WE ARE MEDICS BOOK NOTES

NHS Values:

These values outline the commitment to deliver the highest standards of excellence and
professionalism across the service.

● Working together for patients

● Respect and dignity

● Commitment to quality of care

● Compassion: showing sympathy/pity for those who are suffering/ misfortunate (showing your
understanding)

● Improving lives

● Everyone counts

Principles of the NHS:

1. The NHS provides a comprehensive service, available to all

2. Access to NHS services is based on clinical need, not an individual’s ability to pay

3. The NHS aspires to the highest standards of excellence and professionalism

4. The patient will be at the heart of everything the NHS does

5. The NHS works across organisational boundaries

6. The NHS is committed to providing best value for taxpayers’ money

7. The NHS is accountable to the public, communities and patients that it serves

STRUCTURE AND ORGANISATION OF THE NHS

After the Health and Social Care Act 2012: the NHS changed its structure so that

CCGs (made up of nurses,GPs and Hospital consultants) are run by these people, and decide how a
budget is assigned to the services needed in their area. NHS foundation trusts are commissioned by
CCGs to provide care. Local GP practices were members of this. Services they commissioned
included urgent and emergency care,elective hospital services and community care. Responsible for
under 100k or 1 million people. They were responsible for achieving the best possible outcomes for
the local community, by developing a strategy to improve public health. THESE WERE REPLACED IN
THE HEALTH AND CARE ACT 2022.
Integrated care boards replace CCGs

An ICB just upscales the area of management of a CCG up to a region rather than just a local area.
They involve stakeholders, which include NHS orgs, local authorities and other partners. This change
resulted in

1) streamlined decision making: less bureaucracy, and duplication of efforts. More coherent
2) better patient outcomes as a result of higher efficiency
3) more unified approach to patient care
4) more cost efficient

EACH COUNTRY IN THE UK IS RESPONSIBLE FOR THEIR OWN HEALTHCARE SERVICE( management and
budget wise)

Scotland, Wales and Northern Ireland now receive an allocation of funding from the UK Parliament
and it is then up to the national government to choose how to spend this money, including what
proportion to use for the NHS budget. Spending on NHS England remains the responsibility of the UK
Parliament, as England does not have its own devolved government.

What are the advantages of Devolution- Healthcare services can be tailored to meet the needs of the
local population

STRUCTURE

Place levels are where hospital trusts and other providers of care exist, refers to towns and cities and
big hospital trusts.

ICBS directly replace CCGs and are the commissioners of care within the local system. They provide
the funding for place levels

ICPs bring the NHS together with other key local partners, eg local authorities, charities, housing
associations etc
NHS Scotland

Managed by the Scottish government health directorate(SGHD) which oversees 14 NHS boards that
act similarly to ICBs but with a full range of services including Hospitals and General practices.

NHS wales

Has local health orgs that manage health . Has 7 boards responsible for areas. Still uses block
contracts between commissioners and relevant providers.

NHS northern Ireland

NHS is referred to as health and social care (HSC). It is free at point of delivery but is also different to
the NHS as it also offers social care services.

Managed by department of health, Social services and public safety. Services are commissioned by
health and social care board and provided by 5 health and social care trusts, eg Belfast, southern,
northern etc

There are also local commissioning groups inside the boards, which cover the same geographical
area as the 5 trusts

Block contract vs payment by results

Block contract was used in England before 2005 – hospitals paid a fixed amount of money each year-
If a hospital exceeded their budget, then the gov would give more money to them. However, if a
hospital didn’t use all of their budget, this money would be paid back to the government. Problem-
no incentive was there for hospitals to try to save money and work efficiently

Payment by results- introduced in 2005 by labour. Hospitals are paid for each activity they undertake,
eg an average tarrif for each activity was set among all of the NHS trusts. Eg Hip replacement-£5000
which would cover hospital stay, treatment and follow up care. This would lead to some hospitals
making a loss and others making a profit. -encourages the hospitals that made a loss, to strive
harder and work more efficiently

However the new policy didn’t encourage hospitals to provide quality of care as well, hence other
actions such as giving patients the choice of where they wanted their care provided, imposing targets
that had to be reached, and ensuring that hospitals were penalised financially (not paid for tarrif) if
they gave poor quality care. Bonus schemes for quality of care were also introduced, which also
caused healthcare providers to compete( raising the overall standard of care)

Private sector of healthcare

Private practice doctors- doctors (part of company) who provide services for money based on market
price

External non NHS providers contracted to do NHS work- provides healthcare to NHS patients at NHS
tarrif price, eg screening, sexual health services, physiotherapy etc.
Privatisation of the NHS-

Would lead to fragmentation of care- as patient info isn’t stored on one database like with the NHS,
but on several private ones. Would make accessing records difficult.

Could lead to conflict of interests, eg a gp that owns a out of hours service may compete with the
NHS hospital trust that they work for.

LONG TERM PLAN 2019

This was published in 2019 and details how the service will run over the next decade

● To base care on individual’s needs

● Improve the quality of community healthcare services

● Make services more accessible, including bringing them closer to people’s homes and providing
online GP consultations

● A focus on cancer, particularly preventing deaths by earlier diagnosis

● Supporting patients to self-manage their long-term health conditions

● Focus on preventing illness to reduce the demand for treatment in the future

● Address the issue of short staffing by training more new healthcare professionals

KEY BODIES:

GMC-

Keeps register of all qualified doctors , issues guidance to promote high standards eg good medical
practice, sets and monitors standards for all trainees and supports doctors with guidance, deals with
doctors who aren’t fit to practise .

Royal Colleges (except college of emergency medicine)

Charged with setting standards in their field and supervises training of doctors within that specialty.

BMA- trade union representing doctors, membership isn’t compulsory

Med defence union MDU, and Med protection society MPS

- defense unions for doctors.

NICE- national institute for health and care excellence

Provides guidance on health technologies (recommendations on efficiency, economy, etc)

Asesses a range of procedures and safety, what treatments are appropriate for different patients with
different clinical conditions, and how to improve QoC, also publish guidelines on public health.

CQC (care quality commission) regulates all health and social care services in England , inspects
hospitals carehomes and other areas where medical services are provided to ensure they are well led
in terms of quality and finances

MEDICAL TRAINING STRUCTURE

2 FOUNDATION YEARS FY1 AND FY2

Core training CT- gives trainees a good basis in their area of interest, anyone who wants to work in
any speciality undertakes 2 years of core medical training , those who want to specialise in surgery
do core surgical training CST. Some specialities may have their own core training, eg psychiatry has 3
year CT period, which only applies to Psychiatry. CT1,CT2,CT3 etc. Once a doctor has gone through
their core training, they can apply for Specialist training through a competitive process (application
form + interview)

Specialist training ST

Ranges form 4 to 9 years depending on complexity.

Can take 7-13 years to become a consultant possibly even longer.

One can become a Gp in 6 years.

REVALIDATION

This is a system that regularly imposes checks on doctors to ensure that they are fit to practise. Aims
to protect patients from poor doctors and increase public confidence in the doctors.

After the Shipman incident, the 5th shipman report which was an enquiry into the role of the GMC
was made, which criticized it for looking after doctors more than patients and not protecting patients
properly by revalidating doctors in the correct way.

This case concerned a failure by the NHS to audit shipmans activities in:

Cremation forms (second signature given without additional checks)

High mortality rate among his patients (mostly elderly and dismissed as natural causes)

Discrepancy in prescription of diamorphine and other controlled drugs

Revalidation was suspended and then officially started in 3rd December 2012.

INVOLVES DOCTORS HAVING TO:

-link with a responsible officer

-maintain a portfolio of info drawn from practice that demonstrates how they are continuing to meet
the values and principles in the GOOD medical practice.
- participate in process of annual appraisal based on their portfolio of supporting info

-The responsible officer will make a recommendation to the GMC about fitness to practise every 5
years, which is based on the annual appraisals in that 5 year period.

PORTFOLIO CONTAINS- general info such as personal development, scope of work etc, continuous
professional development record- eg courses and conferences attended, journals read, etc. Review of
own practice, includes quality improvement activities (clinical audit), review of clinical
outcomes/case review, description of significant events. FEEDBACK on own practice- eg colleague
and patient feedback, and review of complaints and compliments.

PROS AND CONS OF REVALIDATION

PROS- formalises practices that have been done previously

Ensures compliance with some basic requirements and puts a focus on the appraisal process.

CLINICAL GOVERNANCE- PRINCIPLES AND BEHAVIOUR DOCTORS ADHERE TO IN ORDER TO OFFER

THEIR PATIENTS THE BEST QUALITY CLINICAL CARE.

1) Ensure practice is compliant with latest evidence, keep up to date and ensure to constantly
update practice to match new guidelines and evidence from research, must also audit their
adherence to guidelines and best practice
2) Provide safe care to patients- don’t put patients at risk. Feel comfortable owning up to
mistakes and learning from them. Report any incident so that it can be investigated.
3) Ensure that they recognise their limitations and be willing to ask for help wherever
necessary. If you come across others who practice improperly, act on it and raise it with a
senior
4) Constantly develop skills and train and educate others, properly support all staff
5) Be attentive to patient needs and take account of feedback from public to constantly
improve service

Audit process

1)choose audit topic (eg practice to be investigated)

2)say what standard you want to achieve

3)collect relevant data

4)compare results of analysis against standard

5)identify changes needed

6)implement changes and give time for changes to work

7)do the audit again a few months later to measure change impact

WHY ARE AUDITS IMPORTANT?

1)Identifies weaknesses in practice and to increase quality of care

2)helps identify inefficiencies and may lead to better use of resources

3)provides info about QoC to outside agencies

4)Provides opportunities for training and education

4 ethical principles-

Autonomy- patients are entitled to their own opinion and to make decisions for themselves.

They have the right to choose the treatment that they feel is best for them and also have the right to
refuse to be treated.HOWEVER, a patient must have the necessary competence in order to make
these decisions (the ability to understand and process the information at his disposal to make an
informed decision

Benificence – Doctors must do good and act in the best interests of their patients

Non maleficence- Do no harm to your patients, whether it is actively, or by omission

Justice- treat all patients fairly and equally

Patients who are in the same position must be considered in the same way, eg benefits,risks and
costs should be spread fairly.You can only discriminate on the basis of different clinical needs.

Right to confidentiality- Patient has a right to control the information that pertains to their health

This principle links into both autonomy and non-maleficence as not keeping confidentiality. ETHICAL
DILEMMAS normally occur when 2 or more of these principles clash, eg a doctor in IC admits a
patient who is suffering from a lot of pain, and must be given a strong painkiller such as morphine,
however, giving them this could bring them closer to death. In this example, beneficence and non-
maleficence clash, meaning the doctor has to make a choice in order to act in the best interest of the
patient.

INFORMED CONSENT

Definition- patient has consented to a procedure or treatment, after being given all the info and facts
needed to make a decision in their own best interest.

Before informed consent is given, several facts must be explained- eg

- Options for treatment/management (includes option not to give treatment

- Aim of procedure/treatment, and any side effects/consequences
- Details of P/T , pros/cons , risks and side effects, and how they will be managed
- Consequences of having and not having the treatment
- Any secondary interventions needed during the first intervention, eg blood transfusions,
which the patient must consent to.
- Who is performing the procedure and whether doctors in training are involved( esp in
surgical interventions)
- Remind patient can change their mind anytime and can seek a second opinion
- Costs patient may incur

Rules:
Patient must be given any appropriate written info. i.e. leaflets, and must be given enough time
to make the decision in order not to be pressured into a decision.

Only competent patients may give consent

CONSENT MAY BE IMPLIED IN SOME SITUATIONS WHERE IT IS A SIMPLE TASK WITH NO

CONSEQUENCES, EG TAKING BLOOD PRESSURE AND PATIENT ROLLS UP THEIR SLEEVE AND
PRESENTS THEIR ARM TO THE DOCTOR. However it is much safer to ask for consent

PATIENT COMPETENCE-

Competence is a legal judgement.

This is assessed by a team of doctors and nurses who make sure that a patient understands a
management course, can comprehend its risks and benefits, and can retain this info long enough
to make a balanced choice

Capacity to consent is a medical judgement

Although this is also assessed by doctors and nurses, it varies in terms of situation and time, eg a
patient may have the capacity to decide on a breakfast menu, but not on an option to have a
knee amputation.

These two have different meaning so be careful

ADULTS and children aged 16-17 have capacity to consent, if any person in this group has a
serious mental disorder/ not competent , then no other party is allowed to make any decisions
on their behalf

IN THIS CASE THERE ARE 2 OPTIONS:

1)if patient has issued an advanced directive(living will) then doctors would need to abide by the
patients decision, even if said decision isn’t in their best interest. This is a document that states
how the patient wants to be treated in the future, if they at some point in the future become
unable to make decisions for themselves

2)If a patient hasn’t indicated any particular wishes, then the decision is with the doctors as long
as they act in the best interests of the patient . However they should involve relatives if possible
to ascertain what the patient would have wanted

CHILDREN

(gillick competence/Fraser guidelines)

Children under 16 can be deemed competent enough to make a decision if they are shown to be
mature enough to understand info about a procedure and its consequences, however doctor
must discuss the possible involvement of parent/guardian in the discussion. However, if a refuses
to involve anyone, then doctor must respect their decision, otherwise this would breach
condidentiality. Parents are only involved as a must when the child is deemed not to be
competent. AND CONFIDENTIALITY is Broken when child is in danger, so you would call
police/social services
 The competence of the child is assessed in relation to the procedure concerned, eg a 5yr old can
consent to antiseptic on cut, but not an amputation.

In England and Wales, although a child can consent to a procedure or treatment. They
themselves cannot refuse a treatment if it is deemed to be in their best interests. Refusal of this
treatment lies with their parents.

If both parents refuse to give consent on an operation to remove a tumor on a boy with cancer,
(which is a life saving procedure) then doctors can act in the best interest of the patient, and if
needed they can get a court order to impose the treatment . If time is important they can impose
the treatment first and then justify the decision later in court if needed.

HOWEVER IN SCOTLAND CHILDREN CAN REFUSE CONSENT

CONFIDENTIALITY

Any unjustified breaches of confidentiality are serious professional faults and serious breaches
can end your career

When can you breach Confidentiality?

1)when informed consent has been given by the patient, only the info agreed upon may be given
and only to the parties that were mentioned in this agreement. If a patient doesn’t want to share
their info with another colleague then you will have to work around them if possible

2) when implied consent has been given

I.e. when a patient brings a family member like a husband along, and openly discusses things
with you. However if you feel that you will have to break bad news , or deal with a sensitive
issue, then it is best to check with the patient first

3) Information required by a court or judge

If the police need access to medical records for an investigation, this requires a court order

4) In the public interest to protect the patient and others

This includes:
Where the benefit to society of disclosing the info without the patients consent outweighs
the benefit of keeping it confidential
-notification to the authorities of notifiable diseases eg meningitis,
tuberculosis,measles,mumps etc. HIV and AIDS aren’t notifiable
-suspected cases of child abuse or of neglect,physical or emotional abuse
-Informing DVLA if patients condition may affect their driving eg epilepsy.
- When the info can help fight against terrorism or in identifying a criminal

EUTHANASIA AND ASSISTED SUICIDE

Euthanasia-the act of ending someones life through an intentional act in order to alleviate their
pain and suffering

Active euthanasia- ending someones life through a practical action ie, poison/suffocation
Passive euthanasia-where lack of action results in death of person, eg withdrawing
treatment/ventilator (which prolongs life)

Voluntary euthanasia-person who ended their life gave consent for it

Non-voluntary euthanasia- person whose life ended wasn’t able to provide consent, eg in a coma/
vegetative state or unable to communicate.

Involuntary euthanasia- Person who died would have been in a position to give consent, but instead
indicated that they didn’t wish to die, weren’t asked.

Assisted suicide – an individual suicides with the help of someone else

Some institutions abroad allow euthanasia using drugs, however a doctor cannot recommend this as
it would be in breach of non-maleficence

BOTH EUTHANASIA AND ASSISTED SUICIDE ARE ILLEGAL IN THE UK , and in some cases even making
the trip to a swill clinic can get you prosecuted, in the sense that by accompanying the relative to the
clinic, they are effectively assisting a suicide

Doctors may need to withdraw treatment from an individual, which may lead to the death of a
patient, ie if patient isn’t able to communicate their wishes, and doctors believe a treatment isn’t
effective and not within the patients best interest . In this kind of situation, the decision lies entirely
with the doctors , unless the patient has issued an advanced directive.

A common example of this is a DNR on a patient who has stopped breathing.