The Royal College of Physicians has launched a manifesto ahead of the general election hoping to influence the health policies of the next government.
Introducing the manifesto, Professor Ian Gilmore, president of the RCP, said: “There is little doubt that the next few years will be challenging ones for those of us who work in the NHS. Managers and clinicians will be expected, in the face of a growing and increasingly complex disease burden, to preserve the gains made in recent years, but with slowing rates of investment.
“Ultimately, success will depend upon whether or not we can genuinely improve quality of service while improving productivity and efficiency. The alternative, which involves falling back on the panicked ‘slash and burn’ policies of the past, would be disastrous.”
The following is a summary of the workforce-related proposals in Leading for Quality: the foundation for healthcare over the next decade.
1. Leading clinical integration and collaboration
The way healthcare is delivered is changing; increasingly care will be provided in networks that facilitate services closer to home, and outside hospital whenever possible. This process should be underpinned by strong commissioning arrangements. Physicians fully support this vision of care, but are concerned that the transactional costs associated with the architecture and delivery of the internal market and the way incentives are currently aligned do not encourage the leadership and collaboration needed to deliver it. To begin to achieve this vision and provide the best care for patients, we believe that three conditions inherent in the concept of ‘teams without walls’ must be in place: integrated systems, clinical leadership in commissioning and aligned incentives.
Under the current tariff-based system, hospitals are encouraged to treat more patients, while under practice-based commissioning general practitioners (GPs) are encouraged to refer fewer patients into secondary care. This tension can work against the development of integrated services that provide the best quality of care for patients, as it becomes financially easier to admit the patient rather than manage their condition outside the hospital or commission separate specialist services in primary care. It is crucial that we rebalance the disincentives by, for example, introducing ‘payment by pathways’ or ‘payment by conditions’ to ensure that both high-quality generalist and specialist care have a sustainable future for the benefit of patients.
The following is needed:
• Reforms that encourage teams to work across the traditional primary/secondary care and social care boundaries so that patients benefit from high-quality care closer to home where clinically appropriate.
• Patient access to specialists whenever required and sufficient specialist resources in all clinical networks.
• A culture supportive of clinician and patient involvement in the commissioning process.
• An overhaul of the ‘payment by results’ system so that it more effectively supports integrated care pathways.
2. Investing in a strong and sustainable medical workforce
The RCP believes that high-quality patient care depends upon a highly motivated and committed medical workforce. Consultants have a unique role at the core of the NHS, delivering and improving patient care, training and educating the next generation of doctors, and translating research and innovation into tangible service improvements. Given the prospect of increasing demands on the service, the changing workforce demographic and much tighter funding, it is imperative that we link financial and workforce planning at both local and national level. As part of this we must also maintain the current growth in the medical workforce across the spectrum from undergraduate to trained specialist levels, and avoid resorting to cuts in the workforce in the hope of achieving short-term cost savings.
The following needs to be done:
• A reliable and well-planned supply of fully trained consultant doctors to form the linchpin of healthcare teams.
• The medical workforce planned at a national level.
• Service-wide support for the principle of ‘flexible working’.
3. Fostering medical professionalism and leadership
Doctors are advocates for those they serve; their sense of professionalism is grounded in a desire to put the patient first before other interests. Nurturing that professionalism will be a key factor in protecting and augmenting the quality of patient care.
However, there is a widespread view that modern medical training and the current demands of healthcare delivery are no longer conducive to developing the personal skills, competencies and qualities that underpin the medical role.
The following action needs to be taken:
• Wider support for the principle of medical leadership within teams and healthcare organisations.
• Career pathways that support the ongoing development of the physician as a professional, by providing adequate opportunities to keep up to date, to retrain, and reflect on their practice in a systematic way.
• Sustaining a commitment to professionalism throughout long medical careers.
4. Achieving the highest standards of training
Safeguarding current and future patient care requires us to become more intelligent about how physician training is reconciled with the service and the demands of modern NHS trusts.
A shortened training period, increasing clinical service commitments for both trainees and trainers, and changes to ways of working, have led to growing concern that the training available to junior doctors has declined in quality and quantity. A strategy is urgently required to ensure that trainees and trainers are able to recognise and benefit fully from each potential learning event.
Mandatory changes to working patterns as a result of the new Working Time Regulations compound difficulties, with trainees losing opportunities that the traditional ‘post-take’ ward rounds afforded for presentation, discussion and feedback on patients they have seen. As a result, some trainees are managing acute admissions without adequate training.
NHS trusts must ensure that an appropriate number of consultant programmed activities are allocated and devoted to training, with time included for direct supervision, teaching, discussion, feedback and workplace-based assessments.
Study leave and adequate training budgets must be readily available to allow trainees to gain the clinical skills they need.
Given the link between training and high standards of care, any proposed changes to the distribution of funds for training, through the Multi-Professional Education and Training Levy, need to be considered carefully. It is particularly crucial that any changes do not make it more difficult for hospitals to employ and train junior doctors.
The following actions need to be taken:
• Service-wide recognition of the importance of postgraduate medical training and the time that it takes to do it well.
• Protected budgets to allow trainees to gain the clinical skills they need.
• Examination time and the associated resources made available so that junior doctors are able to complete assessments.
5. Promoting research and innovation within the NHS
Innovation is vital for the future of patient care. It is innovation, whether in the creation of new ideas and new medicines, the translation and implementation of research findings, or the development of new ways of working, that has led to the notable improvements to patient care and outcomes over the lifetime of the health service.
Changing models of innovation mean that the talents of the private sector, academia and the NHS will need to be organised differently to meet the dual challenge of competition from overseas for British research talent and investment, and legitimate patient demand for more effective treatments.
The following needs to be done:
• A service-wide commitment to training and employing research-active physicians in order to preserve the UK’s pre-eminent position in the field of translational research.
• Continuing investment in medical research.
• A framework that more effectively supports new models of cooperation and innovation between the pharmaceutical industry, the NHS and medical academics.
6. Ensuring the best end-of-life care
Most people die in hospital, yet there are serious shortcomings. The patchy provision and fragile funding mechanisms of palliative care in the UK, practical and ethical difficulties in diagnosing and managing the clinical symptoms of patients at the end of life, and problems of communication between patients, relatives, carers and the clinical team, are all barriers to patients receiving the best possible end-of-life care.
The following actions need to be taken:
• Increased availability of palliative care services across the UK, both geographically and for patients with non-malignant conditions.
• Sustainable and adequate core funding by the NHS for palliative care services.
• ‘Nil by mouth’ to be a last resort rather than the first option for patients with feeding difficulties at the end of their lives.
• An opportunity for patients to discuss their future care in the event of losing mental capacity.
• Clinicians encouraged to engage with the complex ethical issues raised by end-of-life care.
7. Delivering safe, high-quality healthcare
At the heart of quality rests safety. Many clinical errors could be avoided if the right information was shared at the right time. Recent prominent cases also suggest that the current systems of regulation and supervision do not always identify significant problems before they become acute.
The following actions need to be taken:
• National promotion of the use of clinical guidelines and improved standards of local clinical audit and expansion of national programme of audits.
• Universal implementation of the standards set out by the RCP and the Academy of Medical Royal Colleges for the patient record.
• Greater cooperation between the royal colleges, faculties and statutory regulators so that problems affecting the quality of care can be more easily identified before they become acute.
• Further incentives to promote clinical quality improvement at the local level.
8. Tackling health inequalities
Good health rests on the capacity of individuals and communities to make healthy decisions for everyone, every day and everywhere. However, individuals and communities need the support of the healthcare system, health programmes and governments to create the conditions that allow them to take effective action for good health.
The following actions need to be taken:
• Encouragement of doctors to show advocacy and leadership on the social determinants of health.
• An increased focus on tackling health inequalities in the undergraduate and postgraduate medical curricula.
Read the full RCP manifesto.
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