Changing Clinical Care

Experiences and Lessons of Systematisation

Andrew Gray, Pieter Degeling, Abayomi McEwen

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315347042
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

"Changing Clinical Care" adopts a fresh, nursing and patient-centred approach to systemisation to aid patients and their carers. The evidence-based methodology outlines real-world experiences in various sectors of healthcare including primary care, cardiac services, general surgery, and care of long term conditions. It sheds light on possible difficulties and examines the key lessons learnt in providing effective systemisation including common problems, pit-falls and effective solutions. It includes high profile prologues by Dame Carol Black, (Past President, Royal College of Physicians of England) Dr David Colin-Thome (National Clinical Director for Primary Care, Department of Health, England) and Professor Alison Kitson (Executive Director, Royal College of Nursing). This book is ideal for all healthcare professionals interested in systemising the delivery of care. It is also of great interest to healthcare policy makers and shapers, and academics and researchers.

PART ONE

Concepts and contexts

CHAPTER 1

Conceptualising and practising the systematisation of care

Pieter Degeling and Andrew Gray

This book is about the systematisation of care: who is interested in it, why interest has increased in recent years, the changed structures and practices that are central to it, how some clinicians and managers have experienced these changes and what they and we have learned from them. This conjunction of systematisation and care, however, begs a number of questions. What, for example, do we mean by the systematisation of care? How does ‘systematised care’ differ from other approaches? Are we suggesting that these other approaches are devoid of systematisation? Have our conceptions of what can and should be systematised changed over time? What has stimulated the changes and what have been their effects?

Systematisation is not a new idea in healthcare delivery. On the contrary it has a long history, notably in medical knowledge and skills as well as the licensing of practitioners. For example, medicine’s standing in modern healthcare delivery owes much to the systematisation of bio-medical knowledge that emerged from the Enlightenment’s empiricist reappraisal of the body and the self.¹ Medicine’s writ, at the levels of both society and the individual, has since been built on its perceived capacity to generate, harness and apply a systematic body of knowledge in making expert clinical judgements and intervening on the bodies of their patients for therapeutic effect. Equally, medicine has long recognised that its writ depends on systematic profession-based structures for specifying by whom and to what ends medical knowledge can be applied. Until recent times its success in this regard was continually reinforced as actors in health policy circles, clinical settings and therapeutic encounters routinely enacted the ensemble of practices, rules, values and meanings that underwrote medicine’s institutionalised mandate to define what constitutes disease and illness and to determine what was required for the proper conduct of its work and that of other clinical occupations.

For its part, the development of nursing as a profession has also involved systematisation of its knowledge base and licensing arrangements. More particularly, since Florence Nightingale collected data on hospital mortality rates and devised the Polar Area Diagram to graphically represent her results, nursing’s professionalisation has been founded on the practical systematisation of patient care in respect of, for example, the recording of patient signs and symptoms, infection control, the management of pain, rehabilitation and medications and the development and implementation of more holistic models of care that take account of the experience of both patients and care providers.

Broadly, similar concerns inform the papers presented in this book. Our interest in care systematisation is grounded in a recognition that the pan-professional and across-setting interconnectedness of care provision differs between identified patient groups, such as those undergoing a normal birth delivery, a hip replacement, or an acute exacerbation of an underlying chronic condition. Accordingly, the following discussion proceeds from the view that care delivery for each of these patient populations is systematised in so far as:

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  the interconnected network of tasks that need to be performed (for each case type) has been prospectively designed, planned, sequenced as a consistent and coordinated whole to optimise their instrumentality in achieving specified therapeutic ends, and
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  the resulting condition-specific care processes are observed, monitored and routinely reviewed and benchmarked by the people who are involved and affected by their performance to the benefit of improved efficiency, effectiveness and quality.

Construed in these terms, care systematisation depends on structures and practices whose operations are grounded in a recognition of the centrality of frontline medical, nursing, allied health and managerial staff in the design, provision and improvement of care processes to nominated patient types with whom they are directly involved. In the longer term, these bottom-up structures provide means for re-establishing responsible autonomy as a guiding principle in healthcare organisation. This will occur, largely, through the collective self-control that clinical teams exercise as they prospectively design care processes for nominated case types and then in transparent ways hold themselves accountable for their performance.

Such collective self-control also underlines the centrality of multidisciplinary conversations between doctors, nurses, allied health professionals and managers to engage routinely and in systematic multidisciplinary conversations about questions such as the following.

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  Are we doing the right things? That is, in the light of assessed health needs and existing resource constraints, are we delivering value for money and, on a condition by condition basis, appropriate and effective services?
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  Are we doing things right? That is, are we managing risk, safety, quality and patient evaluations appropriately and, on a condition by condition basis, are we performing the sequence of tasks whose occurrence or nonoccurrence significantly affects quality, outcome and cost?
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  Do we have the capacity to get better? That is, on a condition by condition basis, what strategies are in place for improving the care process and clinical skills development?

The realisation of the grounded developmental potential of this model of systematisation, however, runs counter to historically embedded factors in most healthcare systems. From its inception in 1948, for example, care provision within the National Health Service (NHS), has represented the dayto-day working out of high level bargains between, on the one hand, the State and the electorate and, on the other, the State and the medical profession. The State’s bargain with the electorate is registered in the continuing provision of a National Health Service equally accessible to all, funded from universal taxation, free at the point of use and provided according to clinical need rather than the ability to pay. The bargain with the medical profession is registered in the commitment of the government when establishing the NHS to give the profession ‘all the facilities, resources, apparatus and help I can, and then leave you alone, as professional men and women to use your skills and judgement without hindrance’.²

The deference to professional autonomy embedded in this commitment has left successive governments with the problem of finding ways and means of reconciling their national accountability for NHS performance with the autonomy of professionals working locally. Put simply, while the national government provides for the total level of publicly funded health expenditure, doctors control local allocation of these resources through their clinical decisions. The fulfilment of the government’s obligation to the electorate requires not merely that it provides adequate funding but also that it takes responsibility for establishing organisation and management processes that, notwithstanding the claimed autonomy of medicine, are capable of delivering services as and where they are needed.

Against the backdrop of these cross-cutting tensions, healthcare reforms have through governments of various political hues progressed from a concern about (a) the systematisation of the NHS as an administrative structure, to (b) systematisation of resource management within delivery organisation, and (c) systematisation of the monitoring arrangements for matters nominated as generic to healthcare quality. In the remainder of this chapter we examine these concerns before presenting some thoughts on where ways forward are likely to be found, particularly in respect of the organisation and management of clinical care.

Systematisation of Care as Administrative Structure

At the time of its establishment in 1948, the administrative oversight of the NHS was divided between 850 administrative bodies ‘each with its own separate tradition and fiercely protective of its autonomy’.³ Among others were executive councils (responsible for relations with general practitioners, pharmacists and other independent contractors), local government health authorities (whose writ covered local community-based services), 16 regional hospital boards (responsible for hospital-based services), 36 boards of governors of teaching hospitals and 380 hospital management committees comprising a lay administrator, a medical administrator and a finance officer each of equality of status.

Taken as a totality, the arrangements demonstrated the importance of three principles: (a) the accommodation of institutional interests, (b) the emphasis on localism (the authority of locality-based executive councils, regional hospital boards, local authorities and hospital management committees) and (c) the faith placed in profession, in particular medicine. However, as noted by Klein,⁴ these principles produced three effects. First, stripped of its rhetoric, the NHS actually comprised a collection of nationalised but locally oriented hospital services that were only loosely linked to publicly funded primary care services run by general practitioners who operated small businesses. Second, there was a wide diversity of orientations and outcomes of service delivery at local levels. Third, service development at local level was shaped largely by the historical inheritance of individual localities.

It was soon apparent, however, that changing social, economic and political circumstances meant that the inherited status quo was unsustainable. Demographic change (ageing) and patient expectations (medical science and technology) were increasing demand for acute services, and the lack of integration between GPs, acute services and social services was producing outcome failures and inequities. On a more optimistic note, moderate economic growth furnished the prospect of replacing or refurbishing the existing hospital building stock in ways that improved the distribution and scope of hospitals to optimise new technology and promote service efficiency and effectiveness.

In 1959 the Ministry of Healt...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• List of contributors
• Prologue: clinician views
• Part 1 Concepts and contexts
• Part 2 Experiences
• Part 3 Implications
• Index