Contemporary issues on NHS

A policy is typically defined as a principle or rule to guide decisions and achieve rational outcomes. It is not used normally what is actually done, it is normally referred to as either procedure or protocol. A policy will contain what and the why procedures. A policy can be considered as a statement of intent. Policy may apply to generalized private sector organization and groups and individuals. In another way policy can be defined as a collection of different ideas and methods which is used for the improvement in any field including health care and the other hand, health policy is a practical device or advantageous procedure and positive course of action.

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Social Policy is a subject area, not a discipline; it borrows from other social science disciplines in order to develop study in the area. The contributory disciplines include sociology, social work, psychology, economics, political science, management, history, philosophy and law. The name social policy is used to apply 1) that policies which are used by the government use for welfare and social protection, 2) to the ways in which welfare is developed in a society and to the academic study of the subject. In the first sense, social policy is particularly concerned with social services and the welfare state. Improvements to social policy are a key element of development and the achievement of human rights. Many social policies are addressed by the third committee of the UN general assembly.
Health policy can be defined as the decision, plans and action that are undertaken to achieve specific health care goals within the society. According to the World Health Organization, health policy can achieve several things. It defines the vision of the future. We can define the different categories of the health policies, eg pharmaceutical policy, public health and personal health care policy, tobacco control policy. Before 1990 there was a good collaboration of health and social care policy.
Contemporary issues on NHS
National Health Services is the United Kingdom health services organization. The short form of National Health Services is NHS. It was stabilised in 1948. It was grown the world’s largest publicly funded services. It is also known as a most efficient, most comprehensive and egalitarian. In the Second World War and difficult scenario NHS was established. The principle of NHS always remains in the core. It was born for good health care and should be available to all. The NHS is the free services for anyone who is resident of the United Kingdom. The NHS only charges some prescription and optical and dental services. NHS is giving the free services more than 60 million people. It covers everything such as antenatal screening routine treatment for coughs and colds to open heart surgery, accident and emergency treatment and it also covers the end of life care.
Mainly it is funded from taxation. In United Kingdom they have separate management in England, Wales, Scotland and Northern Ireland; in many respects they are similar. Despite their separate management and funding there is no any discrimination when a resident of one country of the United Kingdom requires treatment in another although a patient will often be returned to their home area when they are fit to be removed?
It is the huge organization. In this organization have more than 1.7 million employees and half of them are clinically qualified, including 120000 hospitals doctors 400000 nurses 40000 GP’s practises and 25000 ambulance staff. The NHS of the England is the biggest part of the system It is caring more than 51 million people and employing 1.3 million people. The number of patients using the NHS is large. Every 36 hours it is dealing a million in the England, in Scotland 463 in minute and more than 700000 people will visit on NHS dentist and 3000 heart operation, here are 10000 GPs in nationwide. Each GPs look more than 140 patient in a week.
NHS is spending big amount of money. When the NHS established the starting budget of the NHS is 9 billion and now the budget of the NHS is 100 billion in year which is increasing by 4% every year. It is spending 60% of the budget to pay the staff, and 20% for the drug suppliers and remaining 20% is spending for the equipment and training costs. 80% of the total cost is distributed by the local trusts.
HEALTH AND SOCIAL CARE BILL: TO REFORM THE NHS FROM WHITE PAPER “LIBERATING THE NHS”
We know that the “health is wealth”. In any country of the world health is the backbone of the country and the main important is government funded health organization. If any policy is taken related to the health it affects the outcomes of the services. In the United Kingdom NHS is only one and which cover the almost 100% of the services. Now the government took a new policy for NHS Which is liberating the NHS. The Health and Social Care Bill was introduced into Parliament on 19 January 2011. The Bill is a crucial part of the Government’s vision to modernise the NHS so that it is built around patients, led by health professionals and focused on delivering world-class healthcare outcomes.
The Bill takes forward the areas of Equity and Excellence: Liberating the NHS (July 2010) and the subsequent Government response Liberating the NHS: legislative framework and next steps (December 2010), which require primary legislation. It also includes provision to strengthen public health services and reform the Department’s arm’s length bodies.
The Bill on health and social care 2011 contains provisions covering five themes:
It is strengthening commissioning of NHS services
It is increasing public voice and democratic accountability.
liberating provision of NHS services
strengthening public health services
Reforming health and care arm’s-length bodies.
Structure of NHS
Department of health
Strategic health authorities
Primary care trusts
GPs Dentists Hospitals
Patients
The Department of Health (DH) is in overall charge of the NHS with cabinet minister reporting as secretary of state for health to the minister. The 10 Strategic Health Authorities (SHA’s) are under the department of health which oversee all activities of NHS IN England. The strategic supervision of NHS is controlled by each SHA in its area. The NHS services of Scotland, Wales and Northern Ireland runs separately by the developed administrations. Primary care trusts are divided into primary care and secondary care. Primary care is the front line services. GPs, Dentists are primary care where people contacts first time. Secondary care can be defined as a acute health care and can be either elective or emergency care. Primary care is the centre of the NHS and they cover and control 80% of the NHS budget. These are the local organizations so they know the needs of community and they can make sure the organizations providing health and social care services are working effectively. The PCTs oversee 1800 NHS dentist and 29000 GP. Here are 175 acute NHS trusts and 60 mental health trusts which control the 1600 NHS hospitals and specialists care centres.NHS ambulance trusts provides the emergency ambulance services, in UK there are 11 ambulance trusts.
The NHS structure shown below which will be happened after reforming,
Independent board
250 + GP consortiums GPs Dentist specialist service
Hospitals, community services, mental unit intensive core
Patients
After reforming the NHS structure there would be the change in the management not in the whole system of the NHS, but changing the management system it directly affect the top to bottom shake of the NHS. which will directly affect the model of care of the NHS.
Reasons of reforming the NHS
NHS is the great national institution. The main principle of the NHS when it was founded is free at the point of use and available to every one based on need and it is not focused for ability to pay. Most of us believe it can be so much better for both the patient and professionals. So that the government took the bold vision for the NHS future, which is ‘equity and excellence’. According to the different surveys and analysis NHS of the United Kingdom is world class. It is giving the facility without cost and it is also employing more than 1.6 million people which mean it is giving a good services. According to the Health secretary Andrew Lansley says that NHS is the world class in some respects but it is not good enough in some areas eg ; rate of mortality, United Kingdom is the 2nd largest mortality rate among the 24 richest country in the world and rates of mortality for some respiratory diseases and the stroke has been the worst in the developed world. Now the NHS has too much bureaucracy, after reforming NHS would be more accountable to the patients and all the staff will free from excessive bureaucracy. In the structure of the NHS there are 10 strategic health authorities, 175 NHS trusts and 60 mental health trusts. After reforming It will increases spending on real terms of the health not in managing. Department of the health says NHS has further to go on managing care more effectively and international evidence prove it.
The changes of NHS are
The main changes are fundamental changes to structure and the operation which changes the social economic and managerial changes. The main structure of changes is a England’s 175 or so primary care trusts will be wound up in 2013 and their work, commissioning healthcare will pass to groups of GPs called general practise commissioning consortiums (GPCCs). Every GPCCs which will have existing practises will have own budget. The constriums will collect the £ 80 billion from the total budget of NHS and GPCCs are agreed to contacts with hospital and other. More than 200 GPCCs have been set up. The outcomes or changes will be taken by keeping the patient on the heart of the NHS. The patients will have more choices and control by the easy access of the GPs and hospitals. Patient will have the right of decision making about their treatment and care. It will be focused in clinical outcomes. Success will be measured by the bureaucratic process targets, but the against results that really matter to patients such as improving cancer and stroke survival rates. The capacity will be increases or will empower the professionals. Doctor and nurse will have right of professional judgement about the patient treatment. This thing will be supported by controlling the front line staff. If patient want they will have the access information, they can make choices. Patient will have the right of choosing the GP practise, consultant led-team and any provider. Hospitals will require to open their mistake, if something wrong patient must know it. The patient voice will strengthen by local authorities. The targets will be removed with no clinical justification. The quality standard of NICE will inform the commissioning of all NHS care and payment system. The drug companies will be paid by the value of their new medicines, follow of money will be transparent, comprehensive and stable payment system across the NHS to promote high quality care, drive efficiency and support patient choices. The service provider will get the money according to their services performance, payment should reflect outcome not just activity and provider an incentive for better quality. The NHS fundamental structure is controlled by the department of health, after reforming there would be one independent and accountable NHS commissioning board, and NHS will be the under control of this commissioning board. This board will allocate the NHS resources lead on the achievement of health outcomes. This board will promote and improves the patient involvement and choices. Another duty of this board will promotes equality and tackle inequalities. Day by day the minister power will be limited for the decision of NHS. The changes will be shaking top to bottom of NHS structure.
Benefits of NHS reforms
It is the big institution of health. After reforming there should be some changes with the facility of the NHS. GPs could more than double their income to £ 300000 per year this is the direct impact of the NHS reforms. It also cuts the bureaucracy. NHS foundation trusts are given significantly greater financial freedom and power. It increases the quality of primary medical services. Now the NHS budget is increasing 4% per year after reforming it will increase just 0.1% per year.
Model of care
Model of care is directly impact to the patients and it affects the whole output of the organization. I have already described the model of care in changes of NHS. when the people born in the world at first he is known only male and female at that time there is no any discrimination like that way United Kingdom National Health Service believes in the universality. In NHS there is no any discrimination for the treatment of the patient, it is only believe for the medical requirement, it doesn’t separate the richest and poorest of the people. It gives the treatment free of the cost. If the people of the different country which have more than 1 year resident permit he is also can take the benefit of the NHS. While starting the NHS at that time people have no right of choices, but now a days they have right of taking decision of their care. Day by day patients are increasing and also the NHS also increasing employee’s which gives the good services for the patient which is the positive point of the model of care. We know that NHS is employing the large number of employees.
Now a day United Kingdom government is focusing the reforms of the NHS, many arguments were taken about the patient of care; I thought it’s better to describe the different arguments here. British Medical Association is the leading association of the medical staff in the UK, but the British Medical Association said against the reforms of the NHS. According to the BMA: more than 150 organizations and 80 percent budget of the NHS will go to the GPs hand. Financially and managerial power is given to GPs which increases the bureaucracy. This proposal is unmanaged damaging and unjustified. This damages the patients care. There are different surveys says after reforming its affect a patient care. According to the Unison after the cutting of the staff its directly increase the workload for the nurses and doctor and other staff. The survey said that 88% think that during first year of the coalition government their workload has increased, and 65% said that rise of hitting patient care and safety. Around 67% of nurses said that increasing the workload direct impact on their health, and 69% said their job is not suitable or bad for family life. This will direct affect the model of care. Beside these arguments I thought that after reforming the NHS the model of care would be better. Equality and excellence liberating of the NHS Says patient are always in the core and after reforming patient will have many choices, they will have their decision for owns care, and they can tell no decision without me, which is not in the today’s model of care. Managerial cost will be saved which will be used to empower the technical and professional things, these things increases the model of care better.
Conclusion
Health is the backbone of the any country without healthy people country cannot be developed. Health and social care policy is directly related to the health of the people. So that government should think about how to take the policy, policy should not be taken without justification. I have already mentioned that policy is the key role of the development. Now the Government took the new policy about the National Health Services (NHS). in the history of the NHS government took many policies related to the health but this policy would be the biggest policy which will change the fundamental or it will shake the top to bottom of the NHS. in my opinion government should take the policy step by step not like big shake up. The implementation of this policy is very costly. British Medical Association already rejects this policy and many people are against of this. Health and social care policy and model of care are interrelated; this means how the patient will be treated, if the policy is failed then what would be the condition of the country. This policy cuts the thousands of jobs which will increase the unemployment, this policy increase the price competition allowing hospitals to undercut one another to attract patients, poses a risk to standard of care. some surveys said doctor will be the account after implementing this policy. ‘Health is wealth’ This is the universal truth so that government should not play the life of the people. According to health secretary Andrew lansley this policy “equity and excellence liberating NHS” will make the NHS bright future.
 

The Nhs In England Health And Social Care Essay

National Health Service had been created in 1948 and for the last decades it has been facing numerous reforms and structural changes in attempt to raise its effectiveness and competitiveness and to reduce costs.
This report focuses on STEP analysis of major external factors and trends that might influence future activity of NHS and shape its structure.
Findings of the report are:
Social:
Population of England has increased by 7% in last 4 decades and with average age of 38.8 years (from 34.1 years in 1971)  . Overweight/obesity, ethnic differences in health care approach and high treatment costs for immigrants present main social challenges for the NHS. Citizen participation, social inclusion and partnership programs are seen as possible answer to these challenges.
Technological:
Coalitional government ended National Programme for IT in England and is preparing new ‘Information Revolution’.
Recent reforms that include abolition of primary-care trusts and establishment of GP commission require new IT solutions.
Increasing community and home based health care are based on efficient telehealth and telecare services and require further development of IT technologies.
Additional investment in research and development of IT technologies is necessary in order to cope with development of modern health care services.
Economical:
NHS will receive significantly lower annual budget increase, compared to previous years and it is expected to present £20bn (GBP) in savings by 2013-14.
With the abolition of PCT budget of roughly £80bn (GBP) will be transferred to management by GP commission.
Political:
Coalitional government presented new reforms that focus on implementing administrative and structural changes in NHS. Emphasis of the reforms is on giving more power and choice to the consumers, decentralising management and significantly reducing administrative costs.
Introduction
This management report is a STEP analysis of the NHS in England. The report sets out the key issues within each STEP for the organisation and can be used as the basis for further analysis. A conclusion identifies the key issues arising from the STEP analysis for the NHS in England and also sets out the strengths and weaknesses of the STEP approach and the challenges encountered when undertaking the analysis.

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STEP 1: Social
The majority of the population in England and Wales use the services of the NHS (about 8% of the population use private health care). The NHS needs to be aware of demographics changes as this will have a significant impact on demand for NHS services as a whole and on demand for particular products and services. The key social issues that the NHS in England needs to consider are:
Population growth rate and age profile
Health of the general population
Issues related to ethnicity
Issues related to immigration
Governance patterns, social inclusion and partnerships building.
Population growth rate and age profile
The UK population reached 59.8 million in 2004; its highest ever level. It has increased in size by 7 per cent in the three decades since 1971, when the figure was 55.9 million. But this population growth has not occurred at all ages. In fact, some age groups have shrunk and so have become a smaller proportion of the whole population.  The ageing of the population will affect the types of services required and the way in which they are provided.
Population health
About 46% of men in England and 32% of women are overweight (a body mass index of 25-30 kg/m2), and an additional 17% of men and 21% of women are obese (a body mass index of more than 30 kg/m2 ). Overweight and obesity increase with age. About 28% of men and 27% of women aged 16-24 are overweight or obese but 76% of men and 68% of women aged 55-64 are overweight or obese. Overweight and obesity are increasing. The percentage of adults who are obese has roughly doubled since the mid-1980’s. The effect of these trends is increasing requirements for different types of equipment (eg. stronger beds).
Ethnicity
Pakistani and Bangladeshi men and women in England and Wales reported the highest rates of ‘not good’ health in 2001. Pakistanis had age-standardised rates of ‘not good’ health of 13 per cent (men) and 17 per cent (women). The age-standardised rates for Bangladeshis were 14 per cent (men) and 15 per cent (women). These rates, which take account of the difference in age structures between the ethnic groups, were around twice that of their White British counterparts. Chinese men and women were the least likely to report their health as ‘not good’. Women were more likely than men to rate their health as ‘not good’ across all groups, apart from the White Irish and those from Other ethnic groups. Reporting poor health has been shown to be strongly associated with use of health services and mortality. White Irish and Pakistani women in England had higher GP contact rates than women in the general population. Bangladeshi men were three times as likely to visit their GP than men in the general population after standardising for age.
Immigration
Since 2004, a record 1.8 million foreign workers have come to Britain, including an estimated 700,000 from Eastern Europe. And yes there have been problems. Migrants have put pressure on the NHS by using casualty departments as GP surgeries. TB rates are also up and the cost of translators in hospitals to deal with foreign patients can be crippling for health authorities.
Governance patterns, social inclusion and partnerships building
Citizens participation becomes more and more important to fill the gaps of government’s failure. Many initiatives related to public health issues, for example reducing the incidence of drug misuse, can never be achieved without involving citizens. The UK is a pioneer in deliberative democracy, which is an ideal vehicle for the promotion of health based voluntary / statutory sector partnerships.
STEP 2: Technological
The increasing efficiency and effectiveness of the NHS in England is dependent upon the appropriate use of technology, and affects both the acute and primary care sectors. The key technological issues currently facing the NHS in England are:
The IT impact of the abolition of Primary Care Trusts (PCTs) and the move to GP Commissioning
How to address the results of the UK Government’s changing national health IT policy
Continuing the development of teleheath and telecare to shift the balance of care from the acute to the community sector
In general, continuing to fund and integrate technological developments in service provision that offer improvements in economy, effectiveness and efficiency.
The abolition of Primary Care Trusts
The abolition of PCTs and the move to GP Commissioning means there is a need to ensure effective IT structures are in place to support the move. PCTs will need support to ensure the data they hold is dealt with appropriately – be it destruction or move to other organisations. There may be a need to consider national guidance.
GPs and service providers will also need support to ensure their IT systems are able to communicate with each other effectively and have the capacity to deal with increased records. There may be a need to consider national guidance.
National health IT policy
The new coalition government ended the National Programme for IT in England and has just finished consultation on its new ‘Information Revolution’.  3The previous programme aimed at providing a number of national IT services, such as Choose and Book (the national electronic referral system); PACS (central picture archiving service for eg x-rays); and the national electronic subscriptions service. Some of these programmes were completed under the previous government, however, many are still in development. The coalition government has expressed their desire for local IT solutions, however, many of the programmes are tied to national contracts with the private sector. The NHS in England needs to examine the cost of termination (and the costs of providing alternative local solutions) vs continuing with the existing contracts, contrary to government policy. There is a need for further clarification from the government and continued engagements from the NHS with the coalition.
The development of telehealth and telecare
Moving care into the community and supporting people to live in their own homes for longer requires increasing use of telehealth and telecare technology. There are numerous benefits for the NHS in England and its users, for example those in rural communities able to access consultant appointments via computer rather than travelling large distances, and more people living longer in their own homes.
These developments need continuing support from the centre if health bodies are to continue to develop these. Central funding may also be required to continue research into this area and technological development.
Continuing technological developments
The NHS in England needs to continue promoting the benefits of new technologies to health bodies and providing support (small scale funding, guidance) to help trusts implement these. The 2009 NHS IM&T Investment Survey indicated that capital investment at local level has remained static over the past 5 years, it is only the injection of central funding that has led to increases in this area. Emphasis needs placed on health trusts to continue to fund developments.  
STEP 3: Economic
The key economic issues facing the NHS are:
The outlook for public sector finances
The effect of GP commissioning
The impact of staff pay and conditions (cost of labour)
The cost of capital/diminishing capital resource and investment
Public sector finances
As a result of the coalition government’s desire to address the effects of the global economic crisis and its attempt to quickly reduce the budget deficit, resources available from central government are projected to increase less quickly than in recent years. The rise for 2011 of just 0.1% represents a significant decrease in funding compared to increases in recent years. This is further compounded by cuts in the levels of cash received by hospitals for treating patients. Commentators suggest that the effect of the cuts will require the identification of £20bn (GBP) in savings by 2013-14. The NHS in England needs to quickly identify how it will continue to provide care with reduced levels of funding. This may include actions such as reducing staffing levels and increasing out-sourcing of services.
Effect of GP Commissioning
The abolition of Primary Care Trusts and the move to GP commissioning brings both opportunities and risks associated with the handover of almost £80bn (GBP) from central to local control. While previous experience would suggest that GP commissioning improves efficient use of resources (efficiency fell by 1.6% after the abolition of internal markets in 1997) (see reference 1) it is possible that individual hospitals, patients and the GPs themselves may lose out. GPs may spend more time involved in administrative tasks and less time with patients; patients may be affected by the level of engagement with commissioning on the part of their GP and some hospitals will fare better than others under the revised arrangements. Retaining control of NHS spending is a significant challenge when accountability for the use of public funds essentially lies in the hands of private contractors. Effective financial controls will be necessary to ensure demand management is not simply ‘left on the shelf’ and that resources are used both effectively and efficiently.
Pay and conditions
Staff costs as a proportion of total costs are high within the NHS. The effects of minimum wage and, more recently, the implementation of the European Working Time Directive continue to drive costs up, even as staffing levels remain static or fall. Efforts to ensure trusts comply with the Working Time Directive have backfired by ensuring staff record hours worked more accurately leading to increased overtime payments and identification of additional need. In addition, the effect of cuts in staffing both through voluntary and compulsory redundancies will place additional (albeit relatively short-term) pressure on finances in the form of pay-offs and pensions.
Capital assets and investments
Many PCTs acknowledge that the current period imposes reductions in capital investment. Short term savings accrued by delaying investment may lead to increased costs in the future. In addition, numerous trusts have sold off capital assets to remain competitive in recent years, thereby reducing asset value now and for the future. The use of PFI/PPP/DBO may offer short-term benefits (by reducing direct capital expenditure) but risks remain with regard to the long-term commitment and associated cost of such contracts.
STEP 4: Political
The change in government from Labour to Conservative/Liberal Democrat in 2010 resulted in a significant shift in political attitudes towards the NHS in England. The drive to reduce centralised control and increase local responsibility has resulted in a number of key policy initiatives.
Coalition programme
The coalition programme for healthcare included the following subjects:  
Greater financial autonomy for local bodies
Involvement of GPs in tackling health care problems
Improved access to preventive healthcare for disadvantaged areas
Reduction of long-term costs.
The specific programme for the NHS included the following:  
Real term budget increase for next 5 years.
Reduction of quasi-non-government-organizations (quangos).
Cut administrative costs by 30% and use these resources to support doctors and nurses.
Discontinue closure of A&E units and of maternity wards.
Restructure health system giving more power and freedom of choice to patients and transferring commissioning powers from PCTs to GPs.
Development of monitoring system to oversee aspects of access, competition and price-setting in NHS.
Establishment external and independent board to allocate resources and provide commissioning guidelines.
Introduction of rating system for health care providers that will allow patients’ contributions and will be accessible online.
Reform NICE into value-based pricing, to allow broader access to drugs and treatments for those who need them.
Introduction of per-patient funding for hospices and providers of palliative care, and allocation of additional 10 million pounds a year from the budget to support these children’s hospices.
Improvement of service quality through involvement of independent and voluntary providers and through giving patients ability to choose provider that suits them most.
Reforms
Andrew Lansley, the health secretary, introduced plans for NHS reform in August 2010 (White Paper of announced reforms is available here).
The main topics were:  8
Delivering commissioning power to purchase health care for the patients to GPs who are to join consortia by 2013.
Abolishment of 10 strategic health authorities and of approximately 150 primary-care trusts and transfer some of their services to external non-for-profit outfits.
NHS hospitals are to become foundation trusts and to enjoy greater autonomy in revenues and funding.
Patients will be available to choose GPs regardless to their geographical areas, to make shared decisions on their health treatments and to enjoy published data on hospitals and doctors (results, waiting times, rates, etc.).
NHS funding will increase in real terms for the following 5 years but it will have to do more for its money: reduction of managerial costs by 45%; efficiency savings of 20 billion pounds, which are to be reinvested to support quality and outcomes.
Establishment of an independent NHS Commissioning Board, which will allocate and account for NHS resources and will audit on implementation of quality improvement and patient involvement and choice.
Conclusion
The NHS in England is currently facing a period of change that will affect all aspects of its operation. Delivering the required political reforms within the constraints of the current financial climate will be challenging. Coupling this with increasing demand for services caused by an ageing population and the associated technological developments that need to be put in place for this to be managed means the NHS in England must be clear on its purpose, its direction and its strategy for achieving these.
Recommendations
Re-examine the purpose, direction and over-arching strategy of the NHS in England to ensure they remain fit-for-purpose
Develop appropriate national strategies for each element of the organisation (eg IM&T) to ensure there is clarity about what is required of trusts.
Emphasise citizen involvement and partnership programs.
Develop appropriate IT and technological infrastructures to support new reforms.
Strengths and weaknesses of the STEP approach
STEP analysis has strengths and weaknesses. The key issues identified by the group are:
Strengths
The analysis can help focus an organisation on the key factors in each environment ensuring they think about each ‘step’. It is quite a simple process that allows consideration of many variables.
It enables the organisation/unit to look outwith their immediate environment to consider important external factors
The approach can be linked with other models (typically SWOT) to increase its usefulness
It encourages strategic thinking and planning and allows the organisation to anticipate future issues.
Weaknesses
Assessing the importance of issues can be challenging if appropriate and robust data is not available. Accessing useful data can be time consuming and therefore has a cost attached.
The use of the four ‘steps’ can mean a pigeon-holing of some issues that span across other themes (such as the impact of government policy)
It is a task perhaps best done with a group in person rather than in isolation so that ideas can immediately be discussed/challenged and priorities for the issues included are agreed by consensus
Considering the factors in isolation makes it difficult to identify linkages between the various elements
It may be useful to keep the focus of the analysis specific as then the outputs may be more useful rather than general statements
Forecasting leads to multiple possible futures; there is a danger of assuming hypotheses are ‘truth’
The exercise needs to be repeated to remain useful to account for pace of change/changing realities.
Challenges encountered by the group in conducting the analysis
The group encountered the following challenges:
considering the factors in isolation made it difficult to identify linkages between the various elements. It may have been useful to circulate our ‘lists’ in advance to encourage cross-fertilisation and consistency across the 4 factors (Delphi approach)
undertaking an analysis of an institution with which some members of the group had little familiarity led to increasing reliance on assumptions
we ended up with quite a broad ‘target’ topic, if we had narrowed our focus the results may have been more useful
accessing relevant data was difficult in some areas and hence time-consuming.
References for STEP:
http://rapidbi.com/management/created/the-PESTLE-analysis-tool/
http://www.healthknowledge.org.uk/public-health-textbook/organisation-management/5b-understanding-ofs/assessing-impact-external-influences
http://www.nhsemployers.org/EmploymentPolicyAndPractice/EqualityAndDiversity/e-d-in-practice/get-to/IdentifyingTheObjectivesAndOutcomes/Pages/PEST_Analysis.aspx
http://www.herefordhospital.nhs.uk/Portals/0/MembersArea/IBP/Appendix%20X%20-%20PEST%20and%20SWOT.pdf
http://newsfan.typepad.co.uk/pestle/2009/03/pestle-summary-united-kingdom.html
http://www.coursework4you.co.uk/essays-and-dissertations/pest-analysis.php
http://www.statistics.gov.uk/downloads/theme_compendia/fom2005/04_FOPM_AgeStructure.pdf
http://www.annecollins.com/obesity/uk-obesity-statistics.htm
http://www.medwaypct.nhs.uk/explore-nhs-medway/news/media-releases/proposed-changes-to-workforce-and-education-in-the-nhs-making-our-views-count/
Does the British media hate the NHS?

http://www.guardian.co.uk/society/2001/jun/14/NHS.conferences
http://www.mirror.co.uk/news/top-stories/2007/10/18/immigration-the-true-cost-to-britain-115875-19969602/
 

Social and Economic conditions and their impact on NHS Funding

Introduction:
In the middle ages, access to health care and sanitation facilities was only available to people belonging to a sound socio-economic background. Hill, Griffiths and Gillam (2007) state that in earlier time, even ensuring the supply of clean water and sanitation facilities was a tough task for municipal authorities. It was not until eighteenth century when provision of health services began to get recognition as government’s responsibility.

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The NHS was founded in 1948 and is the currently the world’s largest health service that is publicly funded. The basic idea behind the establishment of the NHS was to ensure that people from all kinds of socio-economic backgrounds receive health facilities without any discrimination. This makes the service free for any individual who is a resident of the UK. According to the official statistics of the NHS, it deals with about 1 million patients every 36 hours. Funds for the NHS come directly from taxation. The NHS budget for 2008-2009 was more than £100 billion, which means a contribution of about £1980 by every individual in the UK.
Considering the fact that health and education are the most important public services on any government’s priority list, however the functionality of these services is directly related to the social and economic conditions. Same goes for the NHS, which has faced management crisis during times of economic austerity, both in present and the past. Although the NHS has seen a sharp increase in funding over the last few decades, however, given the current economic recession, the chances of future funding are quite uncertain. It is feared that either the NHS will go through a funding cut or the government will have to resort to tax-raising measures.
Health Care and Social and Economic Conditions:
Although good health is a need of every individual, however, the access to health care services is greatly dependent on the social and economic conditions of both the individual and the country he is residing in. An individual can either opt for a private health care service, which is subjected to his willingness and ability to pay for it, or is dependent on the services provided by the government. A large proportion of the population goes for the latter option. A poor socio-economic condition of the country means that either a person sacrifices on his health or will forgo any other of his basic needs in order to pay for medical bills. According to the Social Care Report 2008-2009 issued by the Health Committee of the House of Commons, A care gap may occur if people avoid using services wither because of affordability issues or if the services do not meet their requirement. The report also claims that the past three years have seen a significant drop in the number of people using the public sector health services, despite of the fact that the country’s ageing population have increased by 3%. This makes it apparent that either the public cannot afford to pay for the health care services or the government is finding it difficult to ensure the provision of standardized health facilities on equality basis.
At the same time, given the economic crises, the government itself also gets stingy with providing funds due to lack of resources. Consequently, the quality of service provided by the NHS is compromised. Fowler (Taylor and Field 1998, p. 158) states that lack of resources means that new hospital building would not be built advanced medical technology and equipment could not be purchased and the staff would be working under conditions that would demotivate them. This directly questions the value for money provided by the NHS services.
George and Miller (1997) state that in 1960s and 1970s politicians started to doubt the economic viability of a “universalist welfare state”. They argued that achieving economic growth is the government’s primary objective that is being sidelined due to increasing public expenditure. Consequently, they demanded a cut in public expenditure, which meant less funding for public sector health services.
Powell (George and Miller 1997, p. 8) claimed that public expenditure has overshot economic growth by a substantial margin, thus resulting in disastrous financial effects including internal inflation, external devaluation and foreign indebtedness. Lees (George and Miller 1997, p. 8) argued that medical care should be treated like any other commodity available in the private market. This will not only make the NHS more cost efficient, but will also make it less politicized and will offer more consumer choice.
Although while debating on making the public health services free at the point of use, many social scientists and economists agree that it can be easily funded by taxation, they tend to overlook other factors, which may directly or indirectly effect the NHS funding. McLeod and Bywaters (2000) argue that the inflationary pressures on the NHS funding of the pharmaceutical and medical technology industries and the continued presence of private health care services are two major constraints on measures for equitable health care. Moreover, the deteriorating condition of hospital buildings and their repair and maintenance costs also add to the financial pressures.
Funding Public Health Services:
Although the funds for the functionality of the NHS are directly acquired from taxation, however, it should be noted that all the capital works such as building hospitals are funded through Private Finance Initiative (PFI). This means that these capital works are being financed through loans raised by private sector financing institutions. According to Pollock, Shaoul and Vickers (2002) this is a very expensive way of financing the NHS. Using Private Finance Initiative requires the NHS to pay an annual fee including the cost of borrowing. Considering the fact that the NHS is a free service at the point of use, this method leads to an affordability gap for the NHS trusts. As a result, the NHS is forced to resort to external subsidies, charitable donations, sale of assets and even cuts in bed capacity and hospital staff. This in return makes the NHS questionable as the idea behind its establishment was to ensure access to health facilities to everyone without any class difference.
When a large proportion of a service is being funded by the tax payers, then the service providers are suppose to make sure that they are being cost efficient and provide the value for money. Unfortunately, this has not been the case with the NHS. Davies (2007) states that the NHS was provided with unprecedented funds, however it still overspent by a substantial amount. Moreover, clinical outcomes, waiting periods and the level of satisfaction of patients are all less as compared to that provided by private health care services. According to Davies (2007), the government argues that if the NHS manages itself efficiently, the NHS trusts can achieve significantly positive results.
Conclusion:
The problems in the health sector are similar to any other economic problem. It is facing a price hike due to gaps in demand and supply. The list of people waiting to get medical treatments is mounting up but there is a shortfall of resources to cater that list.
One suggestion given to deal with the problem is to impose user charges on the services provided by the NHS. Some critics argue that if user charges are imposed it will give two benefits. Firstly, it will generate funds for the NHS to finance the shortfall. Secondly, people will start taking care of their health and will make healthy choices in order to avoid seeking a medical care. The first argument is a socially unfair argument. The current economic conditions are such that people make sacrifices even when choosing in between the basic necessities. Imposing user charges on health means that they will start avoiding seeking medical treatment not because they do not need it, but because they cannot afford it. The second argument requires one to assume that people are aware and educated enough about what “right” choices they need to make in order to seek minimum medical help. Countries like France and Germany have already tried this approached and it only resulted in undermining the efficiency of public sector health services, rather than helping to achieve the required results. Therefore, imposing user charges for the NHS consumers should not be considered. Instead, the government and the NHS trusts should look for alternative instruments.
In order to deal with the problem the government will have to make both short term and long-term strategies. In short term, it should be ensured that the NHS becomes cost efficient and the consumers get value for their money. This can be done by minimizing dependency on the private finance initiative.
On long term basis, preventive measures should be taken and the emphasis should be on primary care. People should be educated such that take care of their health so that they are least prone to diseases.
REFRENCES
Davies, P 2007, The NHS in the UK 2007/08, London.
George, V and Miller, S 1997, Social policy towards 2000: squaring the welfare circle, Routledge, London.
Hill, P, Griffith, S and Gillam, S 2007, Public health and primary care: partners in population health, Oxford university Press Inc., New York.
McLeod, E and Bywaters, P 2000, Social work, health and equality, Routledge, London.
Taylor, S and Field D 1998, Sociological perspectives on health, illness and health care, Blackwell Science Ltd., London.
Pollock, A, Shaoul, J and Vickers, N 2002, Private finance and value for money in NHS hospitals: a policy in search of a rationale, viewed 21 October 2010,
Thomson, S, Foubister, T and Mossialos E 2010, Can user charges make health care more efficient?, viewed 21 October 2010,
2004, Health Economics, Biz/ed, viewed 21 October 2010,
 

The Representation of the NHS in The Last Asylum and Blue/Orange

The National Health Service, or NHS, was established on the 5th of July, 1948. England’s division of the NHS provides healthcare to all residents of England. Most services are “free at the point of use”, meaning that most medical care, both critical and non-critical, is accessible and free for individuals who are registered within the NHS system and are legal residents of the UK. It is mostly funded through the general taxation system, with a small amount being funded by National Insurance payments, and it is overseen by the Department of Health. Aspects of the NHS’s role in psychiatric institutions are represented in various plays and novels. In her memoir, The Last Asylum, Taylor highlights the consequences of over prescribing anti-psychotic medications, exemplifies how the UK health system does not provide enough resources for psychotherapy beyond the private sector, and explores the pitfalls of eliminating Victorian era mental asylums. Joe Penhall’s, Blue/Orange allows readers to visualize how lack of resources and bed space in many hospitals due to the underfunded NHS dictates medical decisions while also presenting a divide between junior doctor and senior consultant.Another of Penhall’s plays, Some Voices, explores the importance of the Community Treatment Orders instated in the Mental Health Act of 2007, in detaining psychiatric patients who refuse to take their medications. The authors’ representations of the NHS can be linked to wider issues present in the UK healthcare system, of which many will be explored in this essay.

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Barbara Taylor’s purpose in her representation of the NHS in The Last Asylum, is to bring to light three key issues. In her memoir, Taylor recalls the overuse of medication for long term patients in Friern. Taylor also continuously expands upon the importance of the 21 years she spent in private psychotherapy, something that is wholly under-resourced in the NHS. Lastly, she questions whether the closure of mental hospitals during the Victorian era to adhere to the newly instated “Care in the Community” standards, where patients were to be reintegrated into the community as much as possible, got rid of something of necessity for psychologically ill patients at the time, interconnectedness.

 Taylor steers the reader to view and understand the negative consequences of the overuse of anti-psychotic medication. In the epilogue of her memoir, Taylor brings to light how the issues presented in her memoir are linked to wider issues present in the UK health system. She writes about how research has yet to produce evidence for a neurobiological origin of any  mental illness, yet, for decades, western psychiatrists have been handing out immense quantities of ‘anti-psychotics’. These drugs not only have adverse side effects, but also heighten or even produce the psychiatric symptoms that they are supposed to treat by disrupting the natural brain functioning. Recent studies show a correlation between high usage of anti-psychotic medication and poor patient ‘outcomes’. She cites the fact that, in the UK, patients with serious mental disorders on long term anti-psychotic medication are dying, on average, fifteen years earlier than the general population.

Taylor also steers the reader to view psychotherapy to be underfunded and under resourced in the public health sector, leading patients to have to seek it privately, at a large monetary cost. This viewpoint also links to wider concerns in the UK health system. Many psychiatric inpatients are being treated very far from where they live when beds are not available locally. This has caused much controversy, as some mental health professionals feel that the presence of friends and family is instrumental to recovery for mental health patients, as coping with mental illness is a time of vulnerability, isolation, and fright. Fortunately, there has been increased access to psychotherapy services in the NHS resulting from the Improving Access to Psychological Therapies ( IAPT) service. This service is characterized by: evidence based psychological therapies, meaning they are tested in random clinical trials and highlighted by their ability to get psychological patients “back on their feet”, routine outcome monitoring, and outcomes supervision (“Adult Improving Access to Psychological Therapies Programme” ). However, in recent years, evidence has shown that alongside this increased access to psychological therapies due to the IAPT service, there has been a reduction in choice for patients, a reduction in highly trained and experienced workforce, and the emphasis of the NHS on a narrow Cognitive Behavioral Therapy (CBT) model, which is often seen as a short term intervention focused on minimizing dependency on the mental health system. Cognitive behavior therapy can now be done, on the NHS, without any human contact, due to the introduction of online CBT packages. Another pitfall of this CBT model is that the waiting lists are extremely long. The British psychoanalytic council surveyed members of both the UK Council for Psychotherapy and the British Psychoanalytic Council to obtain a clearer account of the established NHS psychotherapy and psychotherapeutic counselling services. Of the therapists surveyed, 56% saw decreases in the treatment time provided to clients, 38% reported decreases in the range of therapies offered, and 36% indicated that there had been decreases in the frequency of sessions provided (“Quality Psychotherapy Services in the NHS”).

Lastly, Taylor brings to light the wider issues that came about with the installment of the “Care in the Community” Act. The act was to replace dependency and reliance on the mental health system to self-dependency in the community. Individuals were encouraged to get well as soon, so that they can return to work and their normal way of life as quickly as possible. It was hoped that, by doing this, the life of the mental patient would improve and the unhappy figure of an asylum could be eliminated in its entirety. But, Taylor has always been a fierce opponent of the closure of the Victorian mental asylums and the ‘Care in the Community Act’. In her memoir, she states, “For people with severe mental disorders, just being around other people is sometimes all that is desired or tolerable.”  In the epilogue to her memoir, she emphasizes that this lack of interconnectedness brought about by the ‘Care in the Community’ act affects the mentally ill grandly, since it is often failures of social connection, especially in early life, that cause such psychological disorders in the first place. She also highlights the fact that the abolition of patient dependency has created services that completely overlook continuity of care, with patients being shunted from team to team, health personnel to personnel. Taylor continues to emphasize that the greatest and longest lasting recoveries will instigated by patients being allowed to be part of a therapeutic community and establishing continuity of care with their health workers.

 Penhall also contributes to the representation of the NHS in his play, Blue/Orange. This play highlights three key representations of the NHS. The audience sees how a shortage of beds and resources dictates medical decisions, a key theme in many NHS funded psychiatric hospitals. The play also depicts the divide between a junior doctor and senior consultant, something that is very prominent in the healthcare system in England. Bruce represents an advocate of the old asylum system, wanting to keep Chris in the psychiatric hospital for an extended period of time to provide him more treatment time and talking in order to get healthier, whereas Robert represents an advocate of the “Care in the Community” system, as he wants to release Chris and warns that keeping him in the hospital too long might make return to normal life impossible. Bruce seems to be with Christopher more than Robert ever is, and his opinion never seems to matter to Robert, the senior consultant, in the grand scheme of making the decision as to whether or not Chris should stay or be released. Additionally, he is often manipulated by the senior consultant, Robert, who imputes racist thinking to Bruce so that Chris presses career threatening charges against Bruce.  By emphasizing this divide, Penhall also highlights the inequalities and sometimes poor working conditions that junior doctors face.

 Penhall steers the reader to view the negative aspects that cuts to NHS funding have on the health and safety of patients. In Blue/Orange, a major reason why Robert presses for Chris’ discharge from the mental hospital is due to the fact that there are physically not enough beds for Chris. This play brings to light the ever diminishing pool of resources, including money and beds, that is currently prominent in the UK healthcare system due to the underfunding of the NHS. Britain spends a small amount on health compared to other Western countries. In 2013, the UK’s GDP Expenditure on Health (GDPEH) was 9.1%, placing it as 17th out of the 21 Western countries. Over the past 30 years, Britain’s average GDPEH is 6.9%, the lowest of all the Western nations it was compared to. For comparison, France and Germany spent an average of 9.4% ( “Britain’s NHS Is Chronically Underfunded, But Great Value For Money … For Now”) . At present, around 2500 hospital beds are occupied by patients that are fit to leave the hospital but are awaiting social care, and another 2500 are occupied due to delays in community health services (“Funding and Efficiency”). This has a domino effect, as it causes delays for other patients waiting for beds, and routine operations often have to be delayed. Additionally, it shows that the appropriate care for these individuals, who are often elderly and frail, are often not adequately and promptly met. Additionally, mental health services in the NHS are still largely underfunded. Over 4,000 mental health beds have closed since 2010, and there has been a similar reduction in the number of psychiatric nurses since then.

Penhall also steers the reader to view the power struggle between junior doctors and senior consultants, and the inequalities that many junior doctors have to face when working in the NHS. The relationship and power struggle between Robert and Bruce highlight the reality that junior doctors often face much maltreatment and bad working conditions when in their years of training. According to a survey done by the Royal College of Physicians, half of junior doctors agree that patient safety is compromised by gaps in junior doctor rotas, with seven out of 10 junior doctors saying they work on a rota with a permanent gap. This permanent gap means that junior doctors are regularly having to cover these gaps, meaning they are doing the work of two medical doctors. These staffing shortages do not only affect junior doctors, but also nurses, other health personnel, and other doctors. Due to these staffing shortages, consultants struggle to find time for teaching and training junior doctors, meaning that healthy relationships between junior doctors and senior consultants are never firmly fostered. 56.1% of junior doctors reported going through at least one shift in the last month without having a meal, with these shifts often lasting for 12 hours or more. Evidence shows that rest breaks contribute to safe care, however junior doctors cite being unable to take adequate breaks. Four in every five doctors reported that their job caused them excessive stress and 61% reported their job has a negative impact on their mental health, ranging from clinical anxiety, panic attacks, and insomnia (“Being A Junior Doctor: Experiences From the Front Line of the NHS” ).

Another of Penhall’s plays, Some Voices, highlights the importance of the Mental Health Act of 2007. He does so by presenting the disastrous effect of Ray refusing to take his medications on both on his way of life and his relationships with those closest to him. In the present time, this refusal to take medication would no longer be tolerated. The Mental Health Act of 2007 introduced Community Treatment Orders, facilitating the mandatory detention of patients who refuse to take their medication. When this was enforced, it was assumed that this mandatory detention would rarely be enforced, but in fact, in the first three years of this order being put in place, 14,295 people were detained in special units which did not have the space or staff to cope with the amount of people, as the asylums had been shut down (“Mental Health Act.”) . This once again highlights how psychiatric facilities in the NHS are underfunded, under resourced, and few and far between.

Aspects of the NHS’s role in psychiatric institutions are represented in various plays and novels. In particular, Joe Penhall’s Blue/Orange and Barbara Taylor’s The Last Asylum bring to light several key issues present in the modern health care system in the United Kingdom. In her memoir, Taylor chooses to focus on and emphasize the overuse of anti-psychotic medications in psychiatric hospitals, the underfunded and under resourced psychotherapy services in the public health sector, and the downfalls of the ‘Care in the Community’ act. Penhall chooses to focus on the diminishing pool of resources available in the NHS, the power struggle between junior doctors and senior consultants, and the under resourcefulness of NHS psychiatric services as seen by the effects of the Mental Health Act of 2007. These two plays collectively inform the audience and the reader about the healthcare system in Britain as a whole, with a specific emphasis on the mental health sector, as the issues presented in these works relate to the wider issues present in the National Healthcare System.

Works Cited

“Adult Improving Access to Psychological Therapies Programme.” NHS England, NHS, www.england.nhs.uk/mental-health/adults/iapt/. 

“Being A Junior Doctor: Experiences From the Front Line of the NHS.” Royal College of Physicians.

“Britain’s NHS Is Chronically Underfunded, But Great Value For Money … For Now.” Gale Business Insights: Essentials, bi.galegroup.com.proxy.library.nd.edu/essentials/article/GALE|. 

“Funding and Efficiency.” NHS England, NHS, www.england.nhs.uk/five-year-forward-view/next-steps-on-the-nhs-five-year-forward-view/funding-and-efficiency/. 

“Mental Health Act.” NHS , NHS, 26 Apr. 2016, www.nhs.uk/using-the-nhs/nhs-services/mental-health-services/mental-health-act/. 

Penhall, Joe. Blue/Orange. Bloomsbury Methuen Drama, 2016. 

Penhall, Joe. Some Voices and Pale Horse. Methuen Drama, 1996. 

“Quality Psychotherapy Services in the NHS.” British Psychoanalytic Council, www.bpc.org.uk/sites/psychoanalytic-council.org/. 

Taylor, Barbara. “The Demise of the Asylum in Late Twentieth Century Britain: A Personal History.” 2010. 

Taylor, Barbara. The Last Asylum: A Memoir of Madness In Our Times. Hamish Hamilton, 2015.

 

Structural Change Management Process: The NHS

The case study report below is complete dissection of the undertaken structural change process by the Rossett NHS Hospital Trust to achieve its business objectives. Rossett NHS Hospital Trust attempted to introduce generic worker concept involving about 250 employees from its huge employee base of 2800. This change was part of a wider, strategic transformation in the NHS hospital with its focus on human resources issues, and in compliance with government initiatives, in the process realise continual improvement in quality of services rendered to patients and improve value for money.

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The nature of and rationale for the attempt of introduction of the generic worker concept was to achieve significant reduction in waiting times, improve flexibility, responsiveness to the patient needs by combining the roles right to the ward level and creating a central pool. This would enhance multiskilled work force who are eligible enough to conduct other full range of domestic and portering roles and other services including serving patient, clearing, and portering.
The management through this structural change i.e. adapting to generic worker concept wanted to improve the working atmosphere of its employees by improving the flexibility in task allocation and rendering by its employee base and motivation of impacted employee base which in-turn reduce the absenteeism, which, is currently among the highest, when compared to the industry average. The finance department claimed that successful implementation would help to provide good value for money and make cost savings and proposed single grade and pay spine to the impacted employees and performance bonuses on attendance. From the operations perspective, this would bring about enormous benefits of flexibility and would simply and improve efficiency by avoiding waiting for action time and wasted journey and other duplication of efforts. The report below tries to analyze in depth about.
Literature review
Team Management and Team Constitution
When two or more people interact among each other to accomplish a goal then it is called group. A group of people who work intensively with each other to achieve a set goal is called a TEAM. Team members should always be driving by the goal rather than individual results. The success of a team depends on the accomplishment of set objective or the drive to excel the same. Team functionality impacts the organizations effectiveness and performance. The contributing factors from the both the individual and organization context which are the driving factors for team existence and performance:
Contributing factors for team cohesiveness and performance
There are different types of teams which include functional or departmental, cross-functional, and self-managing. Each of these types of teams have certain characteristic features which differentiate their functioning style and objectives set to achieve. There are four essential elements that make the team successful or adventurous; goals/objectives, interdependence, commitment, and accountability.
There are basically three different formats of team functionalities which explain how each team exhibits their cohesiveness and working style, as explained below.

Basic functional team structure
Team should be encouraged to develop:
Positive Interdependence
Face-to-Face promotive Interaction
Individual Accountability/Personal Responsibility:
Teamwork Skills
Reduce social loafing as it is human tendency to put forth less effort in team than individually.
Conflict management among the team members.

Team Development and Management:
Team development is a process which needs to be carried along cautiously and in controlled manner. Team management is set of processes and/or procedures carried out along to achieve the teams’ set objectives or goals. As Bruce Tuckman (65) explained the process is formed of five major steps as forming, storming, norming, performing, and adjourning. Following these steps in true intentions would only build the team to be together, build constructive consensus of ideas/thoughts, and explore newer avenues leading to effective result oriented team.
Bruce Tuckman’s five stage team development
Motivation
The processes that account for an individual’s intensity, direction, and persistence of effort toward attaining goal is called motivation. Motivation is said to be intrinsic, that drives from within or from intangible benefits or extrinsic, that drives from outside facilitators or from the tangible benefits.
The term motivation can be described in many different formats and views, as of author mentions, Dr Stephen P. Robbins, this is the process that account for an individual’s intensity, direction and persistence of effort toward attaining a goal (S. P. Robbins).
In general there are broadly two types of motivation;

Process theory
Content theory

A process theory defines motivation as a rational cognitive process occurring within the individual as explained through Adams’ Equity theory. While on the other hand, a content theory defines motivation in terms of need satisfaction as explained through the Maslow’s Hierarchy of needs theory. Hence, the above two theories defer in many ways because each recognize motivation and its application due to the circumstances.
Motivation Factors that will motivate if they are present are the claim of achievement, advancement, recognition, and responsibility. Dissatisfaction is not normally blamed on Motivation Factors, but they are cited as the cause of job satisfaction.
Herzberg believed that organizations should motivate employees by adopting a democratic approach to management and by improving the nature and content of the actual job through certain methods. Some of the methods managers could use to achieve this are:

Job enlargement – workers being given a greater variety of tasks to perform which should make the work more interesting.
Job enrichment – workers being given a wider range of more complex, interesting, and challenging tasks. This should give a greater sense of achievement.
Empowerment – delegating more power to employees to make their own decisions over areas of their working life.

Hygiene Factors that de-motivate (in absence)
Such as supervision, interpersonal relations, physical working conditions, and salary. Hygiene Factors affect the level of dissatisfaction, but are rarely quoted as creators of job satisfaction.
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Herzberg’s Two-factor Theory
In the case study provided, the two main types of motivational theories which through me reading are most adaptable are the Porter and Lawyer’s theory which is a Process theory, its features and how it adapts to the workplace. And on the content theory side I find the Herzberg’s Motivation-Hygiene Theory, its features and how it adapts to the workplace to be most suitable.
Porter’s and Lawler Theory
Porter and Lawler (1968) explained that modulating the work atmosphere so that effective performance would lead to both intrinsic and extrinsic rewards, which would implicate to increase in complete job satisfaction. Understandably in this model is the assumption that intrinsic and extrinsic rewards are additive and correlated, yielding complete job satisfaction.
According to Porter Lawler Theory, any premises that felt needs cause human behavior and that the effort expended to accomplish a task is determined by the perceived value of rewards will result from finishing the task and the probability that those rewards will materialize (GAGNE and DECI, 2005)
Porter and Lawler (1968) expanded Vroom’s initial work to recognize the role of individual differences (e.g., employee abilities and skills) and role clarity in linking job effort to actual job performance. This is one of most comprehensive motivational structure based on the expectation theory which elaborates on all the factors which can influence each individual’s motivation. Porter and Lawler incorporated a feedback loop to recognize learning by employees about past relationships.
Leadership
Leader is one who can impress upon a group to behave or act according to his/her objectives. The leader’s ability in doing so depends on the ability in process application of both knowledge and skills. According to Northouse’s (2007) definition – Leadership is a process whereby an individual influences a group of individuals to achieve a common goal. The ability of process application of a leader can be explained through the process leadership explanation. (Jago 1982). But, in general there are traits which influences our action, this can be explained through the Trait Leadership (Jago 1982).
Jago’s Leadership theories
This explains that the leadership is learned, leader’s ability of application of process of skills and knowledge depends on the traits or attributes he posses or believes in.
Today, leadership is increasingly associated not with command and control but with the concept of inspiration, of getting along with other people and creating a vision with which others can identify. For example, Adair sees leadership as a combination of example, persuasion and compulsion that results in making people do things they might not otherwise have done.
According to Levine, leaders need to concentrate upon moving people and organisations forward by increasing the competency of staff and the co-operation of teams in order to improve the organisation. A leader’s job is to constantly challenge the bureaucracy that smothers individual enthusiasm and the desire to contribute to an organization.
Leadership and management
Management is more usually viewed as getting things done through other people in order to achieve stated organisational objectives. The manager may react to specific situations and be more concerned with solving short-term problems. Management is regarded as relating to people working within a structured organisation and with prescribed roles.
Management may arguably be viewed more in terms of planning, organizing, directing and controlling the activities of subordinate staff.
Leadership, however, is concerned more with attention to communicating with, motivating, encouraging and involving people. The emphasis of leadership is on interpersonal behaviour in a broader context. It is often associated with the willing and enthusiastic behaviour of followers.
There are other differences between leadership and management. For example, Zaleznik explores difference in attitudes towards goals, conceptions of work, relations with others, self-perception and development.

Managers tend to adopt impersonal or passive attitudes towards goals. Leaders adopt a more personal and active attitude towards goals.
In order to get people to accept solutions, the manager needs continually to co-ordinate and balance in order to compromise conflicting values. The leader creates excitement in work and develops choices that give substance to images that excite people.
In their relationships with other people, managers maintain a low level of emotional involvement. Leaders have empathy with other people and give attention to what events and actions mean.
Managers see themselves more as conservators and regulators of the existing order of affairs with which they identify, and from which they gain rewards. Leaders work in, but do not belong to, the organisation. Their sense of identity does not depend upon membership or work roles and they search out opportunities for change.

Transactional and Transformational
There are two fundamental forms of leaderships – Transactional and Transformational
Transactional leadership is based on legitimate authority within the bureaucratic structure of the organisation. The emphasis is on the clarification of goals and objectives, work task and outcomes, and organisational rewards and punishments. Transactional leadership appeals to the self-interest of followers. It is based on a relationship of mutual dependence and an exchange process of: ‘I will give you this, if you do that’.
Transformational leadership, by contrast, is a process of generating higher levels of motivation and commitment among followers. The emphasis is on generating a vision for the organisation and the leader’s ability to appeal to higher ideals and values of followers, and creating a feeling of justice, loyalty and trust. In the organisational sense, transformational leadership is about transforming the performance or fortunes of a business. This type of leadership is best suited during the structural change circumstances.
Critical Analysis
Proposed change
The management of the Rossett NHS Hospital Trust hospital envisioned to revamp the organizational structure through seven key changes in their business plan for the yea. Of them the reports elaborates on the attempt to introduce multiskilled, ward based teams of support workers. This transformation would impact around 250 employees. The objective of the changes was to achieve competitive advantage over other hospitals and earn greater customer satisfaction. The proposed change is an attempt to introduce the generic worker concept to significantly reduce the waiting time and improve the compliance with government initiatives and introduction of major information systems. The Site service Directorate was responsible for this implementation. It was broadly constituted of Hotel Services (domestic and portering staff), which was managed by Deputy Director of Site Services, but the actual ownership of the change was owned by Director (Anita Patel). The changed comprised all the porter and domestic staff. The staff was divided into three groups under three managers while some of the staff were stationed at specific departments but majority were placed in the central pool to attend to various duties including serving food and assisting nurse ancillary staff. These staffs were to report to the managers at Site Services Directorate (which was a conflict reason in practice). This change required additional training to get acquaintance with new jobs they would have to perform. The staff had to embrace to work flexibility and teamwork and some needed to face change in shifts. This change is structure came out with great news with structured payment system and pay rise along with performance bonuses aimed at improving the employee motivation and job satisfaction.
Actual change
The vision of management was taken bitter tone when it came out open and functional though they envisioned greater and positive response from all involved including middle managers and the actual employees impacted but the story in practice was completely different which lead to failure in implementation to achieve the objectives.
The actual impacted staff showed little or no interest in the change as thought it to be invasive into their working schedule and their interest of work. Though certain women staff were happy to see the men staff doing the cleaning and others and but the nurse felt they were neglected and their duties were invaded by the lower ranked staff. Majority of staff had no clear idea has what kind of activities they would be involved which lead to reduced job identification and satisfaction.
These changes brought out major conflicts among the middle managers and actual working staff as there were not clear demarcation of duties or jobs and who would be involved where and when would be the staff put at work, all this created lots of confusion and job dissatisfaction and conflicts among the actual working staff and also between the department involved. The managers (middle) were not able to clearly identify the conflicts which lead to ineffective actions to tap these differences. The managers were not able to distinguish out the problems and gel the differences due to loss of ownership of job. As one of porter staff mentioned the change as “fire-fighting”- there is no service level agreement in place against which to measure performance.
The other area where conflict and confusion rose was with the rota preparation as manager were having hard time to track who can do what and where to place and when to place them since they to pick from the general pool of employees. The manager were facing difficulty in tracking and employees felt bias treatment bestowed upon few employees and that rota system preparation was not in-line with conditions laid down for change. The other major problem was the gender issue which came out in open when most of men openly showed their dissatisfaction to working as cleaners. This issue was completely neglected, as no manager looked into it right from the planning stage to the implementation stage. From the manager’s point of view they seemed to be completely powerless as no clear demarcation of rules and regulations, which lead to ineffective control by them on the change and could not initiate any mending ways or improvise the circumstances.
To add to the present situation even the union (UNISON) was against the change implementation saying it would radically change employee benefit agreements and that this is just a cost improvement exercise without considering the employee and their concerns and advocated employees to vote against the change. So, to conclude this whole generic working concept was utter failure, though there was last ditch effort to save the change by the management but could not succeed in their effort.
Recommendations and conclusions
On careful dissection of the whole of the happenings during the trial period of the change envisioned by the Rossett NHS Hospital Trust I deem the following recommendations and conclusions as the most suitable and adaptable the trust should have taken to the successful accomplishment of their business vision.
Of note, there were certain positive points to the envisioned generic worker concept, these were (to mention a few);

Simplified pay structure.
Performance bounces linked to attendance.
Option of shift changes.
Job profile enhancement and new job cultivation.
Opportunity of greater team building avenues.
Greater customer satisfaction feasibility.
Improvement to the financial health of the trust.

But these good points were not communicated down to the employees in practical.
On the leadership front, the management though had these benefits on the paper and on the discussion table with the down line managers but did not clear demarcate roles and regulations for the immediate line managers to exhibit and propagate these benefits and also let them exploit their leadership skills in handling the circumstances in day-to-day running during the trial period. The immediate line or reporting managers were left stranded having nothing to do to with various grievances of the actual and effected work force under them. These restrictions and inability led the team manager and members to have job dissatisfaction and lack of motivation to pursue the management vision. There was need for a transformational leader who took up the responsibility and courage to stand up to the occasion driven the team to envision the same vision as seen by the management.
The moral of the image above, when during any change the leader’s transformational ability comes handy as he has to tackle and win over the employee resistance, depending on the complexity of the task, and also the magnitude of change envisioned by the management. But none these ever exhibited by any of line and immediate managers of Trust Hospital.
On the motivational front, after careful literature review the basics of the Porter’s and Lawler Theory which was based on the expectancy theory was completely neglected by all levels of management in the Trust Hospital. The line managers did nothing to motivate the employee effected, or should say, had no say in taking control of the situation, this lead the team to be completely de-motivated and resultant being them to be less inclined to pursue management vision of structural change though it benefited them greatly.
Motivational level at the line manager was equally demoralized as the top management did not let them express themselves during any of the meetings and only positive points were discussed rather taking the holistic view of the structural change into consideration. Both the intrinsic and extrinsic rewards though were present in the structural change present but were not explained to the team effectively which lead to demotivation of the work force.
On the team management front, members were not cohesive with each other and always in their old stigma of work culture and they were confronted upon before going ahead with the changes which lead to the feeling of neglect growing in them. The basic contributing factor of team cohesiveness were not put to practice, when the members felt that their rota was prepared as the change structure specification there was no one to provide them with consolidating reasons showing single lane attitude from the management.
The trial team formed (reciprocal task based team) where exposed and were happy with the structural change (voted in favor of vote) but management could not duplicate their satisfaction and motivation to the rest of the actual work force impacted by the proposed structural change envisioned. Team members were not introduced to the new change and their conflicts and concerns never made to the change meetings between the line managers and top management. The delicate gender issues were also equally neglected. This clearly shows the areas where the management completely failed and needs to improve if they ever needed to achieve their objective in the future.
To conclude for the failure of the envisioned structural change proposed by the management cannot be restricted to one area or department but a complete collapse of non-adherence to basics of structural management theories to mention a few team building and management, motivation, and leadership as discussed in the report above. Had the top management been able to clearly embark the capacity and specified roles along with rules and regulations to the line managers and taken into consideration the concerns of the actual work force to be effected by the generic workers concept the results would have been in favor of the structural change. To sum up, there was utter chaos and neglect to stick to the basic structural change management theories which lead to negate the structural change to generic worker concept by the actual work force to be impacted though there were numerous benefits to the Trust hospital and employees to be impacted.
 

Social and Economic conditions on NHS Funding

In the middle ages, access to health care and sanitation facilities was only available to people belonging to a sound socio-economic background. Hill, Griffiths and Gillam (2007) state that in earlier time, even ensuring the supply of clean water and sanitation facilities was a tough task for municipal authorities. It was not until eighteenth century when provision of health services began to get recognition as government’s responsibility.

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The NHS was founded in 1948 and is the currently the world’s largest health service that is publicly funded. The basic idea behind the establishment of the NHS was to ensure that people from all kinds of socio-economic backgrounds receive health facilities without any discrimination. This makes the service free for any individual who is a resident of the UK. According to the official statistics of the NHS, it deals with about 1 million patients every 36 hours. Funds for the NHS come directly from taxation. The NHS budget for 2008-2009 was more than £100 billion, which means a contribution of about £1980 by every individual in the UK.
Considering the fact that health and education are the most important public services on any government’s priority list, however the functionality of these services is directly related to the social and economic conditions. Same goes for the NHS, which has faced management crisis during times of economic austerity, both in present and the past. Although the NHS has seen a sharp increase in funding over the last few decades, however, given the current economic recession, the chances of future funding are quite uncertain. It is feared that either the NHS will go through a funding cut or the government will have to resort to tax-raising measures.
Health Care and Social and Economic Conditions:
Although good health is a need of every individual, however, the access to health care services is greatly dependent on the social and economic conditions of both the individual and the country he is residing in. An individual can either opt for a private health care service, which is subjected to his willingness and ability to pay for it, or is dependent on the services provided by the government. A large proportion of the population goes for the latter option. A poor socio-economic condition of the country means that either a person sacrifices on his health or will forgo any other of his basic needs in order to pay for medical bills. According to the Social Care Report 2008-2009 issued by the Health Committee of the House of Commons, A care gap may occur if people avoid using services wither because of affordability issues or if the services do not meet their requirement. The report also claims that the past three years have seen a significant drop in the number of people using the public sector health services, despite of the fact that the country’s ageing population have increased by 3%. This makes it apparent that either the public cannot afford to pay for the health care services or the government is finding it difficult to ensure the provision of standardized health facilities on equality basis.
At the same time, given the economic crises, the government itself also gets stingy with providing funds due to lack of resources. Consequently, the quality of service provided by the NHS is compromised. Fowler (Taylor and Field 1998, p. 158) states that lack of resources means that new hospital building would not be built advanced medical technology and equipment could not be purchased and the staff would be working under conditions that would demotivate them. This directly questions the value for money provided by the NHS services.
George and Miller (1997) state that in 1960s and 1970s politicians started to doubt the economic viability of a “universalist welfare state”. They argued that achieving economic growth is the government’s primary objective that is being sidelined due to increasing public expenditure. Consequently, they demanded a cut in public expenditure, which meant less funding for public sector health services.
Powell (George and Miller 1997, p. 8) claimed that public expenditure has overshot economic growth by a substantial margin, thus resulting in disastrous financial effects including internal inflation, external devaluation and foreign indebtedness. Lees (George and Miller 1997, p. 8) argued that medical care should be treated like any other commodity available in the private market. This will not only make the NHS more cost efficient, but will also make it less politicized and will offer more consumer choice.
Although while debating on making the public health services free at the point of use, many social scientists and economists agree that it can be easily funded by taxation, they tend to overlook other factors, which may directly or indirectly effect the NHS funding. McLeod and Bywaters (2000) argue that the inflationary pressures on the NHS funding of the pharmaceutical and medical technology industries and the continued presence of private health care services are two major constraints on measures for equitable health care. Moreover, the deteriorating condition of hospital buildings and their repair and maintenance costs also add to the financial pressures.
Funding Public Health Services:
Although the funds for the functionality of the NHS are directly acquired from taxation, however, it should be noted that all the capital works such as building hospitals are funded through Private Finance Initiative (PFI). This means that these capital works are being financed through loans raised by private sector financing institutions. According to Pollock, Shaoul and Vickers (2002) this is a very expensive way of financing the NHS. Using Private Finance Initiative requires the NHS to pay an annual fee including the cost of borrowing. Considering the fact that the NHS is a free service at the point of use, this method leads to an affordability gap for the NHS trusts. As a result, the NHS is forced to resort to external subsidies, charitable donations, sale of assets and even cuts in bed capacity and hospital staff. This in return makes the NHS questionable as the idea behind its establishment was to ensure access to health facilities to everyone without any class difference.
When a large proportion of a service is being funded by the tax payers, then the service providers are suppose to make sure that they are being cost efficient and provide the value for money. Unfortunately, this has not been the case with the NHS. Davies (2007) states that the NHS was provided with unprecedented funds, however it still overspent by a substantial amount. Moreover, clinical outcomes, waiting periods and the level of satisfaction of patients are all less as compared to that provided by private health care services. According to Davies (2007), the government argues that if the NHS manages itself efficiently, the NHS trusts can achieve significantly positive results.
Conclusion:
The problems in the health sector are similar to any other economic problem. It is facing a price hike due to gaps in demand and supply. The list of people waiting to get medical treatments is mounting up but there is a shortfall of resources to cater that list.
One suggestion given to deal with the problem is to impose user charges on the services provided by the NHS. Some critics argue that if user charges are imposed it will give two benefits. Firstly, it will generate funds for the NHS to finance the shortfall. Secondly, people will start taking care of their health and will make healthy choices in order to avoid seeking a medical care. The first argument is a socially unfair argument. The current economic conditions are such that people make sacrifices even when choosing in between the basic necessities. Imposing user charges on health means that they will start avoiding seeking medical treatment not because they do not need it, but because they cannot afford it. The second argument requires one to assume that people are aware and educated enough about what “right” choices they need to make in order to seek minimum medical help. Countries like France and Germany have already tried this approached and it only resulted in undermining the efficiency of public sector health services, rather than helping to achieve the required results. Therefore, imposing user charges for the NHS consumers should not be considered. Instead, the government and the NHS trusts should look for alternative instruments.
In order to deal with the problem the government will have to make both short term and long-term strategies. In short term, it should be ensured that the NHS becomes cost efficient and the consumers get value for their money. This can be done by minimizing dependency on the private finance initiative.
On long term basis, preventive measures should be taken and the emphasis should be on primary care. People should be educated such that take care of their health so that they are least prone to diseases.
REFRENCES
Davies, P 2007, The NHS in the UK 2007/08, London.
George, V and Miller, S 1997, Social policy towards 2000: squaring the welfare circle, Routledge, London.
Hill, P, Griffith, S and Gillam, S 2007, Public health and primary care: partners in population health, Oxford university Press Inc., New York.
McLeod, E and Bywaters, P 2000, Social work, health and equality, Routledge, London.
Taylor, S and Field D 1998, Sociological perspectives on health, illness and health care, Blackwell Science Ltd., London.
Pollock, A, Shaoul, J and Vickers, N 2002, Private finance and value for money in NHS hospitals: a policy in search of a rationale, viewed 21 October 2010,
Thomson, S, Foubister, T and Mossialos E 2010, Can user charges make health care more efficient?, viewed 21 October 2010,
2004, Health Economics, Biz/ed, viewed 21 October 2010,
 

Public Health Obesity And Nhs Health And Social Care Essay

When the NHS was established in 1948, one of its founding principles was that it should improve health and prevent disease as well as providing treatment for those who are ill. In November 2004, the government produces a white paper choosing health, and one of its main purposes was to improve health of the national by setting goals, putting strategies and guidelines that would have the effect of increasing the general standard of the Public health (Choosing Health 2004). Although this white paper has many strands but the one which will be looked on this assignment is obesity as a Public health issue.

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This essay will start by looking the concept of health and it will look Public health and how it relates with overall care of obesity. A scenario will be used to describe the physiology of obesity’s patient and how it is affecting psycho social perspective of their life. The essay will also explain the roles of nurse in supporting individuals with health problems within the community setting as a part of inter-professional team. Government policies and frameworks in relation to patient needs will be provided. Different sources of information such as internet, books and journals to demonstrate the points will be used. Any name mentioned in this scenario has been changed in order to respect individuals’ confidentiality and comply with the code of NMC (2008).
Health has been seen as a complex concept. It means that health has different things to different people and is affected by a wide range of factors such as lifestyles, social, economic and environment such as whether people live in as a free society, what social support network are available, and how they live in terms of employment, income and housing (Simnett et al 2003). Health has two common meanings, one is negative which is the absence of disease or illness and is the meaning of health within the western scientific medical model. The other meaning of health is a state of complete physical, mental and social wellbeing, not merely the absence of disease or illness (Naidoo et al 2000). Other writer such as Seedhouse suggests that health is about improving people’s quality of life by enabling them to fulfill their own potential and empowering them so that they are capable of becoming (Simnett et al 2003). According to Ottawa Charter of November 1986, a conference primarily was response for growing expectation for new Public health movement around the world has seen health as a resource of everyday life not the objective of living (W.H.O 2000).
There are huge ranges of factors that affect health. Health can be affected by genetic, gender, lifestyle and behavior, housing, environment, food policy and many more. In Acheson report into inequalities in health on socio economic model of health, it shows the main determinants of health as layers of influence one over another. At the centre are individuals with their inbuilt genetic, age and gender related factors. Surrounding the individuals are layers of influences that in theory could be modified to allow the best possible of health. The inner layer is their personal behavior or lifestyle, with factors such as smoking and drinking habits, and physical activities with the potential to promote or damage health. Individuals are seldom alone; they interact with friends, relatives and community and come under social and community influence. This model emphasizes interaction between these layers. The model has been used to guide research for example it shows that the social environmental people live is related to their health behavior, patterns of eating, drinking, smoking and physical activities. The model also demonstrates the various interventions on attempting to change individuals’ risks by encouraging people give up smoking and change diet (Acheson 1998).
Obesity is a condition which weight gain has reached a point where it causes a significant risk of health (NICE 2006). World Health Organization defined obesity as abnormal or excessive fat increase that may impair health; this means BMI (Body Mass Index) is equal to or more than 30. (BMI is defined as the weight in kilograms divided by the square of the height in meters) World Health Organization indicated that, globally approximately 400 adults and 20 million children under the age of 5 were obese on 2005 and by 2015 the number will reach more than 700 million. Obesity is one of the most Public Health challenges of the 21st century in the world and is already responsible for 2 to 8% of the health cost and 10 to 13% of deaths indifferent parts of the region. Obesity is also a major contributor to the global burden of chronic disease and disability (WHO 2010). Public health is a social and political concept aimed at the improving health, prolonging and improving quality of life of the population through promotion, prevention of disease and other forms of interventions (Acheson Report 1988).
According to the Department of Health guidance of March 2006, obesity is one of the biggest public health issues facing England. Estimates suggest that more than twelve millions adults and one million children will be obese by 2010 if no action is taken (NICE 2006). Obesity has grown up almost by 400% in the last twenty five years and it will entail levels of sickness that will put huge pressure on the health services (The House of Common 2004). According to the government study of 2007, half of the population could be obese within 25. Obesity has a substantial human cost by contributing to the start of the disease and premature mortality and it has serious financial consequences for the National Health Service (NAO 2001). It suggests the cost of epidemic, in terms of health care provision could reach 45 billion a year by 2050 (BBC 2007). There is also a cost to society and economic mostly on sickness absences which reduce productivity (DOH 2010).
The cause of Obesity is complex, and can be grouped into different areas. Individual’s genes may play an important part in influencing metabolism and the amount of fat tissues in the body. Genes could also affect individual’s behavior, inclining individual towards lifestyle choices that may increase the risks of obesity. The risks of excess weight also can be contributed by the pattern of growth during early life. The growth of the baby’s rate in the womb, following the birth is the part determined by parent’s factors especially with regards to mother’s diet and how she feed the baby (DOH 2008). The availability of more variety, cheaper and testes processed food with bigger size portion has also contributed obesity. More people are eating pre package food, fast food and soft drinks which are regularly high in calories, salt, fat and sugar. These foods are heavily advertised especially to children (Cancer Research UK 2009). The modern physical environment has contributed to increasingly inactive lifestyle over the past fifty years because of changing in work and shopping patterns from local to distant that has results people dependence on motorized transport. Other factor is UK has changed from an industrial to a service based-economic therefore fewer jobs are now requiring physical work. Obesity has also been contributed by poor urban planning where pedestrians and cyclists have lower priorities than for motor vehicle. Most people now spend less time on active games and more time in sitting at the computer, watching TV and playing video games. Our exercise, eating and drinking habits also are greatly influenced social and psychological factors (DOH 2008).
This example relate to an obese and a type two diabetes patient whom has been referred to District Nurse by a General Practitioner following her health condition. Her name is Maria, sixty two years old and she lives alone in a one bedroom flat. Maria is hardly walks because of her condition; she spends more time sitting in a chair and sleeping on her bed. She depends on Carer for her personal hygiene and preparing meals. A District Nurse visits her twice a day to administer insulin. Maria sometimes looks to be confused. She has been advised several times by Dietician and District nurse on her habits of eating unhealthy food, but she says she is not bothering and she does not feel sorry with her condition. Maria background shows that her father was obese and a diabetic, he dead from heart failure.
Obesity is a central player of pathophysiology of diabetes mellitus and insulin resistance. It is a major contributor to the metabolic dysfunction involving lipid and glucose. It influences organ dysfunction involving liver, endocrine, pulmonary and reproductive functions. It also increases the chances of myocardial infarction (Redinger 2007). Diabetes can cause heart disease, amputation, kidney failure and more death than cancer (Diabetes UK 2080). The case study shows that Maria father had died from heart disease.
People like Maria needs support to improve their health. The support could be treatment, a promotion activity, or a care services. According to the Ottawa Charter, health promotion is a strategy that aims to integrate skills and community development and to create supportive environments for health, make efforts to build healthy public policy and look at re orienting health services (WHO 1986). The Jakarta declaration on leading health promotion into the 21st century confirms that this strategy and action areas are relevant to all countries including cities, municipalities, local communities, schools, workplaces and healthcare services. The declaration identifies priorities on promoting health social responsibility, expand health promotion partnership, empower the individual and expand community capacity and secure health promotion infrastructure (WHO 1998). The WHO global strategy on diet, physical activities and health urged all the stake holders to take action to support healthy diets and physical activity global, regional, and local levels to reduce the prevalence of chronic disease and their common risk factors, primarily unhealthy diet and physical activities (WHO 2010).
In 1999, the UK government document Our Health Nation, has identified a three way partnership for a better health. The government, local communities and individual have to work together in partnership to improve our health. Partners include the government, health authorities, local authorities, business, voluntary bodies and individuals (DOH 1999).
Locally, Community care means to provide the right level of intervention and support to people and enable to achieve maximum independence and control over their own lives (Titterton 1994). The Acheson report on Public health, it defined public health as the science and art of preventing disease, prolonging life and promoting health the organized effort of society (Naidoo et al 2000). NHS original goals of providing a comprehensive health service, improving physical and mental health and to prevent, diagnose and treat illness is much in common with the health promotion. Use of the health services is universal so that everyone at some point in their lives comes into contact with the health service providers. Primary health care is the first level of contact of individuals and community with the national health system bringing health care as close as possible to where people live (MacDonald 1993). Primary health care provides a setting where health promotion at primary, secondary and tertiary levels takes place (Naidoo et al 2000). The primary prevention is to delay or prevent the beginning of disease. Joyce treatment of diabetes would have started at this point by screening and advising on changing diet and her lifestyle (SIGN 2007). The secondary and tertiary prevention is sought to reduce the occurrence of relapses and the establishment of chronic conditions through example, effective rehabilitation (WHO 1998). At secondary stage patients are vulnerable and require regular monitoring such as weight monitoring, signs of deterioration, etc.
One of the aims of the district nurses in the community is to improve health of the population by reducing obesity and increase the awareness of the positive healthy behaviors in community. Nurses delivering public health by influencing public policy and health promotion and are working to create the opportunity for people to live positive healthy lives (RCN 2007). The first visit of District nurse to Maria’s home was to assess the needs and prepare a care plan. The plan will include advice and educate on health eating and blood sugar management. District nurse visits will include administering of insulin depend on how serious the diabetes is. Because Maria spends more time sitting, the chance of developing pressure sore and leg ulcer is higher, a District nurse will advice Maria on how to avoid possible break of skin. The district nurse will refer Maria to dietician for advice on Maria’s diet, physiotherapist to help her on physical problems and occupational therapist who will work to improve her ability to perform daily tasks. A district nurse will do referral to social service if required. The general practitioner will be involve in the care of Maria on prescribing insulin and losing weight medicine such as orlistat which works by blocking the action of enzymes that is used to digest fat ( NHS choices 2010).
On the government side, Department of Health is responsible for policy on public health aspects of diet, nutrition and physical activities. It ensure that public and others have the information they need to improve health. It sets national priorities to improve health and reduce health inequalities. It also commissions research on the effectiveness of interventions. Department of Health works together with the Department for Education on promoting education and health school also encourage young people to be active by participating in sports within and beyond school. Schools provide a healthy diet and education and nutrition so that young people can eat a balanced nutrition diet. Department of health also works with other department such as the Department the culture, media and sports to promoting walking and cycling, facilitate active leisure and to improve quality of life for sporting activities so that more people to participate in sports( NAO 2001).
Many people like Maria do not even know that obesity as a problem because they have no access to health information services or support for individuals need’s for information is sometimes underestimated. It could be even health practitioners do not use their skills to promote health of individuals. Health professionals need to work face to face to with individuals so that to provide advising and persuading them to make them change their lifestyles. Accurate and appropriate information about people’s health should be provided and what social and behavior factors can affect their health. People should be made aware of important of health benefits associated with active lifestyle for examples, improve their self efficacy and confidence and enhanced their social opportunity. They should be aware that food high in fat, sugar and salt are not necessary and should be avoided or eaten in minimum (SIGN 2010).
To summing up, obesity is possibly dominating the public health issue in UK today and its effect can not be seen as an individual but is a society a whole. Communities, individuals and other groups need to work together in tackling obesity epidemic and work together in promoting health and well being.
 

Nhs Social Class Health Inequalities Health And Social Care Essay

The National Health Service has a lot of health inequalities regarding to people with gender, race and social class, this has become of interest to myself because there are a lot of issues that relate to the health inequalities of the National Health Service therefore I would be looking at the inequalities of the social class. For this I will be looking at how the NHS began and how the NHS has proceeded throughout the years. I will also be looking at how the government supports and funds the NHS. For the social class inequalities what health impacts there are between the upper and lower class, how private health care benefits those who receive private health care. How the Black Report provided evidence that there are health inequalities between social structure and how poverty affects the lower class.

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The National Health Service was introduced in 1948, when health care sectary Aneurin Bevan (Labour) opened Park hospital in Manchester it bought plans for free good healthcare for all, this meant that for the first time all occupations of the healthcare came under one organisation such as nurses, doctors, dentists and opticians. With the approach of that good health care must be available to everyone regardless of the individuals’ wealth. It was the initial for anyone in the world to receive free health care on the basis of their citizenship not on fees. This came with the ideological perspective of that the health care system that all health care would be available to all and financed entirely from taxes, where people pay for the healthcare system according to their personal income.
The post war Labour Government took into place the NHS in 1948 as illnesses were soaring and thousands of people were dying from diseases which now could have been cured in today’s society these diseases included pneumonia and meningitis. Many of people suffered and tragically died because they could not afford to pay for treatment of healthcare or it was unavailable for numerous working class citizens.
Published in 1942 by William Beveridge, the Beveridge Report showed the need for dramatic change for the healthcare system. The report was designed to tackle the five giants of illness, poverty, disease, unemployment and unawareness in which Beveridge recommended the establishment of the National Health Service it recommended that the government should find ways to tackle ways of fighting the five giant evils.
Since 1948 when the National Health Service was born, the NHS has proven to be a success and fundamental to the society of the United Kingdom (UK). It has enabled families to go and seek medical advice in confidence, and receive treatment regardless of their financial background.
Since the NHS has been in place there has been a dramatic change throughout the 20th and 21st century life expectancy has increased from the average age of 45 years for men and 49 years for women in 1901 to over 75 years for men and over 80 years for women in 2006 – 2008. Also infant mortality has declined the chances of a baby surviving the first year of life has greatly decreased, according to the Office for National Statistics (ONS). However this is may be profound but the NHS has not exactly had the ‘smoothest’ of runs throughout the years, firstly with the conservatives opposing the NHS in 1948 then conservatives coming in and out of power throughout the years left years of neglect on the NHS, having lack of resources such as doctors, nurses and equipment. Labour having to somewhat reboot the NHS and make plans and changes to improve the inequalities and resources to the NHS.
The social democratic approach is to provide welfare state, which this consists of a view that social welfare is seen has a type of social citizenship, with the vision that social welfare is a basic right.
With the NHS being established by the post war labour government, it is usually associated with the social democratic approach having a more concern of social welfare, and focusing on the poor and working class citizens rather than focusing on the wealthier class citizens who can afford to pay for their own health care. The Beveridge Report was to tackle one of the ‘five giants’ illness and providing free health care to everyone still remains a key aspect of the Labour government.
There still is a lot of ideological issues in the NHS that still remain the nature of the provision, the NHS still remains free to everyone and is paid through national insurance (NI) and taxes which still tackles one of the five giants, illness. Where society has changed and life expectancy has increased and infant mortality has declined throughout the years.
Health Inequalities of the Social Class
Throughout the years there has been remarkable health improvements and social economic in the UK. People from all walks of life are living healthier and living longer in today’s society than ever before. Although this remains true there are still a lot of health inequalities that occur in the health care. This was established when a report published by Sir Douglas Black called ‘The Black Report’, showed evidence that health inequalities exist in the health care system, he based the report on mortality rates between social classes, ‘A method of comparing death rates between different sections of the population’ (Townsend and Davidson 1990). This also stimulated new research that social class as a key influence of people’s life chances.
With the National Health Service running for more than sixty years there is still a gap between social classes in all sections of societies applying to all aspects of health including life expectancy, infant and maternal mortality and the general level of health. With the gap between the social classes still emerging, there are still geographical differences between women and men; women tend to live longer by five years on average than men.
The social stratification suffers quite a significant gap within the health care system this may be because of the two tier system in the NHS where people who can afford to receive private health care treatment gives them the advantage of no queues meaning that they would not have to wait on waiting lists, where as the lower class who may not be able to afford private health care would have to wait to a maximum of 18 weeks between referral and treatment. For people who pay for private health care they are often to have a ‘choice’ where they can chose their own consultant and where they would like to be treated, unrestricted visiting hours, where as this may not apply towards lower class citizens because they cannot afford to go private.
The Black report does show evidence that there are health inequalities between social classes. For instance, life expectancy at birth for the upper class increased by six years over the last quarter of the 20th century, while infant mortality had risen by less than two years for the lower class by the end of the century (ONS, 2002). There is also double the infant mortality to the lower class compared to the upper class. Despite the improvements and changes that had been made in 1948 to suit all groups in the post war period. Statistics from the health sector has shown that the poor have shorter life expectancies and poorer health despite the Black Report.
Social class is ‘complex’ topic that involves status, wealth, culture, background and employment. There are a number of different influences of health, several of the health influences including social class. In 1943 Sigerist wrote, “The task of medicine is to promote health, to prevent disease, to treat the sick when prevention is broken down and to rehabilitate the people after they have been cured. These are highly social functions and we must look at medicine as basically a social science.” (Socialist Health Association)
The connection of social class and the health inequalities does not give very clear explanations of the reason why there is a gap between the social classes; people have many different variations of the cause. Such as the ‘Material Explanation’ where this explanation blames poverty, poor housing conditions, lack of resources in health and education as well as more dangerous occupations for the poor health in the lower social class. Poverty being a obvious cause towards ill health. Life expectancy is lower in less developed countries, but diseases that affect the developed world such as Britain tend to be diseases that are more self inflicted and can be avoided to an extend such as obesity, smoking and drinking alcohol to an extreme content. These tend to be more common occurrences for the poor or lower class than the more wealthier and upper class citizens.
The cultural explanation, propose that lower class citizens chose to have less healthier lifestyles, having unhealthy diets (eating fatty foods), smoke cigarettes, and drink a lot more alcohol than wealthy and upper class citizens. With healthier foods being more expensive than quick easy solution foods that contain a lot of unhealthy substances, this would be more of a priority than knowing what is healthier for them. People who work long shifts in factories or work all day tend not to seek any activities outside of work because they may not want to after working because of feeling too tired this does not give them adequate exercise for the cardio-respiratory system.
From the Black report that raised a lot questions to the health inequalities had lead to further reports, such as the Acheson Report that was published in 1998 by Sir Donald Acheson, a former chief medical officer. It found little cause for congratulation and also called for the issue of poverty to be addressed. The Acheson Report
In today’s society problems occur in poor healths which are related to obesity, smoking and the influence of alcohol and accidents. Where as in the past poor health was related to sanitation and infectious diseases. Although poverty is still a cause of poor health except poverty should not be equated to social class. Poverty can extend in variations and definitions of the word meaning ‘Poverty’, because it is very different to third world countries and those of the developed countries such as the UK. Poverty is going to affect the elderly and children more because they are most vulnerable and likely to be affected by poor health. Poverty is a real predicament. The Black Report and the Acheson Report both suggested trying to condense the inequalities of income in societies but these have grown instead. Social exclusion may be a result of poverty such as mental health and substance abuse.
Conclusion
The National Healthcare Service still remains to have the ideological perspective of free healthcare for everyone no matter what circumstances they are under or backgrounds as well as the healthcare being paid through taxation and national insurance, which the NHS still remains heavily funded by the taxation since 1948. Since the establishment of the NHS there has been dramatic change of life expectancy, infant and maternal mortality has dramatically improved since the early 19th century. The government and the public have acknowledged the value of the National Health Service which meets the peoples’ healthcare needs through taxation on the basis of citizenship rather than payment or contribution. Although this is a major improvement since the post war there still is a significant gap between the social classes for the National Health Service perhaps the greatest challenge for the government and the National Health Service is to focus on and address the problems of health and health inequalities of the service, with one of them being the health inequalities of social classes.
Throughout the assignment I perhaps had a political of the New Right theory and did not entirely believe in the NHS, however as I gathered research for my assignment I began to rethink my political view of the healthcare and the welfare system. I did not believe that people should be able to pay for private healthcare and get the ‘best’ and quickest treatment in the NHS itself. While people would have to wait for up to a maximum of 18 weeks, seems quite unfair. I believe that the NHS should be funded from taxation because if it was not then people would not be able to pay for healthcare it would be like taken back to the early 19th century where people died from diseases and illness because they could not afford to pay for treatment which could be easily treated in today’s society. With people still living in poverty today there are no major diseases or illnesses that can relate to death, with the only major health issues are mostly self inflicted causes such as smoking, substance abuse and obesity. Which all to some extend can be avoided.
Bibliography
http://www.nhs.co.uk/tools/documents/historyNHS.html
http://news.bbc.co.uk/1/hi/events/nhs_at_50/special_report/23511.stm
Collins, R. (unknown),”Proud of the NHS at 60″http://www.labour.org.uk/proud/labour_nhs accessed 22nd November 2009
School of Economics and political Science (2000), “The Beveridge Report and the Welfare State” http://www.lse.ac.uk/resources/LSEHistory/beveridge_report.htm accessed 22nd November 2009
(Unknown) (2009) “Life expectancy” http://www.statistics.gov.uk/cci/nugget.asp?ID=168 accessed 22nd November 2009
Homfray, M. (2009) Lecture Notes, Glyndwr University
http://www.bbc.co.uk/history/historic_figures/beveridge_williams.shtml
Unknown, 2009. “Health Inequalities” www.dh.gov.uk/en/Publichealth/Healthinequalities/index.htm accessed 22nd November 2009
 

Analysis and evaluation of the NHS

The National Health Service (NHS) provides healthcare for all UK citizens based on their need for healthcare rather than their ability to pay for it. NHS is funded by taxes. This report identifies the problem with NHS with problem solving tools and techniques. For finding this problem Casual Loop and BOT methodologies has been used.
NATIONAL HEALTH SERVICE (NHS):
On 5 July 1948, NHS was launched by Health Secretary Aneurin Bevan and for the first time health care became free to all UK citizen. In 1952, Patients started being charged for prescription. First mass vaccination programme for polio and diphtheria started in 1958. Before this, there were 8000 cases of polio and 70000 of diphtheria each year. In 1961, contraceptive pills were launched which gives women control over how many children they have.

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In 1962, Health Minister Enoch Powell put forward The Hospital Plan which set out a 10 year vision for hospital building. Every population of 125,000 was to get a hospital or district general hospital as they become known. In 1967 Abortion Act was passed by a free vote of MPs and introduced by Liberal MP David Steel which made abortion legal up to 28 weeks if a woman’s mental or physical health was at risk and further limit reduced to 24 weeks in 1990.
In 1968, UK’s first heart transplant surgery was carried out in the National Heart Hospital in London with 18 doctors and nurses operating a 45 year old man for seven hours. CT scanners were used for first time in 1972. CT scanners started to be used on patients through the development of the previous five years. CT scan machines take pictures of the body to develop 3D images, revolutionising investigations of the body. World’s first test tube baby was born on 25 July 1978 before midnight in Oldham District General Hospital. To reduce breast cancer deaths in women over 50, breast screening was introduced in 1988 and along with improved drug treatment screening was estimated to have cut deaths by a fifth.
In 1990 NHS and Community Care Act was introduced by the legislation which was known as the NHS internal market with health authorities given their own budgets to buy care for local populations from hospitals. In 1994 organ donor register created to co-ordinate supply and demand. It was the result of a five year campaign by John and Rosemary Cox whose son Peter died in 1989 and he had asked for his organs to be used to help others. In 2006, patients were given the choice of four or five hospitals, ending the long held tradition of going where GPs decides. The scheme has now been extended to include all hospitals in England but not adopted elsewhere in UK.
PEST ANALYSIS:
A review of the political, economic, social and technical (PEST) environment involves analysing the environment for any organisation. UK based healthcare provider for the public, NHS funded by contributions made from taxes distributed by the government to each of the trusts. NHS operates within a politically stable economy with funds pledged by both previous and current governments to the service for improvements in healthcare and salaries for staff.
NHS facing the economic environment is a growing economy with a rising elderly population and less working people to support them. It has become increasingly difficult to recruit medical staff and shortages have often been counteracted by employing staff from other European Union countries which in turn increases the population within the UK. The social environment shapes beliefs, values and norms (Kotler). Belief is the core values of the health service and the services it offers was high on the public’s list of concerns during the last general election as if NHS is an internal part of the UK and its culture. The technological environment is moving fast within the health care sector with continually development of drugs, advancement of techniques for operations and the use of technologies for both medical and administrative procedures.
SWOT ANALYSIS:
Strengths:
There is no real competitor for the NHS although it doesn’t have monopoly in the market.
Accident and Emergency service is unique to the NHS though private hospitals are available throughout the UK.
The NHS has continued to grow and expand upon its services since it was established in 1948.
NHS maintains good relationship with health community partners.
Weaknesses:
Due to increasing population NHS is unable to cope with the demand.
High waiting time for the patients.
Bad behaviours and attitudes of some staff.
Opportunities:
Uses of marketing strategies to raise the profile of the NHS.
Partnerships and joint ventures with private and voluntary sector.
Threats:
Work of contractors affects image of NHS.
High turnover of staff.
Shift of services to primary care.
CAUSAL LOOP DIAGRAM:
Causal Loop Diagram’s contain several components:
One or more feedback loops that are either reinforcing or balancing processes.
Cause and effect relationships among the variables.
Delays.
Where feedback reduces the impact of change, it is a Balancing loop. Balancing loops try to bring things to a desired state and keep them there.
Where feedback increases the impact of change, it is a Reinforcing loop. Reinforcing loops compound changes in one direction with even more changes in that direction.
Causal Loop Diagram has two kinds of relationships between variables:
When variable A changes, variable B changes in the same(S) direction. It is indicated by (S) in the diagram.
When variable A changes, variable B changes in the opposite (O) direction. It is indicated by (O) in the diagram.
The Causal Loop Diagram for NHS contains variables which are as follow:
Number of Doctors, Nurses and other medical staff: – The number of doctors, Nurses and other medical staff working in the NHS is inversely related to the waiting time for patients. This implies that when the number of staff increases, the waiting time for patient’s decreases because of added capacity. The number of staff working with NHS depends on softer variables such as their morale and work environment.
Number of Patients on the Waiting List: – This refers to the number of patients on NHS waiting list. The waiting list becomes short when a large number of patients shift from NHS to private health care and becomes particularly long due to seasonal peaks.
Waiting time: – This is time a patient has to wait before he/she can be treated by NHS.
Number of hospitals, beds, medical equipment: – The number of hospitals, beds and medical equipment are dependent on the annual NHS budget and funding. If there is a lack of these resources than it would increase tension in the system and it would take longer to treat patients.
Perceived quality of Health Services (Waiting time, Treatment and After Care): -This varies from patient to patient, if the waiting time is too long, the perceived quality of the service is low and this in turn causes more people to complain against the NHS.
Number of Complaints: – Dissatisfaction of the patients due to increase in waiting times leads to an increase in complaints against the NHS. This increases pressure on the government and the Department of Health by acts of the National Audit Office.
Number of Patients shifting to private Health care: – The patients dissatisfied by the long waiting times of NHS, started complaining and shifting to private health care.
Government action: – Longer waiting lists increased media pressure causing the Government to increase its annual NHS budget which relaxes the system temporarily as new funds increases the NHS capacity.
Investment in facilities, Medical equipment and information technology: – An increase in the NHS budget allows the NHS to hire more medical staff and improve the capacities in hospitals. More patients can be treated within short time and the waiting lists can become shorter as the budget increases.
Partnership with Private Health Care: – NHS cannot cope with the excessive demand when the waiting lists become too long. So it tends to outsource its service to private health care e.g. BUPA, NHS express surgery units in partnership with state run German and French health care firms. This is quick and short way to fix the problem and tends to bring down the waiting time in the short run.
Morale of doctors and other medical staff: – This is a soft variable that depends on factors like the quality of the work environment in the NHS hospitals, the work pressure and employee satisfaction. The morale of doctors and other medical staff has a positive effect on the quality of service provided to patients. It also determines the number of doctors and medical staff that stay with NHS or join NHS.
Number of patients coming back to the NHS: – The waiting list tends to decrease when a large number of patients shift to private health care or/and when the NHS budget is increased to support improved health care. The waiting time for the treatment becomes short and due to this some of the patients who had previously shifted to private health care return to NHS. This once again increases the waiting list of the patients.
All the actions and movements of these variables are shown in the Causal Loop Diagram of NHS (figure 1)
Figure : Causal Loop Diagram for NHS
Key: –
= Loop 1(Balancing Loop) = Loop 5(Reinforcing Loop)
S = Augmenting Relationship O = Inhibiting Relationship
The causal loop diagram suggests that a deeper set of forces is at work and the problem situation to be modelled is complex and dynamic. It is necessary to consider both hard variable (number of beds and hospitals) and soft variables (morale of staff). There are 6 loops in the system. There are 2 positive loops or reinforcing loops and 4 loops are negative or balancing loops.
In loop 1, increasing number of patients on waiting list increases the waiting time which leads to dissatisfaction and complaints against the NHS. This also switches some patients to private health care. Increasing pressure from public and media forces the government to increase the NHS budget. This tends to have positive effect on the system by increasing NHS capacity and reducing the waiting list.
Loop 1 is affected by loop 5 which is positive and reinforcing loop. Some patients decide to return to NHS from private health care as waiting list is decline. This increases the waiting list once again. Hence, there are no proper solutions to the problem or solution is difficult to achieve.
Many obvious solutions to the problem like increasing the NHS budget failed in the past. The causal loop diagram contains more negative loops than positive loops. Hence the system appears to be a negative system that tends to counter uncontrolled deviation and stabilise if the waiting list increases significantly.
CONCLUSION:
NHS is the UK health care service run by the government funded through the taxes. This report shows environmental condition of NHS through PEST analysis and Strengths, weaknesses, opportunities and threats of NHS through the SWOT analysis. The causal loop diagram for NHS point out the main problem of NHS which is increasing waiting time for patients and a temporary increase in resources (NHS budget) gave short run solution for the problem.
RECOMMENDATION:
Collaboration with private health service to decline waiting time.
NHS should maintain good relationship with private health service.
NHS should overcome its weakness through its strength and reduce its threats through appropriate use of its opportunities.
Increase its work force and equipment.
NHS should stop the contract based employee and there should be better coordination between doctors, nurses and other employees.
 

Changing Role of HRM: The NHS

The Changing Role of Human Resource Management within the National Health Service: Feeling at Home in an Increasingly Complex Environment.
Abstract
In the context of a widespread programme of reform of the English National Health Service (NHS) this paper considers the changing role of Human Resources Management (HRM) within the service, and reports a study of the changing role of HRM in a large teaching hospital. Empirical research suggests that whilst the perception of the role and effectiveness of the HRM function remains varied, if managed correctly it is potentially capable of having a direct and beneficial impact upon service delivery.

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Introduction
The reforms and changes within the National Health Service (NHS) and its management of staff and services has clearly been well documented, however research into the evaluation of these initiatives remains a neglected area. Walshe suggests that the reason behind this is that researchers do not have time to ‘painstakingly’ document and measure the progress and impacts of reform due to constant change caused by the initial ‘bright ideas’ having been poorly thought out (2002:106). Empirical research can though attempt to offer an understanding into the ‘complex relationships that exist between individuals and how they interpret policies within a wider social and cultural organisational context’ (Clarke 2006:202) and provide insight into the NHS managerial culture to examine how it ‘supports and facilitates the implementation of the recent wave of NHS reforms’ (Merali 2003:550). Through incorporating a review of the literature that surrounds the changing role of HRM within the NHS and empirically based qualitative research, a comprehensive insight into the current context and position of Human Resource Management within an NHS Trust is given. Whilst such research will hopefully be of academic interest, perhaps more importantly in order for the NHS and other public services to be aware of the impact of reforms upon employees and thus on subsequent service delivery, an awareness of HRM practices and their implementation should be a necessity for practitioners (Edgar and Geare 2005).
The Current Context of the NHS
“…the NHS is unique. To name but a few of its characteristics, it is in the public sector, exceptionally large in terms of its resources, activities and numbers employed; domestic not international in its operations; its tasks are infinitely varied, complex and difficult; its goals are unclear; it is subject to an exceptionally wide range of political and economic influences; and it is an organisation uniquely and specially close to the hearts (metaphorically), minds and bodies (physically) of British people. It is run by ‘special’ kinds of people too: dedicated, yet often ambitious, highly qualified and skilled, often bloody-minded and usually tough-minded, yet also caring and even tender.”(Glover and Leopold 1996:256)
The NHS is the largest employer in Europe, employing over a million clinical, infrastructure and support personnel (The Information Centre 2006). Whilst remaining close to the people’s heart in terms of its founding values of a universal and comprehensive health care with its service delivery freely and equally available to all in society (Rivett 1997; Talbot-Smith and Pollock 2006), it is also close to the people’s pockets, with billions of pounds having been invested into the NHS in the last ten years (Appelby 2007). In addition to providing a health service to the population, it is also claimed that ‘health and healthcare play a key role in generating social cohesion, productive workforce, employment and hence economic growth’ (Harrison 2005) and for this reason, as Bach notes, the means to reform health care systems effectively is an issue that confronts policy makers worldwide. (2001:1) As such, the challenges facing the NHS in terms of management, change and efficiency are important to an audience far wider than the UK and those who use and work within the organisation.
In consuming around £50 billion per annum it is no wonder that successive British governments have attempted throughout the history of the NHS to dictate from the centre the ‘minutia’ of the NHS’s activities. A key problem however is that due to the complexity of the organisation itself and the politics that surround it, the methods used are considered by many to consist merely of ‘a plethora of complicated targets and initiatives that confound those who are charged to implement them’ (Bradshaw 2003:90). In recognising the obvious public concern over the management, and expenditure, of the NHS both the previous Conservative and Labour governments and current New Labour invest considerable time, and tax-payers’ money, into attempting to improve the service. Yet it is considered increasingly apparent that in responding to health deficiencies ‘by throwing money at them to see the quick, comfortable resolution of the political conflict that these inevitably cause’ (Duncan-Smith 2002), continual change ‘for change’s sake’ has become the focus at the expense of the ultimate ‘telos’ that created the health service (Kelly and Glover 1996:31).
Changes in Management of the NHS
Since its conception, it is clear that the NHS has undergone many changes, both structurally and ideologically, but it is since the reforms of the early 1980s that the focus of NHS management has attempted to move away from obvious ‘command and control’ techniques and towards local management with local responsibility and accountability not only to the government but to the public that ‘experience’ the service. It was subsequent to these reforms and as a result of the Griffiths Report and policies such as ‘Promoting Better Health’, that ‘Working for Patients'(1989) was introduced which further emphasised the NHS’s aims of better health care, choice, complaints procedures, patient information, and overarching quality.
Currently a number of policy and management initiatives are transforming the structure and organisation of the NHS (Truss 2003). New Labour are heralding the benefits of ‘choice’ within the public services as a whole and many of the recent initiatives focus upon the ‘customer’ and the need for services to attract these customers and the money that they bring, to the extent that within the NHS ‘individual patient preference [is] determining where business will be placed’ (Bradshaw 2003:87). The logic behind this is claimed to be one of providing a new incentive for ‘providers to improve customer responsiveness’, for if money follows patients and patients have a choice of service the power is with the people rather than in the hands of a previous monopolistic service provider (ibid). Such market incentives are driving NHS hospital trusts to perform more like businesses, with a corporate focus based upon meeting the demands of all the various stakeholders, and thus requiring distinct business strategies which will account for all aspects of the organisation and services provided and ultimately ‘enhance their cash flow (Pollock 2004:218).
With the establishment of Foundation Trusts, NHS Trusts which are perceived as high performers can gain Foundation Status, thus becoming corporate bodies, free from the controls of the strategic health authorities and accountable only to those whom they represent – their own managers, staff, patients and local residents (Pollock 2004). The thinking behind this is seemingly one of moving away from what has been perceived as a ‘monolithic’, inefficient bureaucracy to a system of individual services which are autonomous healthcare provider organisations that could be flexible, responsive and innovative’ (Walshe 2002:109). As the Department of Health states:
“The Health and Social Care (Community Health and Standards) Act 2003 establishes NHS Foundation Trusts as independent public benefit corporations modelled on co-operative and mutual traditions. Public benefit corporations are a new type of organisation, specially developed to reflect the unique aims and responsibilities of NHS Foundation Trusts. NHS Foundation Trusts exist to provide and develop services for NHS patients according to NHS principles and standards and are subject to NHS systems of inspection. Transferring ownership and accountability from Whitehall to the local community means that NHS Foundation Trusts are able to tailor their services to best meet the needs of the local population and tackle health inequalities more effectively.”(DoH 2007)
Walshe considers the introduction of Foundation Trusts as providing organisational stability due to them reducing the ability of ‘future Secretaries of State for Health to reorganise the NHS every two or three years’ and thus allowing ‘meaningful service improvements to take place (2002:109). However, it is also recognised that this in turn could potentially cause problems as there will be ‘no guarantee of good management and governance’ resulting in the replacement of ‘one set of dysfunctional behaviours with another’ (ibid).
Many interpret Foundation Trusts as forcing NHS trusts into having to respond flexibly to market forces similarly to private sector organisations, due to the public and political interest in the service it must also contend with the constant barrage of audits, inspections, monitoring, league tables and an increasingly demanding and knowledgeable public (Talbot-Smith and Pollock 2006). The NHS today can therefore be seen as remaining seemingly attached to the ideologies of the business world, and current government emphasis towards ‘modernisation’ suggests that the premise remains dominantly that:
“…no organisational context is immune from the uncertainties of unrelenting change and that, as a result, all organisations – public, private and voluntary – need to develop similar norms and techniques of conduct: if they do not do so, they will not survive. Thus all organisations need to look to current ‘best practice’…Government services are brought forward using the best and most modern techniques, to match the best of the private sector.”(Du Gay 2003:676)
These government initiatives reflect notions that by improving management and employee satisfaction, the NHS could become both an efficient and effective business, able to satisfy these consumerist needs of the customer. For example, the policy ‘Improving Working Lives’ aimed to encourage NHS employers to ‘develop a range of policies and practices which support personal and professional development and enable employees to achieve a healthy work-life balance’ (DH 2000). These management strategies have been labelled within this sector as New Public Management (NPM) and are considered to mark a clear differentiation from the previous strategies of ‘an administered service to a managed service'(Bach, 2000:928). Flynn argues that NPM clearly incorporates all of the changes that have occurred within the NHS following the reorganisations and new rhetorics of the 1980 reforms and the essential components that NPM consists of are clearly visible:
“…more active and accountable management; explicit standards, targets and measures for performance; a stress on results, quality and outcomes; the break-up of large units into smaller decentralised agencies; more competition and a contract culture; more flexibility in the terms and conditions of employment; increased managerial control over the workforce and efficiency in resource allocation.”(1991:28)
With the introduction of this managerialist emphasis in the NHS it has been suggested that there has been an investment of ‘faith in managers’. This faith has been based on the supposition that the ‘language, techniques and values of managerialism’ were, and are, ‘the only way actually to deliver change’; thus an ‘unparalleled’ position of ‘power and authority’ has been placed upon public managers (Exworthy and Halford 1999:5-6). Such managerialism, and its values and beliefs is based upon the assumption that ‘better management will prove an efficient solvent for a wide range of economic and social ills’ (Pollitt 1993:1), and in the case of the NHS these ‘ills’ are well documented in terms of a lack of capital and thus a shortage of resources yet with a need to provide an increasingly efficient and ‘quality’ driven service.
However, the notion of managerialism must be used with caution. ‘Faith’ in managers can be perceived as politicians having faith in their own management in that they have failed to ever relinquish control, instead taking even more tight control through the implementation of numerous health policies and operational procedures. Such a need to keep close reigns on the management of the NHS suggests a deep mistrust in the capabilities of the public servants within it rather than a desire to allow it its freedom.
Overall it is clear that the NHS is very complex for a range of reasons not least because of its complexity and variety of its duties, the range of skills it needs to draw on, the difficulty of reconciling competing priorities, the cost of healthcare, and the way the NHS has been stitched into the political fabric of England. From an organisational perspective too it is a hybrid mix of hierarchy, bureaucracy, market and network. To efficiently manage such an organisation is therefore a highly complex and unrelenting challenge.
HRM in the NHS
The role of HRM pre-reforms was mainly focused on administration and support with a lack of defined responsibility. Named Personnel rather than HR, the function was used to deal with general staffing issues of terms and conditions of employment, payment and holiday options, individual and local staffing issues and the well known ‘hiring and firing’ that it remains renowned for. From Personnel Managers came HR professionals, HR departments, and increasingly HR directors with voting rights on the Executive Boards of NHS Trusts. This has been considered a result of the changes that stemmed from the Griffiths reforms and continue today, and due to a particular focus on corporate business ideals, from which a clear, but nonetheless controversial role was carved out for a function that dealt with the management of the increasingly important resource of people.
‘…the effect of the reforms was to stimulate management to review custom and practice and historical staffing patterns, with a view to achieving better value for money. In this context the HR function was caught up in the continuing tension between those health care professionals who focused primarily on patient care, and those managers responsible for cost-effective use of resources but constrained by a lack of clinical knowledge'(Buchan 2000:320).
The current role of HRM in the NHS, its status within the service, and its success as an effective function has become especially important at this time where ‘human resources’ are considered the key to not only improved staff performance but also competitive advantage (Bach 2001; Clarke 2006). Despite the managerialist rhetoric that clearly surrounds the drive for increasing the role of HR, on a more simple note it is little wonder that such an emphasis has been placed upon the HR function considering the cost of staffing in the NHS – of the £19 billion cash increase in the NHS from 2004/5 to 2007/8 the increases in staff pay ‘swallowed up’ around 34% (Appelby 2007). To add to this, the growing importance of the function is particularly clear in situations where individual NHS trusts are being granted greater financial and operational independence within the increasingly competitive, consumer driven market that the government is creating through such initiatives as Foundation Trust Status. Barnett et al’s research demonstrated that the HR function within a Trust evolved through these changes in political and organisational focus and ‘generated a new focus on labour productivity and on value for money’ from which ‘a new and strategic approach to the management of the workforce was required’ and as a result they decided to ‘embrace the principles of human resource management'(1996:31).
So with the acknowledgement that service funding follows customers, customer satisfaction is linked to quality of service, and quality of service is linked to ‘the skills, motivation and commitment’ of service staff, within such a ‘labour intensive human service industry’ the role of HRM is imperative (Bach 2001:1; Pollock 2004).
The Changing Role of HRM in the NHS
Yet HRM’s move from an administrative role to a function that potentially impacts upon corporate strategy has been my no means plain sailing. Ham succinctly locates a key basis for conflict within the NHS in his suggestion that ‘there is continuing tension between the role of doctors in deciding treatment…and the attempt by managers and politicians to influence priorities at a national and local level’ (1996:96). There is much literature on the dominance of professionals and the conflict with managers within public sector organisations and in particular the NHS (Kember 1994; Skjorshammer 2001; Atun 2006; Hoggett 2006) and it is clear that their dominance remains not only because of their unique skills and knowledge but also because of their obvious importance within the service (Kelly and Glover 1996). However, within the changing NHS, the dominance of the professionals is subject to more and more management constraints, both on their resources and their autonomy and whilst some acceptance of management expertise is recognised by the professional groups their patience reaches a limit when this becomes encroachment on their ‘professional competence’, resulting inevitably in conflict (Ackroyd 1996).
Managers within the NHS are marked by a poor image, often both within the organisation and by members of the public. Merali’s study found that the ‘majority of the managers were convinced that the general public believed that doctors and nurses were the only professionals in the NHS who are motivated by a desire to serve/provide care to society’ (2003:558) and similarly within this research the public perception of management within the NHS was consistently negative: ‘There’s too many [managers] as it is’, ‘The NHS should swap most of the managers for doctors and nurses, then there wouldn’t be waiting lists’, “If you can find out what the management do then that’s an achievement in itself’. Overall it seems that management, especially in a context of attempting to rationalise the NHS and incorporate business ideals of value for money and efficiency which often results in cost-cutting through redundancies and closing services, are deemed by non-managers to hold an entirely different ideology that is a far cry from caring for people. Yet the function of ‘management’ is well placed within the NHS, and its conflict with the medical professionals whilst often cited can appear over-emphasised.
However with HRM now shifting in its role from administration and support to management and strategy at the same time as organisational change that is producing a complex and uncertain environment for many within the NHS, the HRM function faces a hostile crowd. This symmetry between the focus upon business and private sector ideals and the rise in HR as a function in its own right, can begin to explain perhaps the antagonism that many within the NHS express towards the HR departments. Those within the NHS who hold close to their hearts the original ideals of the NHS and their role within it rather than fighting against government initiatives and the corporate business world influence instead could hold to account the one group which was ‘created’ out of these initiatives – the HR function. Bryson et al in acknowledging both the power struggle between doctors and management and the increasing role of HRM note that, with a complex organisational strategy that seemingly has no clear direction and with few colleagues from the traditional management functions to align with, HRM are far from being seen as any part of the ‘NHS tribal club’ (1996:53).
Through becoming part of the ‘Corporate Business Team’ and gaining responsibility and a potential role of ‘power’ within the new NHS environment the HRM function has run into conflict. Starting off on the wrong-foot, as Bach explains, HR within the NHS must struggle with the constant accusation that it is illegitimate as its role does ‘not obviously contribute to patient care'(Bach 2001:12). It would also be expected that any role within the NHS service that had the role of scrutinising staff and reviewing quality of care when they were not medically knowledgeable would come to blows with the medical professionals, especially when the latter has enjoyed far-reaching autonomy and control in the service since its beginning (Buchan 2000). However, to also find few compatriots within the rest of management due to its timely rise with organisational change which has rationalised and constrained many other departments, many HR departments have been left in a no-man’s land.
There are few who would debate the continued dominance of the medical profession within the NHS, nor the importance of it remaining in such a position. However, their importance within the NHS as a business is becoming more complex. Management are increasingly holding the power to dictate for example the working patterns of doctors and they have the ability to withhold or reward resources depending upon clinicians abilities to achieve targets. And, with the introduction of Foundation Status, Trusts are running a competitive business within which all are dispensable, as Pollock describes:
“…in the past, doctors were free to speak out – in fact they were under a moral obligation to do so – if they felt it was in the interests of their patients. In a business culture, however, loyalty is said to be due above all to the shareholders. Where the survival of the hospitals depends on massaging the figures and performance ratings, doctors who expose the inadequacies in the system or rail against underfunding or lack of resources are seen to be criticising their own hospitals…”(2004:203)
With performance targets increasingly dominant in the NHS, to the extent that funding, resources and ‘Foundation Status’ can be given or taken away accordingly, accountability not only for service provision but also initiatives such as ‘Improving Working Lives’ have meant that HRM can also take a large piece of the managerial high-ground (Givan 2005). In addition, with the record investments in staffing and government focus upon improving service delivery through effective people management, HRM has been given legitimacy within the NHS through the Government’s ‘HR in the NHS Plan’ (DoH 2002) which represented the NHS’s ‘first generic HR strategy'(Truss 2003:49) and more recently ‘NHS Foundation Trusts: A Guide to Developing HR arrangements’ which highlighted the importance of the HRM function within Foundation Trusts (DoH 2006). With these initiatives in place the effective functioning of HRM is a measurable target – it matters not whether the medical professionals or other managers accept or value the role of HRM. This not only provides the HRM function with a place within the NHS, it gives it the opportunity to ‘adopt a more strategic role within the ‘new public management: ‘it is no longer consigned to a reactive and administrative role, interpreting and applying national rules, and can be proactive’ (Corby 1996 cited in Truss 2003:49).
A number of commentators have assumed that changes in the role and status of HRM in the public sector merely follow orientations developed in the private sector (Buchan 2000; Thomason 1990). Just as the NHS as an organisation can be seen to have taken on private, corporate business strategies, so too it is considered that private sector HR management techniques were established (Buchan 2000:320). Distinct similarities can indeed be seen between the developments of HRM in the private sector and what is currently expected of the HRM function within the NHS as Begley and Boyd summarise:
“The declining relevance of the command-and-control approach to business has extended into the roles played by HRM. Many companies regard their employees’ talents as providing a significant competitive advantage. they expect their HR professionals to formulate creative, flexible programs and policies to woo, develop, and retain that talent.”(2000:12)
This apparent mirroring of private sector HR techniques within the public sector environment has met with various hostile reactions, with accusations of public managers being forced to adopt private sector HRM styles with the possible ‘dangerous’ result that such language will cause the public domains to ‘neglect their values’ (Boyne, Jenkins et al. 1999:411).
Yet others, and especially some senior HR professionals within the NHS, take a different view. For them, the introduction of more efficient people management is an important and necessary development, one that is sorely needed in an environment where people are not only the service providers, but also the product and customer of healthcare services. The following empirical research and analysis demonstrates that far from being left out in the cold, the HRM function is capable of rising through an NHS Trust, effectively implementing government initiatives as well as producing its own, and finally reaching the position of designing and directing corporate strategy. Whilst the perceptions of HRM by other Trust members may vary, this is not necessarily a hindrance, but perhaps an organisational necessity that must be negotiated.
Methodology
The paper reports a research project that has followed the changing role of the HRM function within a large teaching NHS Trust (herein called ‘The Trust’) in the UK. It reports on in-depth interviews and observations of a number of meetings involving staff from across the hospital hierarchy. The Trust is facing many changes, both in its financial governance and organisational practices. Recently it was granted “Foundation Trust” status and, as a result, a competitive drive for value for money and the need to develop efficient recruitment and retention practices have become key issues.
Despite only requiring access to staff, rather than patients, researching an NHS Trust proved more difficult than originally anticipated. Currently researchers wanting to interview NHS staff are required to gain NHS Ethics Committee approval to the same degree that clinical researchers must do when requesting clinical trials on patients. This can be seen as associated with the increased awareness of the importance and value of hospital staff and their working lives at all levels of the organisation, requiring the researcher to ensure that the research is valid and that staff will not be adversely affected. It could be suggested that by not distinguishing between staff and patients and the need for ethical approval in research the NHS has adopted the understanding that to ensure quality of service and patient care staff must also benefit from an improved working life.[1]
The empirical research took place over a period of nine months within the one NHS Trust and included in-depth interviews with twenty-two members of The Trust’s staff and observations of key meetings with staff from across The Trust’s hierarchy in attendance. A Trust Executive P.A. provided a list of thirty-five potential participants for the interviews, ranging from Assistant Service Managers, Junior Doctors, Ward Managers, Nurse Specialists and Senior Staff (including members of the Trust Executive) who were contacted via email communication. Assurances were given that these participants had not been ‘cherry picked’ for their perceptions of HR or management initiatives (which was reflected in interview content at times).
The interviews were conducted either within an office provided by The Trust or at a location convenient to the interviewee, often a staff room or their office. Each interview was recorded, with the participants’ consent, and transcribed in full, with all distinguishing information such as names, exact details of roles and personal information destroyed to ensure anonymity, in accordance with the Ethics Approval criteria. The Director of Workforce and Corporate Affairs was interviewed twice, before subsequent interviews took place and again once interviewing was completed.
The three meetings observed (Patient and Staff Experience Meeting; Executive Governance Committee for Clinical Effectiveness; and Strategy Advisory Group) were chosen through knowledge of the different staffing groups that would be in attendance in order to attempt to gather information as to how different groups interacted. By chance observation of the RCN Clinical Leadership Programme Presentation to the Patient and Staff Experience Group was also possible. Notes were taken during the meeting regarding staff interaction, comments about policies and Trust issues, though individual names and some meeting content was not recorded due to either anonymity or irrelevance.
Due to the highly qualitative nature of this research and in valuing the need to attempt to provide an accurate and indepth understanding into the perceptions of those interviewed and how these relate to the role of HRM and its effectiveness, the following presentation and discussion of the research will use direct quotations, some at length, to highlight issues. It is felt that it is important to allow these views to be expressed clearly and as distinct from over interpretation thus enabling as honest a reflection of the current context as possible. In order to ensure the anonymity of participants they will usually be identified only by their generic role within The Trust.
Discussion of Empirical Research
The research demonstrates that perceptions of HRM within The Trust remain varied, a stance that is not unknown to those within the role:
“I think lots of different people have lots of different perceptions. I think …a lot of managers are starting to see the value of HR and what HR can actually offer them…Other managers would probably just think we are only here to make their lives difficult and not let them get on with the job but those are the people who perhaps have never really had any involvement or used HR to its capacity…” (Human Resources Staff #1)
This suggests that HRM within the NHS remains in a similar situation to when Currie and Procter researched the role of personnel within the NHS and highlight the differing perceptions that the personnel department, and it’s subsequent human resource strategies, had within a trust:
“Both executive directors and middle level managers see an advisory role as appropriate…They differ in their views as to whether the emphasis of the personnel department should lie with operational or strategic issues in an advisory role…middle managers view the personnel department unfavourably because it is distant from the operational aspects of health care…”(1998:383-384)
Indeed, many of the participants found it difficult to summarise the role of HRM and during the research the role was often described as ‘personnel’ or ‘medical staffing’. This lack of clearly defined role for some within The Trust may, as suggested by the HR staff, stem from minimal contact with the HRM department, other than in specific situations such issues with recruitment and pay-role[2].
“…lower grade staff will still see the HR as a sort of mini police force within the organisation and if you do anything naughty you get disciplined and I guess a lot of the lower grade staff don’t have a real idea of what the HR department does…”( Human Resources Staff2)
Perhaps another reason could be the constantly changing title of the head of the HR department. Initially The Trust employed a Director of HRM but as the Director developed and expanded the remit and function of the HR department’s role his title developed to one of Director of Workfor