ATC131028: Report of the Portfolio Committee on Health on a study tour to London, United Kingdom, dated 23 October 2013

Report of the Portfolio Committee on Health on a study tour to London, United Kingdom, dated 23 October 2013

The Portfolio Committee on Health having undertaken a study tour to London, UK from the 2 – 9 December 2012, reports as follows:

1. Background and Objectives

In comparison to other countries at similar levels of economic development, South Africa performs dismally with regard to its health status indicators. A similar scenario on health status indicators persisted prior to the increase and impact in the number of HIV and AIDS cases in South Africa.

Almost 85% of the population is entirely dependent on public sector hospital services, although a smaller section of the population is dependent on public sector primary health care services.  The uneven distribution of resources between the public and private sectors, relative to the population that each serves, reflects inefficiencies and inequalities that contribute to South Africa falling short of the Millennium Development Goals (MDGs).  The proposed National Health Insurance (NHI) therefore seeks to address these inherent challenges in the health system.

While the idea of an NHI has long been on the policy agenda, there has been limited public engagement and awareness on the issue.  However, it is the public as beneficiaries and contributors who will be directly affected by the NHI and who will affect its implementation.

Members of Parliament as public representatives need to have a clear understanding of what the South African NHI will look like as they will be directly involved in its processing in Parliament when it becomes legislation.  Parliament will therefore also consider public inputs when considering NHI.  The extent to which NHI is acceptable to society is therefore crucial to its success.  To fully understand the implementation of a national health system, the Committee took a decision to assess the implementation of the United Kingdom system to gain knowledge of the strengths and weaknesses as the process gained momentum.

The key objectives of the study tour to the United Kingdom, in particular, were to:

·    Review and learn lessons from features of the National Health Service (NHS) where current pending South African policy and legislation has drawn heavily on the UK experience;

·    Learn more about the United Kingdom’s Office of Health Quality Care Commission and Primary Health Care (PHC) and how it undertakes its work;

·    Understand better oversight functions as Parliamentarians monitors the delivery of healthcare; and

·    Network and develop partnerships with other Parliamentary organisations based in the UK such as the Commonwealth Parliamentary Association.

2. Delegation

The following members formed part of the delegation:

Dr MB Goqwana, Committee Chairperson and leader of the delegation (ANC)

Ms BT Ngcobo (ANC)

Ms TE Kenye (ANC)

Ms RM Motsepe (ANC)

Ms MJ Segale-Diswai (ANC)

Ms S Kopane (DA)

Mr DA Kganare (COPE)

Ms HS Msweli (IFP)

The following Parliamentary officials accompanied the Committee:

Ms Vuyokazi Majalamba:  Committee Secretary

Ms Nokuthula Qumbisa: Assistant to Ms Ngcobo

HLSP Staff (Project Sponsor)

Mr Myles Ritchie

Mr Vusi Shongwe

3. Briefings on the NHS at Blakemore Hotel

Delegation

Dr John James: Lead Specialist in Child Health

Mr Steven Walker: National Health Litigation Officer

Mr Geoff Smith: Management Consultant in Health and Social Care

Dr Keyvan Zahir: Consultant in Public Health Medicine

3.1 Key milestones of the NHS

Mr Geoff Smith presented the key milestones of the National Health Service (NHS).  He informed the Committee that the NHS employs 1.7 million staff of which 77% are females.  The budget for the NHS currently stands at £9 billion. There are 3 million people treated per week within the NHS system.

The NHS was established in 1942.  It is a free at point of delivery to all and funded through taxation.  Its tripartite structure consists of hospitals (regional hospital boards and hospital management committees), general practitioners (executive councils) independent contractors, gatekeepers and community health services, public and environmental health.  This particular structure remained in place until 1974.

3.2 Quality in health care

Dr Keyvan Zahir briefed the Committee on the quality in health care. He informed the Committee that medicine is not a perfect science and sometimes things do go wrong.  He informed the Committee that even the best people could make the worst mistakes.  He reported the recent scandals, such as the 1995 Bristol heart scandal and the 1999 Dr Shipman scandal in the history of the NHS.

3.2.1 Attributes and pillars of clinical governance, education and training components, clinical audits, and information management

In outlining the above aspects pertinent to the NHS, the presenter noted that the key attributes of clinical governance are the recognition of high standards of care, transparent responsibility and accountability and a constant and dynamic improvement of health services.  The seven pillars of clinical governance focus on education and training, clinical audits and effectiveness, research and development, openness (patient and public involvement), risk management and information management. The education and training component focuses on lifelong learning, formal and informal examinations, regular assessments, appraisals, and accreditation.

Dr Zahir informed the Committee on the following clinical aspects:

a)     There is a review of clinical performance, measurement of performance, refining of clinical practice to meet agreed standards and cyclical process of improving the quality of care.

b)    Clinical effectiveness is a measure of the extent to which a particular intervention works. It includes aspects of efficiency and it relates to the right person doing the right thing (evidence-based practice), the right way (skills and competence) at the right time (providing care when the patient needs it), in the right place (location) and with the right results (outcome measures and patient satisfaction).

c)     Research and development is about promoting research, reducing time lag between publication of research and patient care, development of guidelines, care pathways, protocols and developing local strategies.

d)    Openness involves looking at the way in which poor performance and practice can thrive behind closed doors, the need for processes to be open to public scrutiny, meeting local health needs and involving patients, caregivers and the public to listen to developments.

e)     Risk management is the system that assures NHS organisations of their statutory responsibility to manage and monitor health and safety, corporate and clinical risk in their organisation.

f)     Information management involves a focus on demographics, socioeconomic issues, and epidemiological and clinical practice.

The overall aim is to ensure that the system is effective and efficient in determining the healthcare needs of the population, defining priorities, identifying solutions and allocating resources.

In his conclusion, Dr Zahir noted that clinical governance is a quality assurance process to ensure that standards of care are maintained and improved and that the NHS is accountable to the public.

4. Meeting at Westminster Hospital Trust

Delegation

Mr Justin Currie – Business Development Manager

Mr Simon Barton – Clinical Director

Mr Lesley Sinclair – Matron

Mr Carol McLoughlin – Head of Financial Management

Mr Axel Heitmueller – Director of Strategy

Ms Catherine Mooney – Director of Governance

Mr Justine Currie welcomed the Committee and provided more detail on the objectives of the hospital key facts, services and performance measures. The hospital was opened in 1993 and it offers secondary and tertiary services.  The objectives of the hospital are to improve patient safety and clinical effectiveness, improve the patient experience, deliver excellence in teaching and research and ensure financial and environment sustainability.  The hospital was rated by the Dr Foster Hospital Guide as one of the two hospitals in England with lower than expected mortality rates after surgery.

The key services offered at the hospital are paediatric and neonatal surgery, Neonatal Intensive Care Unit (NICU), Paediatric and Emergency Attendance, High Risk Maternity, Burns Unit, Dermatology, HIV, Assisted Conception Unit (ACU), Weight Loss Surgery and Stroke Services.

On key performance measures, he informed the Committee that admissions were 72, 000 per year and 400, 000 outpatient per year (including 100, 000 Government HIV Emergency Attendance).  He mentioned that the majority of their business comes from the NHS, however, policy amendments to the private patient cap offer an opportunity to expand the popular private patient services.  The hospital is also gradually shifting more services from the hospital to community settings to improve patient experience and cost effectiveness for commissioners.

In February 2012, a new unit for patients living with HIV as well as oncological and haematological problems was opened at Chelsea and Westminster Hospital.   This unit includes a new ward, which has 19 inpatient beds, all in single en-suite room as well as day care and outpatient facility. People who have not tested for HIV are encouraged to test.  The unit further provides outreach programmes including teaching children over 18 years of age about HIV.  All overseas visitors are entitled to HIV treatment, irrespective of their citizenship and type of passport.  This unit also caters for patients who have skin problems and most patients prefer to come to Chelsea because of the high care.  Stigma was still a big issue with regard to HIV.

The Committee was then taken on a tour in the hospital and observed the following:

·    The hospital was very clean and well maintained;

·    The hospital has a patient hotel which caters for patients who only come for operations and requires overnight stay; and

·    The HIV unit is separate from the main hospital and attends to patients with dermatological problems even if they are not HIV positive.

4.1 Finance and Accountability

Ms Carol McLoughlin, the head of financial management briefed the Committee on finance and accountability.  She informed the Committee that the English Health Care System has tree main pillars, which are: NHS, Public Health and Social Care.  Services provided on the NHS are primary, secondary and tertiary care delivered by the General Practitioners (GPs), community services and hospitals. Public health, services rendered are: health visitors, infection control and public health campaigns.  Services that are rendered under social care are domiciliary care and social services.

Ms McLoughlin informed the Committee that commissioning in the NHS is the process by which the health care services are effectively provided and meet the needs of the population.  The contract provides an important tool for assuring accountability between providers and commissioners and therefore improving performance

5. Meeting at Bristol Primary Health Care

Delegation

Dr John James: Lead Specialist in Child Health

Mr Niel Montpelier: Practice Manager

Dr John James informed the Committee that the Bristol Primary Health Care is the largest practice in Bristol with over 18 000 patients.  General Practitioners (GP) practices are run as small businesses, which are contracted to NHS Primary Care Organisations.  Contracts are held by the practice rather than individual GPs with the practice contracted to provide care for patients between 8 am and 6:30 pm Monday to Friday. A patient presenting with an acute condition is treated by a doctor immediately.  The move from contracts held by individual GPs to contracts held by practices was a major change that took place as part of the introduction of the current GP contract in 2004.

Dr John James talked about the types of GPs, which includes; GP principal or partner, and sessional GP (non-principal).The GP partners run the practice and sometimes there is only one GP partner known as a single-hander, but more often than not, a number of GPs grouped together in a multi partnership practice.  Many single-handers also work closely with neighbouring colleagues, as well as seeing patients, the GP partner is responsible for running the business side of the practice, usually with the support of a practice manager.

A sessional GP is a salaried GP that is employed by the practice and receives a salary for a fixed number of hours worked.   A GP locum is essentially a freelance GP who mostly works independently or through locum agencies.  A locum GP is used when necessary.

The nature of GP’s work has evolved significantly in recent years, particularly since the introduction of the current GP contract.  Emphasis is placed on preventing people from becoming sick, through the structured management of the long-term conditions, which are becoming ever more prevalent in society.  Many of these problems were managed in hospital but are now taken care of at the GP surgery, at greater convenience to the patient.  It is common for patients to have more than one long-term condition like diabetes, high blood pressure and heart disease, the nature of a GP’s work has become more complex and the intensity of the work during consultation has increased.

Outside of the consultation room, GPs do home visits and a large amount of paperwork relating to their patients care.  They also attend Primary Care Organisation (PCO) meetings and maintain their training and education.  A significant minority also undertake shift work for the local out-of-hours organisation.

The current national GP contract was negotiated between the BMA and NHS employers (with representation from the devolved nations) and introduced in April 2004 with the full agreement of all parties, including the Prime Minister’s Office and the Treasury.  It was brought in because there were serious recruitment and morale problems within general practice and pay had fallen behind.  Before 2004, the UK’s GPs were among the worst paid in the developed world.  All parties agreed that the salary of a GP needed to be better linked to GP’s workload and responsibilities.

Dr James noted that it was good that Primary Health Care was run by GPs so that they can inform government of any changes in disease profile.   Government must be driven by people instead of government driving the people.

5.1 Background on the 2004 GP contract

The new GP contract began in 2003 and was introduced in full in April 2004 following prolonged negotiations and full agreement by all parties.  Prior to the introduction of the new contract, there were serious recruitment and morale problems and GPs pay had fallen behind.  This was officially recognised by all parties during negotiations and is reflected in the scale of pay increases under the new contract.

The new contract allocated resources according to the relative workload associated with each practice’s patient population and gave GP practices greater flexibility and autonomy in the delivery of services.  Almost all funding is practice based.  This means that payments are made to the practice and not the individual GPs.

5.2 The Quality and Outcomes Framework (QOF)

The QOF was introduced as part of the 2004 GP contract.  It currently offers practices up to 1000 points if they deliver proven high quality on a range of services with the points attracting financial resources into the practice.  The majority of the points relate to evidence-based clinical interventions proved to benefit patients with chronic conditions.  The remaining points are linked to the organisation and to patients’ experience of the practice.  The QOF has continued to evolve since the inception of the new GP contract in 2004 and has become a core-funding stream as well as being amended to improve the diagnosis and management of some of the most prevalent chronic disease such as depression, dementia and chronic kidney diseases.

A GP’s practice receives money for quality in two ways.  The practice will agree in advance with the Primary Care Organisation (PCO) on the number of QOF points they are aiming for that year.  A monthly payment equal to the value of 70% of these points is made to the practice. Remaining payments are made once the practice has actually achieved the points.

He then noted the following as challenges the NHS is faced with in Britain:

·    Certain things are being imposed on GP’s instead of involving them; and

·     Change is also being imposed without involving the people who are in charge.

The Committee went on a walk about at the centre and noticed that there was a small theatre that was well equipped.  The Committee also had a privilege of meeting nurses that are working in the centre who informed the Committee that they were also in charge of the running of the centre.

6. Meeting with Associate Parliamentary Health Group (APHG)

APHG Parliamentary Officers

Ms Baroness Cumberlege: Chair

Ms Baroness Masham of Iltion: Member of the APHG

APHG Secretariat

Mr Duncan Eaton (Executive Advisor)

Ms Ella Jackson

Mr Callum Tottem

Mr Duncan Eaton, the Executive Advisor, outlined the role of the Associate Parliamentary Health Group.  It is an all party-parliamentary subject group dedicated to disseminating knowledge, generating debate and facilitating engagement with health issues amongst members of Parliament.  He informed the Committee that the APHG comprises of Parliamentarians of all political parties in both Houses, provides balanced and impartial information and focuses on local as well as national health issues.

The APHG was launched in November 2001, on the basis that Members of Parliament requires as much high quality and impartial information as possible to fulfil their crucial role in the UK’s health programme.  By acting as a forum for discussion and a vehicle for the dissemination of information, it enable parliamentarians, policy makers, healthcare professionals, suppliers, purchasers, universities, voluntary organisations and charities all to play their part in the delivery of the national health programme.

The activity the APHG is engaged in is to inform and engage Parliamentarians through major avenues:

·         The organisation of briefings, seminars and conferences under Chatham House Rule in addressing and providing information on the major developments in health and the NHS;

·         The provision of comprehensive web-based resources; and

·         The coordination of daily media and weekly parliamentary monitoring services.

The Advisor informed the Committee that the APHG’s agenda is set by its all-party team of elected Parliamentary Officers in consultation with its distinguished Advisory Panel, and delivered by a dedicated secretariat. The group is supported by an Associate Membership of 26 of the UK’s leading organisations working in the health sector, as well as providing and independent source of funding, offer a valued insight into present development occurring within the wider healthcare community in the UK.

7. Meeting at the Care Quality Commission (CQC)

Delegation

Ms Jo Williams: Chair

Ms Jane Craig

Mr Paul Durham

Ms Joan Palmer

Ms Jo Williams presented to the Committee and outlined the key features of health and adult social care sectors the CQC regulates.  She informed the Committee that the CQC is an independent assurance to the public that services are safe and of essential quality.  It also provides for the independent accountability for public funds. The CQC provides trusted source of comparative performance information to people using services and provides a broad view across the whole system of care in health and adult social care provision.  The CQC accounts to Parliament.  They produce reports to Parliament and for the public. The CQC reports to the Secretary of State of its day to day running who also appoints the Chairperson. The Chairperson’s contract is four years and he/she cannot be appointed for a second term.

The executives who sit in the board have a health background. They have a mix of inspectors from different backgrounds like police officers and social services.  They should have a background that will give them credibility.  They have recruited 2000 people who are called associates like cancer care and gynaecologists.  They work like consultants and are paid when they performed a job. The following were highlighted as challenges the CQC is faced with concerning working with inspectors:

·    Time constraints as they have to deal with large portfolios;

·    The inspectors lack in some competencies;

·    There is inconsistency in reporting due to a massive number of inspectors with different background and their focus is also different;

·    They have a complex IT system which leads to difficulty in finding information;

·    All inspectors work from home which creates a challenge in supporting each other; and

·    The public perception about the CQC.

Ms Jo Williams informed the Committee that the above challenges have been recognised and are being addressed.

Under the Health and Social Care Act 2008, the CQC have a responsibility to involve people in their work.  They train and involve people with experience in health and social care services and it has 240 trained experts by experience.

Ms Jo Williams informed the Committee that they work with voluntary organisations to see if the information they receive can help them target poor health care.  They also work with Relatives and Residents Association and the Patients Association to receive structured feedback from their helpline.  The aim is to assess the value of how soft intelligence from the helpline can inform regulatory risk. Helpline workers at the RRA and Patients Association will notify CQC via their website of concerns that relate to essential standards.  This information will feed into Quality and Risk Profiles, which they use to guide the assessment of regulatory risk.

Inspections to monitor compliance are planned to inspect all care homes, domiciliary care agencies and hospitals at least once a year. The inspections are targeted and usually unannounced.  They focus on areas of non-compliance with the national standards. They publish what they have found and take enforcement action where they have concerns.  Providers are allowed to make an input on the accuracy and not judgment.  A site visit includes:

·    Talking to people who use the service (and their families and carers);

·    Talking to staff and managers;

·    Observation; and

·    Examination of records.

Ms Jo Williams informed the Committee that it is the duty of health and social care providers to ensure compliance at all times.  If a provider is not compliant with the standards, CQC can:

·    Give or issue a warning notice;

·    Impose conditions;

·    Suspend registration of some services;

·    Issue a fine;

·    Prosecute; and

·    Close services by cancelling registration.

She informed the Committee that if evidence of a minor non-compliance to regulations, they look at the impact of the safety of the people and request an action plan of when they are going to attend to it.  If it is a major non-compliance, they issue a warning notice and seek legal advice on what enforcement they need.

The new site was developed with the help of inspection staff, the public and providers and it was launched in October 2011.  Every provider and location has a profile page where they publish their reports, latest judgments about the care provided and latest regulatory activity.  People visiting the site have access to detailed information on services including full reports by inspectors and information from people who have used a service.

The CQC is currently revising its strategy for 2013-2016.  The six strategic shifts/changes include:

·    Differentiated approach to regulation which will lead to greater use of information and evidence and also get information from other regulatory bodies;

·    Strengthen work with strategic partners;

·    Build better relationships with organisations providing care;

·    Strengthen the delivery of their unique responsibilities on mental health and mental capacity; and

·    Continue their drive to become a high performing organisation.

8. Parliamentary Health Ombudsman

Delegation

Mr Donal Galligan: Ombudsman’s Policy Manager

Ms Sue Heaven

Mr Martin Pike: Director of Health investigation

The Parliamentary Health Ombudsman office works like the South African Public Protector.  It is independent and is appointed by the queen.  The budget for the ombuds comes directly from Parliament and it reports to Parliament through the Public Select Committee.  Everyone has a right to approach the ombuds and complain but not every complaint is investigated.  That prerogative is left to the Ombuds.  They also have powers of a court to get information on whatever issue they are investigating. They mostly deal with complaints of maladministration and services provided by the NHS and some are about clinical care.

Mr Martin Pike the Director of Health investigation informed the Committee that they get approximately 16000 complaints.  The challenge they are faced with is sometimes people don’t complete the NHS procedure before approaching the Ombuds, as law requires them.

Investigations are done through interviewing the complainant and getting clinical advice.  A draft report is then issued to both parties (the complainant and the service provider) to check whether there has been a service failure.  If remedies to address the situation have been provided by the provider, the Ombuds does not go back to them.  The Ombuds does not have an appeal process and their reports are final.  If a person is unhappy with their ruling, they can take the Ombuds to court or to the review team.  There is a separate review team within the Ombudsman.

Ms Sue Heaven told the Committee that the Ombuds is not a regulator and therefore is not responsible for monitoring standards.

Mr Martin was however concerned that the South African Ombuds will be appointed by the Minister of Health and can be dismissed by him/her.  He was of the view that this might lead to political interference and felt that it was not totally independent.  He therefore suggested that it should be called a commissioner. He also made an example on New Zealand where the term “ombudsman” is protected and cannot be used anyhow.

9. Observations by the Committee

·    The Parliamentary Health Ombudsman functions like the Public Protector’s office in South Africa;

·    The office is entirely independent and is appointed by the Queen and its budget comes directly from Parliament.  It also reports to Parliament;

·    Everyone has a right to come and complain to the ombudsman but not every complaint is investigated;

·    Most complaints are about clinical care and some about NHS;

·    The Ombudsman is not responsible for monitoring norms and standards;

·    The recommendations that are made by the Ombudsman are not legally binding; and

·    The primary health care in the UK is called practices, which is run by general practitioners.

10. Conclusion

The Committee would like to extend a word of appreciation to the Strengthening South Africa’s Revitalised Response to AIDS and Health (SARRAH) for sponsoring the trip and for giving Members of the Portfolio Committee on Health an opportunity to learn more about health systems in particular to benchmark on the National Health Insurance and the Office of Standard Compliance.

Report to be considered