For decades a general lack of funding in the NHS has resulted in poor service delivery, which for some time went unquestioned (Box 1). The prevailing culture was to function without direction and without input from outside sources such as voluntary groups and those who used the service. Control was bureaucratic and so service delivery deteriorated resulting in a growing number of complaints. The number of cases of litigation against the NHS grew, prompting the government to take action.
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Baljinder Kaur, BA, BHSc, is A&E staff nurse, Bradford Royal Infirmary, and will soon start employment as health visiting staff nurse at Manningham Health Centre, Bradford City Primary Care Trust.
For decades a general lack of funding in the NHS has resulted in poor service delivery, which for some time went unquestioned (Box 1). The prevailing culture was to function without direction and without input from outside sources such as voluntary groups and those who used the service. Control was bureaucratic and so service delivery deteriorated resulting in a growing number of complaints. The number of cases of litigation against the NHS grew, prompting the government to take action. The culture is changing within the NHS, as members of the public are demanding better and fairer services. Expectations are growing and so must the notion of choice. The NHS used to function on the premise that people should be dependent on it. This meant that professionals were not questioned - they were the experts. Today the patient is no longer passive and government policies (Box 2) advocate public and patient involvement (DoH, 1999). The change process is slow but policy is allowing people to reap the rewards of service delivery. Patient-centred care actively includes the patient in the decision-making process. Nurses should offer information on the choice of treatment and any other services available to them. The NHS cannot continue operating in isolation of public views. Access to information, services, and involvement have become of prime importance to all, and nurses need to be aware of this if they are to be instrumental in driving the changes. Complaints
Strategies for open communication and honesty, where patient complaints can be heard and assistance can be given to resolve them, have been rolled out in hospitals. The Patient Advice Liaison Service (PALS) is geared up to deal with dissatisfied patients or carers and can also give advice. If necessary, complaints can be taken further to the Independent Complaints Advocacy Service (ICAS), which records all patient complaints. NHS staff should learn from the complaints and make sure that services are improved to prevent complaints in future. Initiatives
New policies are continually released but those that can make a positive difference to the lives of service users are the ones nurses should be driving forward at local level. This requires cultural change throughout the NHS, which may not be easy since resistance to change can breed contention, fear and low morale on the part of staff and patients. The way that care is delivered is changing in a number of ways: - The public are increasingly becoming involved in their own care; - The NHS and social services are beginning to work in an integrated manner; - Nurses must ensure they continuously work in partnership with other agencies and strengthen these relationships to deliver quality care. Patient involvement
Shared decision-making and working in partnership with patients is important in ensuring a fairer service. One example is the Expert Patient Programme (DoH, 2001a) which teaches patients with a chronic illness or disease to manage their condition and take control of their lives. Such programmes last for about six weeks and patients learn about assertiveness, social and financial support, how to manage and live with their condition, and how to ask for what they want. When patients become knowledgeable about their condition or disease they in turn cascade the information to other patients. This means there is a positive and proactive channelling of NHS funds with greater promotion of independence. Nurses can inform patients about expert patient programmes or encourage them to liaise with primary care nurses to see if such programmes are running or can be set up. An example could be where group support is provided for patients with chronic leg ulcers who are experiencing isolation and anxiety. Management of the condition could include discussion about nutrition, pain, and mobility. Nurses fulfil the role of educator and facilitator as patients become increasingly knowledgeable. Nurses should attempt to identify how the expert patient programme can be incorporated into their practice because in the long term, increased awareness and understanding of their condition can improve patients’ quality of life. National patient surveys and patient forums provide other means of identifying patients’ concerns with regard to care delivery. The National Institute for Clinical Excellence also has a role to play in ensuring clear, fair and equal standards of service for everyone. An example of this was the controversy over the postcode lottery provision of in vitro fertilisation (IVF) treatment. This has now been addressed and treatment is available to all women regardless of where they live. The Dipex website (www.dipex.org), which catalogues personal experiences of health and illness, and The NHS Plan (DoH, 2000) reveal that most complaints are about staff attitudes and cancelled appointments, yet neither is recorded by the National Performance Assessment Framework. It would appear from early evaluation that the NHS is not responsive enough and patients’ real experiences must be taken into account as well as information derived from committees and forums consisting of lay members. We can only make improvements to practice if we listen to the experiences of service users. The NHS Plan (DoH, 2000) advocates keeping what is good and getting rid of what is not working. The NHS is no longer about taking the cheapest tendered contract but efficiency, carefully managed budgets, and ensuring best practice. Benchmarking
Notice is being taken of influencing factors such as the Bristol inquiry (DoH, 2002). Benchmarking best practice means that tried-and-tested interventions can be recorded and repeated, ensuring everyone receives the best care available. Essence of Care (DoH, 2001b) promotes benchmarking best practice, although not in isolation, as clinical governance decides which policies are implemented at a national and local level. Three-yearly audits of patients’ experiences of services are included in the audits. The idea is to make the NHS more responsive and more transparent by involving patients and taking on board their comments to ensure that future decision-making incorporates their ideas and recommendations. External input
Health service public representatives on the Overview Scrutiny Committee can now walk into health organisations and scrutinise documents, sit in on board meetings, and give their input to decision-making bodies at a national and local level. The Healthcare Commission also has a role, for instance in raising concerns about patient safety and ensuring trusts appoint risk managers. Hospitals have been given a lot of information and responsibilities where the patient is the focus. Choice has increased, making the NHS more responsive to patient needs. For example, patients are now able to choose where they want to have surgery. To reduce waiting times patients may have the choice of going abroad for an operation. Continuous improvements have been made, including the introduction of the National Commission for Patient and Public Involvement in Health Care. Its aims are to work with diverse groups in the UK population to ensure shared, equal decision-making. Conclusion
It is too soon to say whether patient involvement has been effective. Patients and health professionals may be confused about the rapid changes in NHS structures and patients may have certain expectations. The picture will become clearer over the next couple of years as results of surveys and audits are published. However, this entire process is being driven by a huge cultural change among the government, NHS staff and patients, and it is hoped that the new raft of policies emerging will allow both health care staff and service users to reap the rewards. This article has been double-blind peer-reviewed.