nhs portfolio

Executive Summary
The Nation Health Service is one of the United Kingdom’s largest service suppliers and a government agency, so the value to the customer comes in many forms. The attached report looks at the means NHS uses to provide value to its stakeholders including customers, employees and taxpayers. This study completes both a qualitative descriptive study and a quantitative review of the issues that stakeholders consider when evaluating the value of NHS. The researcher looked first at patient reviews of NHS services, followed by an evaluation of how well those patient needs are understood by the NHS provider. Finally, the researcher examined value chain activities that could contribute to the perceived value and/or the actual value provided by NHS. The researcher concludes that much of the value problem at NHS is due to value perceptions rather than actual value and many could be resolved via scheduling modifications.
 
Introduction
Value chain management should be able to improve the value of an organization’s services to all of the stakeholders, but when an entire nation are stakeholders, how do you balance the needs of the many with the needs of the few? This paper looks at the perceptions of some of the stakeholders for the National Health Service, the patients, and then attempts to determine how the needs of those stakeholders are being addressed by the organization itself. The researcher will also look at value chain activities that are ripe for improvement and may result in better value perceptions for all stakeholders.
The National Health Service of the United Kingdom is the largest government funded provider of health care services in the world. “Since its launch in 1948, the NHS has grown to become the world’s largest publicly funded health service. It is also one of the most efficient, most egalitarian and most comprehensive. The NHS was born out of a long-held ideal that good healthcare should be available to all, regardless of wealth,” (NHS, “About the NHS”, 2010). The National Health Service provides all manner of health services to consumers in the United Kingdom, including advice for staying healthy, routine and emergency health care, and health information services. To the end user, the NHS is a source of feeling better, fighting illness and disease, and creating a longer, more enjoyable life. The value then to the consumer is enormous. Every resident of the United Kingdom is potentially impacted by the services and operations of the NHS and believes that the goal of NHS should be to provide “High Quality Care for All” (NHS, “Next Stage Review Implementation”, 2010). However, the question arises as to how well the organization is accomplishing that goal.

Evaluating NHS from a consumer point of view
In an effort to evaluate the consumers’ view of the service value of the NHS, the researcher considered several different study methodologies. Based on personal observation, the reviewer believed that wait times might be a major factor in the public perception of NHS value. The researcher also believed that a descriptive study was more appropriate than any form of empirical study as an empirical study would take considerable amounts of time and would have too many variables to control. Additionally, the researcher has observed that the perception of health care value can be directly related to the health and attitude of the individual; that is, persons in poor health may be more likely to rate the value of the system negatively and some patients with chronic illness may inappropriately blame the NHS for their health conditions. To that end, the researcher decided to do a combined qualitative and quantitative questionnaire that would be administered over the course of three days via telephone and at three NHS office locations until a total of 50 patients in each manner, in person and via telephone, had been surveyed. “ In quantitative research your aim is to determine the relationship between one thing (an independent variable) and another (a dependent or outcome variable) in a population. Quantitative research designs are either descriptive (subjects usually measured once) or experimental (subjects measured before and after a treatment). A descriptive study establishes only associations between variables,” (Sportsci.org, 2000). Based on the standards of most research, the researcher’s sample size is too small to offer conclusive evidence of anything. At best, it shows a predominance of opinion.
Due to the many variables, the only quantitative issue to be addressed will be one that is easily measured. Respondents will be asked specifically to describe how long they waited beyond their original appoint time during their most recent visit to an NHS facility. The remainder of the survey will be qualitative in nature.“Qualitative research should not be viewed as an easy substitute for a “statistical” or quantitative study. It demands a commitment to an extensive time in the field, engagement in the complex, time-consuming process of data analysis, writing of long passages, and participation in a form of social and human science research that does not have firm guidelines or specific procedures and is evolving and changing constantly.” (socialresearchmethods.com, 2008). However, because the researcher is attempting to limit the variable of personal health, the qualitative methodology is more appealing. The locations of the sample sites as well as the questionnaires used are available in Appendix A.
Significance of the problem
The researcher chose this organization precisely because it is more difficult to assess than a retail outlet or non-government agency. The NHS has millions of stakeholders across the United Kingdom and therefore potentially has the most to gain from better value chain management. The purpose then of this research is to determine what parts of the value chain most significantly impact the view of the consumer. The researcher anticipates that the groups of questionnaires may have significantly different results regarding the perceptions of NHS value. The researcher’s hypothesis is that patients interviewed at NHS sites will be more concerned about value issues that directly impact their visit including wait times, professionalism and friendliness of the staff, and quality of care. She believes that consumers contacted by telephone may be more concerned regarding the overall cost of the NHS and quality of care.
Research Results
Compiling the results from the questionnaire, the researcher was surprised to find that most of the respondents agreed with the NHS assessment that this is the best they have ever done. Though the NHS release refers to waiting times for major procedures, treatments and surgeries, the agency is right to brag about its improved services. “"Progress made in bringing down waiting times has been one of the most significant achievements of the past decade," said the head of Birmingham University's department of health policy and management. "Going into the election saying he [Gordon Brown] has brought an end to waiting times would be good." (Bowcott, 2009). Most of the patients surveyed said their waiting time at their last NHS office visit was less than 15 minutes and only 1 patient in one hundred claimed to have waited more than an hour. Based on personal observations, the researcher had anticipated greater complaints about the efficiency of the NHS operations. However, that does not mean consumers were without complaints. In the comments section of the survey, many patients suggested that the organization needs to reduce the number of patients seen in a day so that health professionals can spend more time with individual clients.
The general rating of the professionalism of the staff was high (averaging just over a four on a five point scale where “5” was excellent), but respondents rated their quality of health care at an 2.7, lower than the “average” label on the survey. Additionally, the researcher was surprised that patients, both at the offices and those reached by telephone, agreed that the cost of NHS services (in terms of tax dollars) was higher than the value of the services they received. The survey showed that nearly all (87%) of respondents rated the organization’s money management skills as average or below, with 20% claiming NHS was “very poor” at managing its budget. Among the changes recommended by respondents were fewer appointments sandwiched into a day and better attentiveness by health care providers. One respondent commented that the doctors seemed so rushed that she wondered if she was getting enough attention to address all her medical needs.

Post Research Review
The initial impression of the researcher is that she perhaps misunderstood the primary concern of patients of NHS. While many seem to whinge about the wait time at the offices in casual conversation, the real issue seems to be the lack of time spent with the doctor. When asked to clarify their responses, many patients told the researcher that they would not even mind longer waits if they felt that it meant the doctor was spending adequate time with each patient. The distress arises when patients feel the doctors are overbooked and running from patient to patient without devoting serious time and energy to each person’s particular needs. The researcher also believes that the questionnaire could have been compiled with more specific questions and that a follow-up study asking such things as how much time did you spend with the doctor might prove to be more demonstrative in terms of actual changes needed to improve the value perception of patients. Finally, the researcher believes that the number of patients surveyed was exceedingly small and sho0uld be significantly increased in future studies.
Conclusions of Research
The most simple of the requirements of NHS customers, i.e. patients, is that health care providers spent more time listening to the patients. Patients feel as though doctors and other health care personnel are in such a rush to get to the next patient that their needs are not sufficiently addressed. The second biggest change that patients requested was that staff members be friendly s well as professional. Many respondents said that while the staff always seemed professional, they sometimes seemed distant and unfriendly. Finally, patients complained about the difficulty in getting medical questions answered when not directly during an appointment. Older patients in particular said that telephoning the offices often led to extensive hold times and automated answering services where they were required to leave messages. Many claimed those messages were never returned.
Prioritising Customer Values
From the research it is clear that patients at NHS want to be perceived as individuals, not simply as a number or a part of an ever-extending queue. Patients wanted to feel as though they were getting their money’s worth for the taxes they pay to support the NHS, but even more so they wanted individualised service –health care professionals who were familiar with their specific health issues and who at least gave them the perception that they cared about the patient.
Providers’ Perceptions Regarding Customer Needs
Customer Needs
In recent years, the NHS has been trying to become more responsive to customer needs and to address the issues that have plagued the system. As little as a decade ago, NHS was considered among the worst health care systems in the European Union and horror stories about variances in care and long delays in treatment were all the rage. “The performance problems of the NHS are no secret. Some reflect random episodes of malfeasance, such as the murderous Harold Shipman, but more chronic problems afflict the NHS as a whole and, in aggregate, cause far more suffering and waste. They include long waiting lists, postal code variation in practice, and poor outcomes in cancer care, and they caused the UK to lag ninth out of 15 European Union countries in the World Health Organization's recent ranking of health systems,” (Leatherman and Berwick, 2000). But the NHS developed a plan to address those issues and has created specific measures, such as the wait for treatment described previously, to determine how the organization is improving.
As recently as 2004 the organization also began to focus on customer service with its largest group of employees—nurses. “Alternative accounts suggest that public sector organization cultures have been successfully orientated toward a customer service ethos, and that the convincing discourse of 'quality' is achieving some success as a normative control device,” (Bolton, 2004). Nurses are being instructed in customer services as well as patient care, a definitive step toward improving the value for customers. Another way that the NHS is addressing customer service issues is via the development of the NHS Constitution, a contract between the organization and its patients regarding the rights of patients. The Constitution, published in March, 2010, is the first time that the rights of the patients have been clearly delineated. “The NHS is there for us from the moment we are born. It takes care of us and our family members when we need it most. The NHS Constitution has been created to protect the NHS and make sure it will always do the things it was set up to do in 1948 - to provide high-quality healthcare that’s free and for everyone,” (NHS Constitution, 2010).
Recognizing that the most important issue to the patients is the standard of care they receive, NHS addressed that very issue in the Handbook explaining the Constitution and the rights of patients. “You have the right to be treated with a professional standard of care, by appropriately qualified and experienced staff, in a properly approved or registered organisation that meets required levels of safety and quality.” (Handbook, 2010) The goal of the NHs to meet these customer needs is reflected in the organisation of NHS, the opening of additional offices and other initiatives to get patients requiring critical treatment to their treatment faster.
Improving Value Through Perception
The NHS is also well-aware that in offering a service, the way the service is packaged can have a huge impact on perception. Thus, one of the things stressed in the new Constitution is customer choice. Customers requiring treatment are allowed to choose treatment centers that are most convenient to them or where better treatment options are available (Handbook, 2010). In addition, the NHS has created a better feedback system to allow patients and their families to complain directly at the local level when they feel their rights are not being met. The organisation has also created patient advocates who will make sure that patients are being treated fairly and according to their right, (Handbook, 2010).
How does this combine with value chain management?
To be able to promise clients improved customer service, one of the first things that NHS must do is run an efficient operation and add value at every step of the way. Unfortunately, it seems that right now, the organisation is still stuck in older management theories, with a web page devoted to its supply chain management. At the most basic level, NHS needs to rethink its supply chain in terms of the value chain. “Our aim is to provide more than £1 billion savings to the NHS over the next 10 years so that resources are released for NHS trusts and healthcare organisations to focus on quality frontline patient care, manage costs and achieve sustainable value. We provide end-to-end supply chain services incorporating procurement, logistics, e-commerce, and customer and supplier support. We manage the procurement and delivery of 620,000 products for more than 600 healthcare organizations,” (Supplychain.nhs, 2010). While their objectives sound something like a value chain, unless NHS recognizes the difference, the old methodology is likely to steep through.
Understanding global value chain management requires looking at real world examples and analyzing the things those examples do right. The value chain is a business model first discussed by Michael Porter in 1985 and offers an explanation of how companies achieve a competitive advantage.
Value Chain Model: The Porter Model

To achieve this success in a value chain, the company must choose a strategic model for maintaining profitability. One reason to choose the Porter model is that it clearly defines each step of the process of adding value for the customers. For example, NHS needs to implement proper training for employees as a means of adding value. In the Porter model, support activities including procurement, technology development, human resource management and firm infrastructure are means to encourage the development of value added processes. By looking at a value chain model which considers support activities, NHS will able to identify every avenue for increased value.
Another advantage of the Porter model is it clearly defines the steps towards adding value in the acquisition of goods for resale. The productivity starts with these areas of the model, especially the procurement department; because of the understanding of value need for the customer in buying good products at the right cost in order make the good margin. “Procurement – the function of purchasing the raw material and other input used in the value-creating activities.”(QuickMBA, 2007).
Customizing the value chain and the Porter model can provide with a competitive advantage over the competition.

Exhibit A (Porter, 2009)



In this case, because what appears to be most lacking, from the end user perspective is customer service, the first value-added activity that NHS should undergo is training for employees that focuses on adding value via good patient services. After that, NHS can apply value chain principles to ordering supplies, developing new offices and even personnel distribution
How does this model differ from other value chain models?
A value chain is the system of organizations, people, technology, activities, information and resources involved in moving a product or service from supplier to customer. Value chain activities transform natural resources, raw materials and components into a finished product that is delivered to the end customer. In sophisticated value chain systems, used products may re-enter the supply chain at any point where residual value is recyclable. Supply chains link value chains (12Manage, 2009). The value chain model can differ from many types of supply chain models, such as the 3C’s model, the Delta model, the diamond model, or the Deming Cycle. In all, there are many supply chain models that can differ from the value chain model. Many supply chain models focus on measuring the total supply chain performance. It is a process reference model for supply-chain management, spanning from the supplier's supplier to the customer's customer. The difference is a value chain is a chain that focuses on the activities, and not measuring total supplies.
The Value Chain Frame of Michael Porter is a model that helps to analyze specific activities through which firms can create value and gain a competitive advantage. The primary activities that are included in the model focus on the line functions, which include: Inbound Logistics, Operations, Outbound Logistics, Marketing, Sales and Services. The support activities that are included in the model focus on staff functions and overhead, which include: Procurement, Technology Development, Human Resource Management, and Firm infrastructure. In all, the value chain is a chain that focuses on the activities. The value-chain concept has been extended beyond individual organizations. It can apply to whole supply chains and distribution networks. The delivery of a mix of products and services to the end customer will mobilize different economic factors, each managing its own value chain (12Manage, 2009). In essence, the difference between the Porter model and other models of supply chain or value chain management is that it focuses completely on each step along the way rather than on the big picture. By making it clear that value must be added at every step along the way, the Porter model increases efficiency in the value chain.





Conclusions
What is abundantly clear from this look at the National Health Service from the perspective of value chain management is that several value-adding activities could be added to NHS procedures and policies without significant increases in costs. Since the stakeholders in this organisation are both the customers and the financiers of the organisation, reducing costs through strategic implementation of value chain management will likely result in increased satisfaction across the board.




Appendix A
On-site Locations for Surveys:
Office locations
Leeds
Princes Exchange
Princes Square
Leeds
West Yorkshire
LS1 4HY
London
7th Floor
New King's Beam House
22 Upper Ground
London
SE1 9BW
Newcastle
Units 8 & 9 Hi Tech Village
Witney Way
Boldon Business Park
Newcastle
Tyne & Wear
NE35 9PE

Each office was surveyed during the week of April 11-17, 2010.

Questionnaire
1. At your most recent visit to an NHS office, how long did you wait beyond your scheduled appointment time?
2. What is your age?
3. Why did you visit the NHS office?
4. On a scale of 1 to 5, how would you rate the professionalism of the office staff?
5. On a scale of 1 to 5, how would you rate the friendliness of the office staff?
6. On a scale of 1 to 5, how would you rate the care you received from your health practitioner?
7. On a scale of 1 to 5, how happy are you with cost of the NHS?
8. On a scale of 1 to 5, how well do you think the NHS manages your health care?
9. On a scale of 1 to 5, how well do you think the NHS manages your money?
10. What, if any, changes would you like to see in NHS services?

APPENDIX B
INFORMED CONSENT AGREEMENT
You are invited to be in a research study examining value chain management in the National Health Service. The study is being conducted by Shanaya Williams as part of the requirements for a degree from

Background Information
The purpose of this study is to examine value chain management and provider perceptions in the NHS. The research will use the Delphi study method, which requires you to respond to questions about the topic. You will be part of a panel of experts, but you will interact only with the researcher. A full description of the Delphi study method and your role is explained separately.

Risks and Benefits of being in the Study
The study has no significant psychological or physical risks to the participants.

Confidentiality:
The records of this study will be kept private. In any sort of report we might publish, we will not include any information to identify you as a participant. In addition, your identity will be known only to the researcher and not to the other members of the expert panel. The final data compiled for the study will only be available in the aggregate and no individual person or organization will be named in the research. Research records will be stored securely and only the researcher will have access to the information. All records of the study will be destroyed after the data is analyzed and the expert panel reaches a consensus.

Voluntary Nature of the Study:

Participation in this study is voluntary. There is no compensation for participation. The NHS, however, may benefit from the findings of the study. If you agree to participate in the study, you can withdraw at any time prior to the completion of the study. The researcher anticipates the Delphi study will last approximately one month with correspondence several times a week via email.


Contacts and Questions:
The contact person for any questions regarding the study is Shanaya Williams

If you agree to participate in the study, you will be given a copy of this information to keep for your records.

Statement of Consent:

I have read the above information, and have asked any questions I had and received answers. I consent to participate in the study.


Signature:___________________________________ Date: __________________

References
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