Clinical Management in Anaesthesia

42 Pages·2010·0.72 MB·English

Clinical Management in Anaesthesia
Published by
The Association of Anaesthetists of Great Britain and Ireland
21 Portland Place, London, W1B 1PY
Telephone [phone] Fax [phone]
[email protected]
www.aagbi.org May 2010
Membership of the working party
Dr I H Wilson Chair and AAGBI President Elect
Dr V R Alladi AAGBI Council Advisory Member
Dr P Bell AIM Council Member
Dr L W Gemmell AAGBI Honorary Secretary
Dr A Hartle Secretary and AAGBI Honorary Secretary Elect
Dr I G Johnston AAGBI Honorary Treasurer
Col P F Mahoney Defence Professor in Anaesthesia & Critical Care
Dr C Meadows GAT Immediate Past Chair
Dr W Rawlinson AIM Council Member
Dr E Tierney AAGBI Irish Standing Committee Member
Dr C Williams GAT Representative
This guideline has been seen and approved by the Council of the
AAGBI.
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Contents
1. Recommendations 3
2. Introduction 4
3. NHS structures 6
4. Hospital structures 13
5. Leadership roles in anaesthesia, intensive care and pain services 16
6. Managing people 22
7. Training in management 25
8. Clinical management and the law 28
9. Defence medical services 30
References 32
Glossary and resources 33
To be reviewed in 2013.
© Copyright of the Association of Anaesthetists of Great Britain & Ireland.
No part of this book may be reproduced without the written permission of the
AAGBI.
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1. Recommendations
Clinical management is a core responsibility within the consultant role that
requires training and development.
Effective clinical management is key to running a safe and efficient hospital
including anaesthetic services.
Clinical managers must have the time, resources and administrative support
to perform the role.
Clinical managers should have clear lines of accountability and a formal job
description.
There should be an open and transparent process for the appointment of
clinical managers.
All doctors take legal responsibility for their actions involving colleagues,
trainees and patients.
Clinical managers take legal responsibility for the safety of their service;
chief executives are legally accountable for the quality of care within their
hospitals.
All doctors need to understand local and national management of their
health service.
All doctors and managers have a responsibility to work together for safe
patient care.
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2. Introduction
The National Health Service (NHS) is the fourth largest employer in the world
and spent more than £100 billion in 2009. The system is hugely complex
and needs expert management from political level to the patient interface to
ensure that healthcare is prioritised appropriately, the funds are used well and
that care is delivered safely.
Clinicians have many responsibilities in management and anaesthetists are
involved at all levels of healthcare management. The term NHS is used
throughout this publication to indicate government provided health services.
This small guide about management will describe:
• Information about how the separate national health services in the
UK, Eire and the Armed Services are organised.
• How NHS hospitals and departments are organised.
• Management roles within the NHS for clinicians including training
opportunities.
• Routine management tasks.
• A glossary of organisations contributing to healthcare management.
We anticipate this information will prove useful to trainees grappling with
the complexities of the NHS, particularly as they prepare for a consultant
interview. Anaesthetists who are interested in taking up a management role
will find the information helpful, and the accompanying website resource
will continue to develop both as a library of articles and as a source of
extensive links to relevant external organisations and publications.
Every doctor is a leader/manager
All doctors are managers of some description, in organisational, supporting
or training roles, as well as running their clinical service. Anaesthetists make
up 15% of the consultant workforce, work with a wide range of services
and are ideally placed to contribute to running services. Sub-specialties of
anaesthesia, such as pain management and critical care, involve a great deal
of organisation. Most medical leaders start learning their skills in a small way
such as rota management, representing their peers or chairing a committee.
Many anaesthetists find the challenge of management in medicine absorbing
and progress to medical director posts.
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Why should I be interested?
Those working in publically funded health services would always aspire
to improve services, but in reality are part of a political system that grants
money to health, education, social care and defence, amongst others. The
decisions as to how money is apportioned, and how effectiveness is judged,
are complex issues. Doctors need to be involved at the highest level where
decisions are made. All of us should ensure that our own part of the service
runs effectively and safely, but also develop a view that takes the whole of
the NHS forward.
For many years consultants in departments have traditionally taken it in turn
to fulfil the management/leadership role, instead of recognising that the task
involves expertise different from anaesthesia. More recently Trusts have
appointed medical managers with a job description and paid sessions to
carry out the work.
Unfortunately the role of clinicians being involved with management is
seen negatively by some colleagues as having ‘moved to the dark side!’
Fortunately this culture is improving, and it is the view of AAGBI and
Anaesthetists in Management (AIM) that clinicians should be managing
clinical services with the support of their colleagues if the NHS and
anaesthetic services are to advance. The importance of management as
part of a doctor’s role has been emphasised by specific guidance from the
General Medical Council (GMC). Management is also one of the five areas
assessed in the NHS Clinical Excellence Award scheme.
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3. NHS structures
United Kingdom
In 1948 the Health Minister, Aneurin Bevan, established the NHS as a free,
comprehensive health care service, available to the entire population. When
the NHS was launched in 1948 it had a budget of £437 million (roughly
£9 billion at today’s value). In 2008/9 it received 10 times that amount -
more than £100 billion. Nearly 80% of the total budget is distributed for
patient care. The money to pay for the NHS comes directly from taxation.
In the view of independent bodies such as the King’s Fund, this remains the
“cheapest and fairest” way of funding health care when compared with other
systems.
The NHS has three main components: family practitioner services,
community based services, and hospital services. The general principles
governing the NHS have been the same throughout the UK, although the
ways in which health services have been organised have varied. Devolution
led to the first elections to the Northern Irish Assembly in 1998 and the
Scottish Parliament and the Welsh Assembly in 1999. All of these bodies
have responsibility for the organisation and delivery of health services which
has resulted in a system of four different national health services across the
UK, and patients in England, Scotland, Wales and Northern Ireland receiving
different standards of care.
There have been several re-organisations of healthcare provision over the
years and the following represents the situation in 2010.
England
The Government allocates funds to the NHS in England via UK taxation.
The Secretary of State for Health decides how these funds will be spent
and is accountable to Parliament for the overall performance of the NHS in
England.
Department of Health (DoH)
The DoH is responsible for running and improving the NHS, public health
and social care in England. This organisation provides strategic direction,
secures resources, sets national standards and invests in the service.
Strategic Health Authorities (SHAs)
There are 10 SHAs which manage the NHS at local level and act as a link
back to the DoH. Responsibilities include:
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• Developing plans for improving health services in their local area,
• Ensuring quality of local health services,
• Increasing the capacity of local health services,
• Making sure national priorities - for example, programmes for improving
cancer services - are integrated into local health service plans.
Primary Care Trusts (PCTs)
There are 152 PCTs in England, each charged with planning, securing and
improving primary and community health services in their local area. They
work collaboratively with patients, the public, GP practices, and partners to
deliver these healthcare services. PCTs are allocated 75% of the NHS budget
to fund services and are accountable to their local SHA. PCTs commission
secondary care from hospitals, independent hospitals and treatment centres
via service level agreements.
Hospital Trusts
NHS Trusts employ the majority of the health service workforce. They obtain
most of their income via service level agreements negotiated annually with
their local PCT on a ‘payment by results’ basis. Trusts that exceed contractual
expectations receive more funding. Trusts that fail to deliver their contract
have their funding reduced.
Foundation Trusts have more financial and managerial independence than
Hospital Trusts and are appointed and regulated by Monitor. Monitor has
statutory powers to authorise NHS Trusts as NHS Foundation Trusts, oversee
compliance by NHS Foundation Trusts with their terms of authorisation
(like a ‘licence’ to operate) and intervene in the event of significant non-
compliance with the terms of authorisation and other statutory obligations.
Other Trusts
Ambulance Services and Mental Health Care are also delivered by NHS
Trusts.
Arm’s Length Bodies (ALBs)
The DoH works with three kinds of ALBs:
• Executive agencies that have responsibility for particular business
areas - the agencies are still part of and accountable to the DoH. The
Executive agencies are the Medical and Healthcare Products Regulatory
Agency (MHRA) and NHS Purchasing and Supply Agency (PASA),
• Special health authorities are independent bodies, but can be subject to
ministerial direction like other NHS bodies. There are 13 special
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health authorities that include the National Patient Safety Agency
(NPSA) and the NHS Litigation Authority,
• Non-departmental public bodies have a role in the process of national
government, but are not part of government departments. There are
nine non-departmental public bodies. The Council of Healthcare
Regulatory Excellence is an example.
Scotland
In 1999 direct responsibility for health and education was devolved in
Scotland to the newly established Scottish Parliament led by the Scottish
Executive. In 2008 the Scottish Executive was rebranded as the Scottish
Government and the post of Minister of Health replaced by the Cabinet
Secretary at the Department of Health and Wellbeing. The Scottish
Government Health Directorate is now responsible for both NHS Scotland
and for the development and implementation of health and community care
policies.
The Chief Executive of NHS Scotland leads the central management of the
NHS, is accountable to the Government for the efficiency and performance
of the service, and heads the Health Department which oversees the 14 NHS
Boards responsible for planning health services and 8 additional ‘Special
Boards.’
Regional Health Boards
Health services are delivered through 14 regional NHS Boards which are
responsible for the provision and management of the whole range of health
services in their areas, including hospitals and general practice. Hospital
Trusts (introduced by the UK Government in the early 1990s) were abolished
in Scotland in 2004 and amalgamated into the Regional Boards.
Each Board has its own individual structure but generally includes a
Corporate Services Division (management and planning), Specialist Services
Unit (hospitals), Community Health Partnerships which include community
health services and form a link between primary care and specialist services
and sub-divisions such as Managed Clinical Networks , mental, sexual and
dental health, and pharmacy.
Special Boards
In addition to the 14 regional Boards Scotland also has 8 Special Boards
which are funded directly by the Scottish Government Health Directorate.
These comprise of:
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• The Scottish Ambulance Service,
• The NHS National Services Scotland. Formerly known as the Common
Services Agency, this provides a variety of specialist services including
health statistics, blood transfusion services, communicable disease
surveillance, national screening programmes and remuneration of
primary care practitioners,
• NHS 24 – a 24-hour telephone health advisory service for patients,
• The State Hospital (Carstairs) – the sole high security hospital in
Scotland,
• NHS Health Scotland – a national focus for improving health in Scotland
by encouraging healthy lifestyles,
• NHS Quality Improvement Scotland (QIS) – has the remit of improving
the quality of healthcare in Scotland by implementing and monitoring
national standards of care. The Scottish Patient Safety Programme
(similar to the NPSA in England) harbours under the umbrella of QIS,
• NHS Education for Scotland – the training organisation of NHS
Scotland,
• National Waiting Times Centre Board.
Funding
The National Health Service in Scotland is funded by UK taxation and the
predicted budget for 2010 exceeds £11 billion of which approximately
£8.6 billion will be allocated to the Health Boards. Since 2000, 70%
of the available funds have been allocated to Health Boards in line with
the ‘Arbuthnott Formula’ which was based on patient population and the
additional costs of supplying healthcare to specific areas and patients with
greater needs. It is planned, in view of the subsequent changes to the service
and patient demography, to replace ‘Arbuthnott’ in 2009-10 with a new
formula derived by the NHS Scotland Resource Allocation Committee.This
will also be based on patient population and area specific costs, but will
take better account of the effects of increasing life expectancies on available
resources and the under-utilisation of services in deprived areas.
Wales
Following devolution in 1999, the National Assembly Wales (NAW) has
full legislative power for health in Wales. It contains the Office of the Chief
Medical Officer [CMO] (who advises the government on health matters) and
the Health and Social Services Committee (who contribute towards NAW’s
health policy development). As a result of the Government of Wales Act
1998, the NAW has adopted the powers of the old Health Authorities, which
ceased to exist on 1st April 2003. The Welsh Assembly Government (WAG)
is the executive body of the NAW, comprising of the First Minister and the
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