THE DONABEDIAN MODEL OF THE BRITISH HEALTHCARE SYSTEM

This is the second part of the Donabedian model for measuring quality of care developed by Avedis Donabedian (Donabedian, 2003). The first part reflected on United Kingdom’s (UK) historical background, government, and economy, including its healthcare overview. The keys to Donabedian’s approach to quality assessment and quality assurance are manifested in three ways of approach: structure, process, and outcome (Donabedian, 2003). Featured in this section is UK’s healthcare system systematized in the Donabedian model approach.

The Donabedian Model of The British Healthcare System

Structure

               Following the election of a Labour Government in May 1997, a new health care system was recommended and received a royal assent in 1999.  Under the new system, the Department of Health (DOH) headed by the Secretary of State for Health, together with his team of five ministerial appointees is responsible for health and personal social services in England.  Separate responsibilities are held by the Secretaries of State for Scotland, Wales and Northern Ireland.  Overall health policies are set by the Department in England which also has the overall responsibility for the NHS.

Facilities, Licensing and Accreditation

According to the Organization for Economic Cooperation and Development (OECD, 2000), NHS hospitals are not subject to formal regulation through systems of accreditation as in some countries, although nongovernmental organizations such as the King’s Fund in London have offered accreditation services for which a number of NHS private hospitals have taken up.  Official government regulation exists, however in mental institutions, residential and nursing homes.   Government regulations for new pharmaceutical products based on safety grounds are rigorous.  Long standing contract has been in effect since 1957 between the Department of Health and the Association of the British Pharmaceutical Industry.  The profits that pharmaceutical firms make through their sales to the NHS are regulated through the Pharmaceutical Price Regulation Scheme (PPRS) [OECD, 2000].

The General Medical Council regulates the education, training and professional standards of doctors while the UK Central Council of Nursing and Midwifery regulates the education, training and professional standards for nurses (Dixon & Robinson, 2002).

Distribution of Hospital Beds and Physicians

Hospitals are mainly publicly owned while private hospitals provide services to privately insured patients or those who are willing to pay directly.  There are approximately 230 independent medical or surgical hospitals in the United Kingdom.  There are five main groups of hospital groups that dominate the market. They account for just over 60 percent of hospitals and a combined share of approximately 65 percent of total private beds (cited in OECD, 2000).  National data for England (2000-2001) shows that there were 186, 091 beds in the NHS and the occupancy rate is about 84.0 percent.  Utilization rate for the general and acute sector shows an average length of at 7 days and the admission rate was 150 per 1000 population in 1998.  British for-profit companies dominate ownership of private hospital beds in the private and independent sector (over 50% of the total). For-profit companies own 65% of beds in the private sector (Dixon & Robinson, 2002).

Most of the England’s doctors are members of the British Medical Association (BMA) at about 80 percent.  Professional registration and regulation is the responsibility of the General Medical Council.  Each of the medical specialties are governed by a Royal College, which is responsible for the assessment and awarding of qualifications in the specialty, continuing medical education, issuance of clinical guidelines and medical auditing (Dixon & Robinson, 2002).

General practitioners (GPs) mainly provide the primary care services.  Included in the change of 1997 is the formation of primary care groups (PCGs).  PCGs are groupings around GP practices in a geographical area covering populations ranging from 50,000 to 250,000 people.  Accordingly, PCGs are given more direct authority and responsibilities by NHS culminating in the formation of a primary trusts. The government plans also include a far greater degree of interagency collaboration with PCGs working closely with local government social services department (Dixon & Robinson, 2002).

GPs do not receive a salary but are paid through a system of payments designed to deliver a certain level of gross income for the average GP. The basic elements of the current payment system are: capitation fees, allowances, health promotions payments and item of service payments.  Thus, for individual GPs the amount of income they derive from fees and allowances will depend on the number of registered patients on their list, whether or not they qualify for specific fees and allowances, the number, and level of activities undertaken and the performance achieved (Dixon & Robinson, 2002).

According to the WHO (2000) data, there are currently 36,000 GPs in the NHS.  At about 60 GPs are assigned to cover primary care per 100,000 of the population. The NHS has added an extra 2,000 GPs, 20,000 nurses and 6,500 therapists in 2004.

When Brown became the Prime Minister, he abolished the internal market in the health service introduced by the Conservatives in the 1990s, in which half of the GPs have become fund holders with their own budget for drugs and elective care, giving them an incentive to curb demand and tool to bargain with hospital. Based on Department of Health, PCGs development will occur in four stages (Dixon & Robinson, 2002):

1. Support the health authority in commissioning care for its population, acting in an advisory capacity.
2. Manage the budget for healthcare in their area.
3. Become established as a free standing body accountable to the health authority for approving care.
4. Responsible for the provision of community health services that they serve.

PROCESS

Financial and Health Resource Allocation

UK’s budgets are currently set every three years with no strict earmarking of revenue or expenditure; budgets can be adjusted during the three year cycle.  National taxation is the main source of revenue for health care.  UK spends 6.9 percent of its GDP on healthcare before 1997 (CIA, 2010).  According to OECD data, UK’s spending is the lowest among the industrialized nations (OECD average = 7.8%) at that time.  After 1997, England increased their healthcare spending to 8.4 percent.  According to Dixon & Robinson (2002), NHS revenues comprised of 80 percent taxation, 12 percent national insurance contribution (NICs), 4 percent charges and miscellaneous, 3 percent from Trust interest receipts and 1 percent from capital receipts.

In terms of health resource allocation, equity of access is based on need, rather than one’s ability to pay, where one lives, or the one’s particular health care provider.  Local health authorities and primary care commissioners determine the level and type of services to make available in accordance with national framework of policies and priorities (Day, 2000).

Taken from Dixon & Robinson (2002, p. 87) is this example of a typical patient journey to seek a medical care:

“A typical patient in need of non-emergency medical care will seek a consultation with a GP. No payment is made for this consultation. The GP will treat the patient in the surgery and if necessary prescribe medicines for which charges may be levied.  In around 5 per cent of cases, usually after more than one primary care consultation, the patient may be referred for a hospital outpatient appointment with a specialist. This will usually involve a wait of around two and a half months depending on the specialism and severity of the case. No payment is made for this consultation. After the consultation, if deemed necessary, the consultant may recommend hospital in-patient treatment. Again a wait of up to about three months is likely, depending on circumstances. In an increasing number of cases this will be offered on a day-case basis involving no or only one overnight stay. Following hospital treatment the patient may be discharged home, to an intermediate care facility or to a nursing home. NHS services are not subject to charges, but accommodation and personal care (the latter in England but not in Scotland where it is free) in a nursing home is subject to means tested charges, as is domiciliary social care delivered to the patient at home.”

Diagnostic Services

Most diagnostic procedures are carried out at community and acute general hospitals, some in primary care.  Most diagnostic and laboratory services such CT scans and MRI are located within the NHS.   GPs may now refer patients directly to hospitals to obtain some tests.  Pathology services are increasingly contracted to private sectors (OECD, 2000).

Ambulatory Care

Ambulatory care is provided mainly by GPs in group practices of four or more.  Patients may choose to register with any GP within their designated practice area.  GPs are not obligated to accept everyone who asks to be registered. An average GP list size is about 1800 patients.   Private GPs are very small and mainly are located in London.  There are only about 200 exclusively private GPs in the United Kingdom.   There are currently 36 NHS walk-in clinics and several privately run walk-in clinics.  Specialists are not allowed to work directly in primary care although specialist outreach clinic are becoming more common.  Just like in the U.S., a primary care clinic consists of just not GPs but also nurse, midwives, physical therapists, occupational therapists, etc. (OECD, 2000).

Secondary care

Secondary care is known as acute healthcare and can be either elective care or emergency care. Elective care means planned specialist medical care or surgery, usually following referral from a primary or community health professional such as a GP.  Secondary care in the NHS is provided in general acute hospitals, small community hospitals and highly specialized tertiary hospitals (Dixon & Robinson, 2002).

Rehabilitation/ Intermediate Care

Intermediate care is generally a short stay facility, covering up to six weeks and designed to prepare patients to return home.  The NHS made a commitment for the provision of additional 5000 beds in 2003 and 2004. NHs has subcontracted the private sector efforts in providing additional beds for intermediate care, although the funding will come from the public (OECD, 2000).

Drug Administration

Pharmaceutical services are provided mainly by community pharmacists who supply drugs from prescriptions ordered by GPs.  GPs are also allowed to dispense medicines.  There are about 10, 482 community pharmacies in the UK in 2001.  The drug market is categorized into categories: pharmacy-only (P) and general sales list (GSL).  P status drugs are prescription medications and may only be sold in pharmacies registered through NHS and supervised by a qualified pharmacist.  GSL drugs (over-the-counter medicines) may be sold in drug stores, supermarkets and pharmacies (Dixon & Robinson, 2002).

OUTCOME

One of the major public concerns about the NHS is waiting time for both inpatient and outpatient appointments. The average waiting time is four months for inpatient care with around two million people (2% of England’s population) waiting.   According to the UK’s Department of Health, in the second quarter of 2001 and 2002, twenty two percent of patients waited for more than 13 weeks for first outpatient appointment, while twenty seven percents waited six months for an inpatient admission (Oliver, 2007).

The table below shows the number of people waiting for more than 13 weeks, 20 weeks and 26 weeks over the four month period (September 2006 to January 2007) and it appeared to be quite stable. Oliver (2007) contend that the effect of the demands to reduce waiting times across the whole of the NHS may raise patient expectations to the point of being detrimental to the health care system, not least because expectations have to be met within a fixed budget, and they may therefore distort the priorities of the health care system.

Table 1. The number of people waiting for more than 13 weeks, 20 weeks and 26 weeks over the four month period (September 2006 to January 2007). [Health Policy Monitor, April 2007].

Analysis of patient satisfaction of acute care is reflected in the findings of the NHS survey in 1999 of acute care patients with coronary heart conditions. Thirty four percent on the waiting list thought that they should have been admitted sooner. Those who had been waiting for three months or less, they thought that they were admitted as soon as necessary.  Those who had been waiting for more than this were more critical.  Of those who had been in the waiting list for twelve months or more, three quarters considered they should have been admitted sooner.

Life expectancy at birth provides one of the broadest indicators of the overall health of a population.  In the UK, the life expectancy for female rose by five and a half years, male by six and half years. Survival rates for cancer which accounts for around a quarter deaths in the UK was improving but lagging behind the rest of Europe. Infant Mortality – defined by the number of deaths of children under one year of age was at 5.8 deaths per 1000 live births in 1999.  The UK was above the European Union (EU) average of 4.9. (OECD, 2000).

Cesar Aquino, PhD, MBA, CT(ASCP)