management is a management philosophy which links customer needs to organizational goals. It involves every department, function and process in the organization and the active commitment of all employees to meeting customer needs (Searstone, 2001, p. 251). total quality management then is a cultural phenomenon and is non-existent in the Chinan healthacre and as such quality assurance is not the same as total quality management. quality assurance ensures that controls are in place to ensure excellence in the provision of services (Cheng, 2002) and furthermore to ensure that the service meets customers' needs and expectations of quality. total quality management is much more than that. As Giles and Williams (2001,p. 30) put it, total quality management is a long-term and holistic approach to people and systems which links quality consciousness and culture into the whole organizational strategy. Often, there is confusion about total quality management and quality assurance. There is the tendency to label all other approaches to quality management as total quality management. THE RANGE OF INTERVENTIONS INDICATING PERFORMANCES The range of interventions necessary to support a comprehensive, community service for people with severe and enduring health problems are well described in the `Spectrum of Care' document (Department of Health, 2004a). They comprise the following elements. Accommodation It is something of a truism to state that without adequate accommodation effective community care is impossible, but nevertheless it bears repeating. What is difficult is to specify the precise levels of the different kinds of accommodation that are required. Attempts have been made (e.g. Wing, 2002; Strathdee et at., 2000); however, general prescriptions always require qualification based on local conditions. The greatest shortages are still probably regarding high support housing of various kinds (including `24-hour nursed beds') but even then the possibilities of substitution of one kind of facility or service by another (e.g. intensive support teams instead of high support housing) make `normative planning' difficult. In UK we find proper facilities but in China patients die before they even get a chance to see the doctor. Work and employment Next to accommodation, most users place work and/or employment as their next, most urgent, priority. Again, the aim must be to provide a range of work opportunities -- assessment and training, placement in open employment with support, sheltered social firms and co-operative businesses, etc. (see Pozner et al., 2000) to cover the range of users' needs. However, just as is in housing, one should not expect everyone necessarily to move through the system, acquiring progressively more skills and independence and therefore requiring less and less support. Some will and some will not. It is therefore important that individuals are allowed to settle at their own `level'. There must be opportunities to move on (e.g. toward open employment) but also opportunities to stay if this is more consistent with the individual's wishes and abilities. Users also value services that they see as having a positive `image' and as being well regarded by others (Dick & Shepherd, 2004). It is thus insufficient that professionals regard a particular work programme as representing `good practice'. The crucial question is, `Do users want to go?' If not, then it does not matter what the professionals think, it is unlikely to engage some of the most difficult, younger people with fitness troubles who actively reject conventional day and work programmes. Again work and employment are such crucial factors that indicate progress in performance. We see growth opportunities for British people but China lags behind miserably. Over population is a major cause for it. Though the government is now trying to solve the issue but the infrastructure has to be addressed at the grass-root level for any positive change to take place. Specialist community teams If services are going to work successfully with the most difficult and disabled people, then there need to be specialist teams, clearly targeted, with small, protected caseloads (n=10-15), `extended hours' of operation (i.e. outside Mon./Fri. 9-5) and the capacity to deliver intensive support (i.e. daily visits) using an `assertive outreach' model. Such teams have been developed in the UK (Thompson, Griffith & Leaf, 1990; Hambridge & Rosen, 2003) and are now beginning to appear in China (Ford et al., 2004) but progress is slow. It is important to distinguish between these `intensive support' teams and `crisis intervention' services. Although the two kinds of teams share some features in common (e.g. assertive outreach, extended hours, intensive visiting) the skills mix and methods of working are quite different. Thus, `crisis teams' tend to be focused on the short-term, with an emphasis on symptom resolution; whereas intensive support teams have a longer-term perspective, with more of an emphasis on support and the optimizations of social functioning. Crisis teams are therefore much more reliant on the use of medication and hospitalization, with the aim of rapid symptom stabilization; while intensive support teams give more emphasis to practical help, social support, and facilitating access to `mainstream' community activities. In-patient beds The final elements in the necessary range of services to support people with serious and enduring illness in the community are in-patient beds. No matter how good the models of intensive support (or crisis intervention) are in the community, from time to time users will continue to require in-patient admission. It was noted earlier that, currently, acute inpatient beds are often in very short supply. However, as many as a quarter of such beds may be occupied by people who staff consider to be `inappropriately placed' (Shepherd et al., 2004). The majority of these would be better (and less expensively) looked after in a variety of supported settings in the community if these were available. The problem is that such facilities are generally in very short supply and so are the intensive community teams which would make possible the use of a wider range of ordinary housing options. Hence, we have the impression that community care is `failing'. CONCLUSION This brings us to the final area: that of reducing stigma and presenting more positive role models. The direct involvement of users in service provision may be one route into this, but for many people with severe and enduring health problems living in the community `stigma' is a palpable reality, a recurrent feature of their everyday lives (Rose, 2004). It is not only a source of distress, but also a barrier to housing, jobs, friends, etc. It would be comforting if we could rely on the media to present more positive coverage of health issues, but this seems unrealistic. However, we can undertake to work with user (and career) groups to form genuine partnerships that recognize each other's different perspectives and do not try to gloss over differences. We can also try to ensure that positive achievements are, at least, recognized locally. REFERENCES BOWMAN, M.P. (1986) Nursing Management and Education: A Conceptual Approach (London, Croom Helm). CHENG, T.C.E. (2002) A case study of hospital quality assurance, International Journal of Quality and Reliability Management, 9, pp. 21-29. 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