Health Care Delivery Systems

Professor Sue Frost

Themes…………...• Health Systems

• Development of English Health Care System

• Care Delivery

Beliefs & values

Organisation of care

Setting standards

• Changing and developing systems

References……………….

• The Nursing Process & Quality Care Kemp N & Richardson E. 1994 Edward Arnold

• Primary Nursing in perspective Ersser S & Tutton E Scutari Press 1991

• Foundations of Nursing Practice Hogston R & Simpson P. 1999 MacMillan

• Conceptual Bases of Professional Nursing Leddy S & Pepper J Lippincott 4th ed 1998

Question……………...

• What health Care systems do you know of?

• Is health care the same in all countries, services?

• What are the major differences?

• How do you know?

World views……...

• Systems vary depending on cultural value of health and sickness

• Individualism vs. collectivism

• Funding systems vary (state or individual)

• Political base of systems vary

• Simple & complex systems

e.g. Traditional Indian medicine

• Practitioners of traditional Indian medicine as huge resource

• Parallel systems of allopathy and homeopathy• Developed together as part of government

policy• 90% health care outside “modern” system• Different systems of evidence and belief

…traditional Indian medicine• Indigenous system is a major feature of system• Used more widely - clients feel more accessible• Less costly• Located closely to where needed• Fit with lifestyle, beliefs and values of people

served• Enable a dual system to operate with cross

linkages

Health Care in revolution - Nicaragua

• Public Health Led programs of care• Third world health problems• Changing life experience through public health• Working under complex and changing political regimes

(destruction of hospitals)• Access for the poor and not wealth alone• Prevention Prioritised• Participation of local communities in establishing their own

health priorities

US Health Care

• Federal and Private health care system

• Single tier system with patient direct access

• Insurance dependent system. (32% have no insurance)

• Role of Nurse as part of client funded contract

• Separation of health and social care services

UK health care systems

• Government funded - treasury dependent

• System of NHS funding and PFI

• Health policy is in the political domain

• 85% care in public sector but changing - in Yorkshire more private beds

• Major changes in health care modeling

Ministry of Health

Local Authority HospitalsExecutive Council

RegionalHospital Board

Hospital Management Committee

Teaching hospitalwith Board ofGovernors

GP'sOpticiansdentistsPharmacists

Community health services

The NHS in 1948

NHS 2000……….

• Department of Health & Social Security

• NHS Executive (NHSE)

• Regional offices of NHSE

• District Health Authorities &NHS Trusts

• Primary Care Groups

• Primary Health Care Trusts

• Fundholding

Changes………………...

• Partnerships and power• Roles of Nurses • Medical role change• Internal economy for health care• Growth in private health care• National Service Frameworks• NICE/CHImp/• Clinical governance

What do you think these things mean for nursing?

• ?Opportunity or threat

• ?Using political power

• Enhanced or extended roles

• Leadership to influence the NHS shape and direction

• New systems of care delivery

• New experience for patients and clients?

Organising care

• Primary Care

• Secondary care

• Tertiary care

• Hub and spoke models

• vertical integrated models

Care delivery systems

• Nurse as technician

• Task allocation

• Individualised Care systems (patient allocation

• Primary Nursing

• Team Nursing

• Key worker

• Care management programmes

Primary Nursing

“The delivery of comprehensive, continuous, coordinated and individualised patient care through a primary nurse who has autonomy accountability and authority to act as the chief nurse for her patients

Maria Manthey 73

Key concepts in primary nursing

• Responsibility for the quality of nursing care

• Case method assignment

• Direct channels of communication

• Care giver as care planner

Primary Nursing

• Make own decisions

• Liaises with others (Associate nurses)

• Part of a primary nurse group

• has authority (power to act)

• has autonomy(freedom to act)

• has accountability (responsibility to act)

Strengths of primary nursing• Individualised care is real and involve the

patient/client• Relationship develops with trust and knowledge• Total care package• Role modeling• Multi-disciplinary teamwork• Effective continuity of care• Professional advocacy• Communication with family & carers

Weaknesses of primary nursing

• Style is important (autocratic, over protective• Skill and knowledge requirements are

considerable• Problems with “ward routines” - who is not

my patient• ?Night nursing in primary nursing• Preferences of nurse over needs of patients

Team nursing• Group of nurses to a group of patients

• Most popular approach in acute hospital care

• Manages the skill mix available

• Team leadership roles emerge

• A modified form of primary nursing where team leader manages the nursing diagnosis and plan and the team members act as care givers

Team Nursing offers

• Continuity of care

• Named nurse

• communication channels

• closer liaison over planning and evaluating care

• Always someone from team on duty

• Team environment to learn and develop

Weakness in team nursing

• Task allocation reverts

• Dependency on team on not focus on patient

• Who is the key person in charge?

• Named nurse can be eroded

Patient allocation

• Care allocated daily for a patient

• enables total care rather than tasks

• nurses get to know patients

• may not be continuous care

• planned care is fragmented

• does not build authority and autonomy

Key workers

• Similar to primary nursing - lead worker for a client

• Key worker coordinates the programme of support or care

• most common in services for people with learning difficulties or mental health problems

• enables enduring and continuing support to be developed

Case Management

• Caring for people DoH 1989

• Commonly used where sidcrete case work is identified (community/mental health services/learning disability services)

• The key worker extends their role to incorporate the lead role for the multi disc team

Questions……………….

• What approach happens in your service settings?

• Do they work?

• How do you know they work?

• How is quality managed in individualised systems?

• What other possibilities exist?

A professor is one who talks in someone else's sleep.

Anonymous