There have been many indicators such as high mortality rates Nolte and McKee, 2011 and disparity in health outcomes between social groups Ham, Dixon and Brooke, 2012 depicting the imperfect state of health and social delivery system. A report commissioned by the King’s Fund (2011) in London found that at some of the practices, almost only 10 percent of the people were able to see the doctors of their choice. A study commissioned by the London School of Economics and Political Science (2012) found that 75 per cent of the patients reporting depression or anxiety did not receive any medical care.
There is a strong need for service improvement and improvement in both patient safety and care delivery is an imperative for modernisation of health can social service. Service improvement can be effectively brought about with the help of empowering leaders at different organisational levels who can implement multi-institutional approaches to improving services (Janes and Mullan, 2007).
Improvements in the standards of NHS care can only take place if the need for imminent service improvement is recognized and plans using service improvement tools are conceptualised and implemented. The quality and productivity of NHS medical and social care can be sustainably improved if such tools are implemented to the healthcare setting. If used correctly, these tools can help NHS officials in problem-solving at the minimum cost possible. Therefore, it is an imperative for the NHS staff to know about these tools and implement them whenever and wherever possible (NHS, 2006).
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One of the fields in medical and social care that needs radical disciplining and improvement is referral management of mental health patients. The problem of inappropriate referrals to Community Mental Health Teams (CMHT) has been well evidenced in the past (Singh, 2000; Williams and Healey, 2001). This is mainly due to inability of the patients to visit their general practitioners (GP) or due to their no previous experience with the mental health unit. The CMHT is multidisciplinary and constitutes of doctors, psychologists, nurses, therapists and social workers. It is essential for the GPs to make patient referrals to CMHTs and it is usually only vulnerable people that need to be referred. The proper care can only be ensured when the information provided by the referrer is comprehensive and accurate (NHS, 2009).
In most of the cases, the first point of contact is and should be the general practitioner (GP) or the family doctor. GPs can make an accurate assessment of the situation and if not serious can prescribe medication or refer to a specialist if need be. Patients referred for mental health issues are taken care off in primary care along with the patients who have been diagnosed with more serious health problems and receive additional specialist care. The rate of referrals rose by four times 1971 – 1974 (Verhaak et al., 2000 cited in Slade et al., 2008) which, shows that effective managing the balance between primary care and specialist care is a priority. Depending on the severity of the condition, that can be adjudged triage, patients with minor issues are managed in primary care and patients with severe mental health issues are looked after by specialist care givers (Slade et al., 2008).
A problem that mental health system faces continuously is to make sure that right care givers see the right patients. GPs identify less than 50% of the patients with common mental health problems like depression and then the decision whether the patient should be treated at primary care level or referred to a specialist lies with the GP. It has been found that the severity of the patients mental health is not the only factor that affects this decision but patients gender, patient-doctor relationship and the tolerance of the GP for that patient also have an important role in decision making process (King, 2001; Vázquez-Barquero et al., 1999; Ross et al., 1999; Evans, 1993; Chew-Graham et al., 2007; cited in Slade et al., 2008). The guidelines implemented to follow the referral system do not help the primary care as there is no way to ensure that only patients with severe mental health problems are referred to them (Harrison et al.,, 1997; Chew-Graham et al., 2008; cited in Slade et al., 2008).
When patients only with severe mental health problems are not referred to primary care system, the efficiency of CMHT is reduced as is the access for some people who are in more urgent need than others. A priority for improvement for innovations is the appropriateness of the cases referred to the CMHT’s as there is evidence that about 20% of the referred cases are inappropriate referrals that can be handled by the GPs (Slade et al., 2002 and Slade et al., 2008). “Introducing local protocols to manage demand at this interface may not be successful and more attention needs to be paid to human and organizational factors in managing interfaces between services” (Slade et al., 2008).
The relevance of service improvement
NHS Institute for Innovation and Improvement (NHSIII) highlighted the practicality and relevance of service improvement for the practising medical fraternity by stating that every single medical and social care provider was enabled and encouraged to work in a team while improving their own part of the service (Penny, 2003). It is important for all healthcare staff to adopt this change and it does not apply to doctors and medical practitioners only. Nurses, for example, are often good at reflective practice and may be able to identify areas for improvement easily, but they may not have the necessary understanding, self-assurance, determination and ability to take necessary action in this regard (Janes and Mullan, 2007).
If the prospects for bettering services provided and the standard of patient care in the NHS are to be maximised and the goal of increasing the efficacy of the NHS is to be achieved, the efforts have to be envisioned and implemented as an aspect of daily routine in the nurses’ work routine and not viewed as an external, supplementary goal to be met or an peripheral dimension to be added to the work system. Integration of quality service at the very core of day-to-day patient care has to be realised (Janes and Mullan, 2007).
If the NHS is to meet the needs and demands of patient care in the 21st century, the change needed has to be affected at all levels of the system such that a never-ending cycle of growth, improvement and progress is created. The transformative forces need to be directed at all levels and aspects of the health care system so that all staff members may be productively involved in modern and result-oriented methods of working and constant development is seen (Janes and Mullan, 2007).
The Knowledge and Skills Framework (KSF) is now centred on the aspect of service improvement, and in the light of a promising trial by the NHS trusts, NHSIII and some institutions for further education, the growing trend has been to promote capacity-building through service improvement education. It is assumed that this requirement of training and education regarding service improvement will possibly grow to be an essential constituent of the pre-registration education that is required of professionals and support staff members working in the fields of healthcare and patient care (Janes and Mullan, 2007).
Several varieties of methods and devices to enable and advance the execution of service improvement in the NHS are on hand. Penny (2003), for instance, has classified four foundational and interconnected aspects of service improvement that are of equal significance (Fig. 1).
Fig 1.png
Figure : Model of discipline in the improvement of care (Adapted from Penny, 2003)
These four central aspects form the basis on which all actions and plans to better patient care rest upon. The empirical data supporting the value and usefulness of these aspects was gleaned from experiences and workings of the NHS.
Employing a single or multiple plan-do-study-act (PDSA) cycles thus is the best manner in which staff can be facilitated in checking the potential and effectiveness of service improvement schemes so that the building and implementation of successful schemes across a variety of services and levels of the NHS may be possible.
These patterns of growth and transformation can lead to substantial developments, which will not be limited only to the provision of quality health care but will also augment the professional atmosphere and job satisfaction experienced by the staff members.
The Model for Improvement aims at enabling staff members to actively better different aspects of the service they provide, and hence, is a noteworthy mechanism for restructuring the NHS.
Nurse Managers must become actively involved with service improvement as it is an essential aspect of KSF. Service improvement also empowers professionals to meet the current demands of the system such as clinical governance, client-oriented care and patient safety as per the ideal modern health care system the Standards for Better Health (DoH, 2004) has defined. It is also important to note that service improvement creates a framework and hence enables nurse managers to ensure the wellbeing and care of their patients, improve the professional fulfilment that the staff receives from the job while mitigating stressors in the workplace and finally, raising overall productivity within the system.
The number of institutions using and applying techniques such as Lean Thinking (Bicheno, 2004), Protocol Based Care and Clinical Systems Improvement (Walley, Rayment and Cooke, 2006) has increased drastically and the capacity of these methods to result in visibly improved service standards has been recognized in several publications (Westwood James-Moore and Cooke, 2007).
Techniques like these, however, usually are made possible only with niche planning and research along with significant fiscal investments. On the other hand, Langley et al.’s (1996; cited in Janes and Mullan, 2007) Model for Improvement (Fig. 2) can be applied to any sector or stage of organisational structure without needing any financial inputs or preparation. This model includes three significant questions and a ‘Plan, Do, Study, Act’ (PDSA) scheme that work together in building an effective background for promoting focus on service improvement.
fig2.png
Figure : The model of improvement (Adapted from Janes and Mullan, 2007)
The PDSA cycle is best applied to cases wherein growth and development are affected in sequential stages because this makes it possible for the changes and their effects to be observed and tested before they are re-introduced in phases.
Upon closer inspection we find that the PDSA cycle has many similarities with the different steps of the nursing practice; that is to say the assessment of what the client needs, setting up the most appropriate care process, executing the plan and monitoring care. The commonalities between the standard nursing procedure and the PDSA cycle should make it easier for nurses to relate to the latter and apply the tool for concrete results in daily practice. Similarly, in case of mental assessment referrals, assessing client’s needs is the first and the foremost, where the GP plays a vital role in assessing the client and deciding on further actions. The second step can be setting up a care process, which can be prescribing anti-depressants in case of mild symptoms or referrals to CMHTs if a patient is vulnerable.
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In a study conducted by Kravitz et al., in 2006 to recognize the factors that lead to referral from primary to specialist care, they found that 36% of the 298 patients were referred to specialist. The specialist with good knowledge of antidepressant therapy were less likely to refer the patients whereas, the physicians who spent about ten per cent or more time on other activities outside clinic like academia or administration, have had history of antidepressant therapy or access to specialist consultation were more likely to refer the patients to specialist care.
Looking closely at the Kravitz et al., (2006) study, it can be concluded that the study was carried out in a PDSA cycle that is, getting the answer to the defined question. They planned (P) the experiment to test the question, “What Drives Referral from Primary Care Physicians to Mental Health Specialists?” Secondly, they did (D) the experiment/conducted the survey to gather the data. Studied (S) the outcomes and predictions and decided (A) on the questions that need to be addressed in next cycle based on the outcomes of this one.
Kravitz et al., (2006) concluded that the issue that needs to be addressed next is to “whether interventions designed to enhance the referral process can lead to better outcomes.” This study clearly shows that the GPs tend to address the issues of 64% patients without referring them to specialist care. One possibility to reduce the number of inappropriate referrals would be to encourage the patients to see their GPs or family doctors first before opting for specialist care. Looking at the findings of Kravitiz et al., (2006) study, it is clear that more patients would be treated by the GPs provided the patient sees the GP first.
GPs should be encouraged to work in collaboration with other members of the CMHT’s and follow protocol based care (PBC). PBC provides a framework for working efficiently in a multi-disciplinary team and helps put to action the findings of a study and answers the questions like whom, when and where. ‘Integrated care pathway’ or local protocols are a list of steps that have to be followed while treating a patient. It can play a very important when role in patient referral systems and determines where and who should take care of the patient (NHS, 2008) and would considerably reduce the number of unimportant referrals.
Conclusion
Community working environment has become stressful due to inadequate resources, poor management of workloads and interference of bureaucracy. The number of acute beds available has reduced rapidly if the recent past and blaming others for inefficiency, adds to the stress of the community working. It is important to judge the difference between what can be achieved and what cannot. As suggested by Singh (2000), “Hence, a team consensus on targeting serious mental illness, using evidence-based practice and equity of case-load are vital to improve effectiveness. Undergraduate training of all mental health disciplines needs to be modified to ensure that basic knowledge and core skills necessary for providing effective mental health care can be developed early in the training.”
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