Put the patient first, NAO tells the NHS

20 Apr 00
Just as the NHS is becoming accustomed to the government's burgeoning reform demands, the National Audit Office decides to roll up its sleeves and join the modernisation melee.

21 April 2000

While attention has been focused on the new health watchdog, the Commission for Health Improvement, the NAO has been quietly adopting the government's 'frontline first' mantra. It has already released four highly critical reports in a series focusing on core patient concerns.

The style and recurring themes of the reports, into medical equipment, infections, bed management and hip replacements, are just a hint of things to come.

'All four reports show serious weaknesses within trusts,' Martin Pfleger, the NAO's deputy auditor general, told Public Finance. 'Trusts don't follow through patient care, they don't know the costs or monitor the quality of what they are doing – so how can they manage?'

The latest report into hip replacements, published this week (see page 6), highlights some of these issues and reveals a wide variation in performance, poor management standards and a lack of general and financial information.

Pfleger and the report's author Tim Fry describe what they found as both bizarre and outrageous. Some 14% of consultants fitted replacement hips without any medical evidence of effectiveness.

More than 50% of consultants failed to keep any records on the numbers of re-operations and dislocations, and a third of all trusts could not provide information on the overall costs of hip replacement surgery.

For the NAO, such poor standards are a familiar story, and sum up the health service problems that have so far frustrated this government. But, according to Pfleger, reforming the NHS is not just a question of new resources, it also involves tackling poor management standards and removing a cultural resistance to modernisation.

'We have to reach groups of consultants who are not willing to operate in the modern NHS,' he says. 'They are resistant to change and see recording and valuation simply as an increase in bureaucracy. They don't see the value of modern approaches to patient care.'

To address this and to slot into the government's 'cross-cutting' modernisation agenda, the NAO is departing from simply auditing and reporting on health services to take the fight directly to frontline staff. 'It is really a question of getting best practice into the system,' says Pfleger.

Fry adds: 'Trusts have already shown a great deal of interest in our work on hip replacements. Because of the lack of management information generally, there is little best practice available in many areas.'

The NAO has already put together a long-term health strategy and hopes to win over recalcitrant consultants and managers through a combination of its reports and, in what it describes as 'an emerging trend', through face-to-face conferences and seminars. It has already begun this work in the area of e-commerce, persuading government e-envoy Alex Allan to speak alongside auditor general Sir John Bourn.

It is also likely to continue its close association with the National Institute for Clinical Excellence, which has already issued new guidelines on hip replacement in the light of the NAO's investigation.

This new, best practice, patient-focused role fits neatly into the government's reform agenda and aligns with its new stable of independent health bodies designed to provide 'non-political' evidence of who, what and where is in need of reform.

'The health data we have produced is far better than anything the Department of Health has,' says Fry. 'From our databases we provide a source of new information on several areas and expect it to dovetail with that of other organisations.'

The message from the NAO is simple: better management means better use of resources. It intends to deliver the message personally. 'A lot of what we are saying isn't about money. If we look at what the best hospitals are doing within the same resources it really comes down to better management,' Pfleger says. 'If everyone could get to the upper quartile within existing resources then additional money would really improve services.'

Waiting lists, the National Blood Service and issues concerning obesity can expect the new NAO treatment within the coming months. A joint Audit Commission report into NHS training procurement is also expected.

Pfleger, previously the assistant auditor general in charge of Scotland, has now been given responsibility for all revenue departments to add to health, education and social security, as the NAO integrates its social policy departments.

He is determined that there will be no let-up in the pressure on the NHS.


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