6. Outcomes not income

Resolution submitted by the RCN Hertfordshire Branch

That this meeting of RCN Congress calls on Council to lobby for services to be provided on the basis of outcome rather than income

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Progress report

Submitted by: Hertfordshire Branch
Council lead and committee assigned: Andrew McGovern, Nursing Practice and Policy Committee
Committee decision: Existing work addresses this issue
Members involved: Members extensively consulted on the Government white paper, and through the RCN’s Frontline First campaign

Final summary update May 2012

The RCN has used its Principles of Nursing Practice as a benchmark for influencing outcomes. This is borne out of its overarching UK policy position to support improved clinical and patient-focused outcomes and to demonstrate that nursing input makes a significant difference to the delivery of high-quality, safe care.

The adopted policy position is underpinned by the RCN’s response to the NHS white paper and the Health and Social Care Bill in England. (now the Health and Social Care Act 2012). In the response to the NHS white paper the RCN published 18 key assurances against which it benchmarks the Government’s proposals (provide link to this document on RCN web site).

Work in this area reflects the different approaches to planning, organising and delivering of health care in each of the four countries but the RCN recognises that outcomes are influenced by issues such as staffing numbers and skill mix; internal processes influencing team work; safety systems and supervision; and particular patterns of behaviour.

The RCN also acknowledges the cost pressures facing health and social care across the UK.
Recently, the RCN in Scotland responded to a limited Scottish Government consultation on the future performance management system for NHS Scotland.

In Northern Ireland the RCN has submitted evidence to the Review of Health and Social Care.
In Wales, the RCN continues to be involved in any proposals for change, emphasising the need for outcomes based on patient need.

Update at November 2011

The new Coalition Government in England set out its intentions for services to be provided on the basis of outcomes in the NHS White Paper ‘Equality and Excellence: Liberating the NHS’ and the supporting consultation document ‘Equality and excellence: transparency in outcomes: a framework for the NHS’.

The NHS in the UK is financed primarily from general taxation but with a small amount of income generated from patients via prescription charges (in England only) and from private patients. In the Government’s Comprehensive Spending Review the chancellor announced an annual rise in NHS funding in England of 0.1% above inflation overall health service spend increasing to £114bn by 2014-2015. In addition efficiency savings of £20bn must be made over the same period under the ‘Nicholson challenge’. All countries are facing the same core challenges from rising health demand and limited resources, however each country has different approaches to planning, organising and delivering health care with differences in the role and scope of the independent sector, including not for profit and commercial organisations.

The Scottish Government’s national performance framework includes 15 national outcomes by which all public bodes should be measured. This includes an outcome that “We live longer, healthier lives”.  The RCN’s recent report Taking the Pulse of NHS Scotland makes clear that many decisions about workforce and service redesign appear to be being made on the basis of available resource not improved patient outcome.

In Northern Ireland, the current review of Health and Social Care is considering a broad range of issues relating to the structure and functioning of the Health and Social Care service. One of the terms of reference commits to “provide a strategic independent assessment across all aspects of health and social care services on the present quality and accessibility of services, and the extent to which the needs of patients, clients, carers and communities are being met by existing arrangements, taking account of the issues of outcomes, accessibility, safety, standards, quality of services and value for money”. This is set against a background of a projected £2.3 billion funding deficit by the end of the current CSR period. The Health Minister has also stated his desire for the review to consider “removing roadblocks to the charity and voluntary sector providing services ... [and] in driving change and innovation”. The RCN is currently preparing its evidence to the Review and is emphasising the need for service realignment and strategic refocusing to be based upon patient need and quality of care, rather than financial constraints. It is also highlighting the centrality of nursing to these processes and for the need for nursing to be fully engaged throughout the process.

In England the NHS Future Forum’s June 2011 report highlighted that the Government’s aim of making improvement in quality and healthcare outcomes the primary purpose of all NHS funded care is universally supported. The report also stated that because the NHS ‘belongs to the people’ and there must be transparency about how public money is spent, and how and why decisions are made. And finally the outcomes being achieved at every level of the system.

The RCN’s overarching UK policy position is to support the focus on improving clinical and patient focused outcomes.  The RCN has consistently highlighted that there is a wealth of evidence to connect nursing practice to high quality care and improved patient safety and patient experience.  Nurses’ input into outcomes frameworks will ensure it is effective and meaningful, with key insight into the delivery of high quality, safe care. We have also stated that it is important to recognise that outcomes are influenced by issues such as staffing numbers and skill mix; internal processes influencing team work; safety systems and supervision; and particular patterns of behaviour. Lessons learnt from previous NHS failures in England at West London Mental Health Trust, Stoke Mandeville Hospital, Mid Staffordshire NHS Foundation Trust and Maidstone and Tunbridge Wells NHS Trust must be applied in any future system.  Quality of care and patient safety depends on appropriate staffing, an appropriate culture of care, and a climate of openness and transparency. These principles have informed the RCN’s lobbying work on the 2011 Health and Social Care Bill in England.

The RCN’s key reference document continues to be the ‘Principles of Nursing Practice’ and this promotes the highest possible standards standard of nursing practice, which makes a major contribution to achieving successful outcomes. The RCN continues to produce a range of outcomes based standards for by providers or commissioners of services. The RCN also has a policy work-stream on public and patient involvement and engagement.  Work has continued to keep up to date on Patient Reported Outcome Measures (PROMS) including presentations to members and advice to the Department of Health via membership of the External Advisory Group on Payment by Results on linking hospital income to PROMS. There is an opportunity for a greater focus on patients outcomes via the NHS Outcomes Framework.  This has not been formally implemented but will relate to how organisations, and within organisations, teams can work to support improvements in the outcome measures that will be measured and assessed across the NHS in England. There is also ongoing RCN work to build on the concept of designated services and how the NHS failure regime can maintain essential services, vital to support vulnerable patients, and without which their health is likely to be compromised

When the RCN responded to the NHS White Paper in England it identified 18 key assurances that the Government must provide in order to ensure that the proposed reforms will work in practice to deliver a health service that is sustainable and fit for purpose. The 18 assurances continue to provide the benchmark for assessing the Government’s NHS reforms. A recent Government amendment to the re-committed Health and Social care Bill places a new duty on Monitor to exercise its functions with a view to enabling services to be provided in an integrated way, where this would improve their quality or the efficiency of their provision, or where it would reduce inequalities for patients. The RCN has continued to be in constant dialogue with the Government to highlight our key concerns on the Government’s overall reform vision . In its communications and lobbying work the RCN has highlighting that the NHS still faces immense challenges over the coming years, and nurses must be allowed to help build a service which can manage long term conditions, keep people out of hospital and improve the health of the public. The RCN has welcomed the Government’s more evolutionary timetable in moving over to the new NHS structures. The reality of tougher financial times is highlighted in the Kings Fund analysis of how the NHS is performing. This showed the number of trusts predicting a full   year deficit by April 2012 trebled compared to the same period last year.

In Scotland, RCN has responded to a recent limited Scottish Government consultation on the future performance management system for NHS Scotland highlighting the confusing plethora of public sector targets that have evolved over time.  We have argued that, “central government could far better support practitioners’ delivery of national policy on collaborative, outcome-focused service delivery by instituting an integrated performance management system. Whilst some individual clinical targets may still be relevant to the NHS alone, broad outcomes and many specific indicators should be clearly shared across public bodies. The Scottish Government should be providing clear leadership to frontline staff in developing a genuinely joined up approach to performance management at this time.”RCN Scotland have continued to press this argument in concurrent discussion about prioritising health and care spending decisions in the current debates on the Scottish Comprehensive Spending Review and the proposed 2012-13 Scottish Budget. In addition RCN Scotland has recently joined Oxfam Scotland – and 33 other Scottish civic organisations – to call for the Scottish Government to shift its stated primary purpose away from “economic growth” as an end in itself and to focus instead on a range of indicators, including wellbeing and social progress, to measure development in Scotland.

Debate report

Sarah Biggs from the RCN Hertfordshire branch, proposer of this agenda item, started the debate by mentioning the £20bn savings the NHS has to make by 2015. She called on RCN Council to lobby for patient outcomes not income and to focus on patients’ wellbeing not on profit.

In a passionate debate, members spoke of nurses being the voice of health care and that the austerity cuts were the “stealth disintegration of the NHS”.

Julian Newell, from the Emergency Care Association asked the question “will there be a discussion on industrial action in the near future?” and stated that lobbying was good, but as nurses we need to “get involved, get active and get out on the streets”. One member reiterated this point by saying it’s not just Council that needs to lobby; it’s the responsibility of individual nurses too.

Members spoke of their concern over particular specialties, poverty in rural areas as well as cities, the utilisation of private companies and also of our nursing students and newly qualified nurses who are the future of our profession.

Chris Knight from the Society of Orthopaedic Trauma Nursing stated that if the Government goes ahead with “short-term cost cutting, long-term outcomes will be affected”.

A point of order card was raised at the end of the debate about whether the agenda item should go straight to Council for consideration, rather than going to a vote, as the debate didn’t particularly focus on the issue but this was rejected by members. 

Result

For:          97.40% (374)
Against:   2.60% (10)
Abstain:     10

Background

In the NHS white paper Equality and excellence (Department of Health, 2010) the Government set out its intent that NHS services in England should to be provided on the basis of outcomes. Further detail on the Government’s plans to prioritise health outcomes over ‘nationally determined process targets’ was provided in its NHS outcomes framework document (published December 2010), which sets out outcome indicators for five ‘domains’:

But the realities of the Government’s Comprehensive Spending Review mean health service efficiency savings of £20 billion must be made in England by 2015, exacerbating the challenges already placed on staff and services by the ambitious timeframe for NHS reform.

The 2011/12 operating framework for the NHS in England (published December 2010) indicates providers will be able to offer services to commissioners at below the national average level under the Payment by Results (PbR) system. Many stakeholders, including the RCN, have expressed concern that this move encourages greater ‘price competition’ and changes the NHS from a ‘quasi-market’ system of fixed prices (under the PbR system) to a more ‘open market’ system. In addition, proposals have been made to cap the amount of private income hospitals can make and the extent to which patients can use NHS funds to access care outside the NHS via the Extended Choice Network.

The Health and Social Care Bill was introduced in to Parliament on 19 January 2011. It takes forward the NHS White Paper 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 arms length bodies. The 354 page bill represents the biggest shake up of the NHS since its inception, confirming through statute a shift in power from hospital trusts, regional strategic health authorities and primary care trusts to newly-formed primary care commissioning groups.

All four UK countries face similar challenges in relation to growing health demand versus limited resources. However each country has a different approach to planning and delivering health care – especially in respect to the role and scope of the independent sector, including not-for-profit and commercial organisations.

The Scottish Government’s national performance framework, for example, includes 15 national outcomes against which all public bodies should be measured. However, in its recent report Taking the pulse of NHS Scotland (RCN Scotland, 2010) the RCN highlights many decisions relating to workforce and service design appear to have been made on the basis of available resource and not improved patient outcome.

Responding to the NHS white paper Liberating the NHS the RCN (2011b) welcomed the focus on improving clinical patient outcomes, calling for a framework flexible enough to allow for local responses yet capable of delivering the robust national benchmarking needed to ensure populations across England are not disadvantaged through poor commissioning or service delivery, or inappropriate resource allocation.

In its response, the RCN (2011a) also highlighted that patient outcomes are influenced by issues such as staffing and skill mix, internal processes such as team work, safety systems and supervision, and an appropriate culture of care, and that the patient experience is also a by-product of staff wellbeing and their experience of the workplace context of care.

References and further reading

Department of Health (2010) Equity and excellence: liberating the NHS, London: DH (Cm7881) Available at: www.dh.gov.uk  (Accessed 3/2/11) (Web)

Royal College of Nursing (2011a) RCN response to ‘Liberating the NHS: transparency in outcomes – a framework for the NHS’ (England), London: RCN. Available at: www.rcn.org.uk/support/consultations/responses (Accessed 3/2/11) (Web)

Royal College of Nursing (2011b) RCN response to the NHS white paper ‘Equity and excellence: liberating the NHS’, London: RCN. Available at: www.rcn.org.uk/support/consultations/responses (Accessed 3/2/11) (Web)

Royal College of Nursing Scotland (2010) Taking the pulse of NHS Scotland: a report from the Royal College of Nursing on the finance and workforce pressures facing NHS boards, Edinburgh: RCN Scotland. Available at: www.rcn.org.uk (Accessed 7/2/11) (Web)