The Changing NHS

 

I've just finished working on a set of strategic scenarios that describe four 'edge of plausibility' possible futures for Health and Wellbeing systems. The work was commissioned by NHS North West and the detailed scenarios can be downloaded from their website.

The scenarios are titled; Corporate Cures, Community Cures, Shopping for Health and Living for Health. They have been developed, over the course of 12 months, involving nearly 400 NHS managers and clinicians, local authority senior officers and Councillors, MPs, 3^rd sector leaders, private healthcare leaders etc.

The rationale for the work, basically, is that NHS strategy making is sometimes too narrowly-focused and short-term in nature. Senior leaders (national and local) often assume that the NHS is sufficiently powerful to exert a dominant influence on its’ strategic operating environment. Unfortunately this assumption is proving less likely as a number of fundamental drivers bring stronger pressures to bear over the next 10-15 years. These drivers include:

1. Approaching the limits of the welfare state (expressed through a more solid public consensus about the ‘tax take ceiling’)
2. An explosion of new treatment and diagnostic possibilities
3. An ageing population; and
4. Increasingly sophisticated and demanding forms of consumerism

Building and using strategic scenarios is one way of helping leaders explore possible ways of coping/thriving in the light of these drivers. Hopefully NHS organisations can use the scenarios to help them improve the far-sightedness of their local strategies. Essentially by:

1) mentally immersing 'strategists' in the 4 future ‘worlds’ that depict, in differing ways, how English Healthcare and Wellbeing systems might evolve through to 2020; and

2) subsequently ‘returning to the present’ to discover a) new or sharper insights into what strategies might be appropriate over the next few years or b) new insights into how robust existing strategic intent is and what conditions might trigger it being re-thought. 

Anyway, we will see, as local Trusts and PCTs start to use them. 

nhs

strategic scenarios

I played Scrabble on Sunday evening with my wife and youngest daughter (aged 11). I came last, with a miserable 85 points. The boss had 136 and my daughter, much to her delight had 86.

Pondering my defeat I realise that my strategy (such as it was) was wholly flawed. At one point I was very pleased with myself as I had secretly formed the word ‘ Senate’. This word appealed to me quite a bit. I thought it would impress my daughter and being an ex-politics junkie it appealed to me also. So much so in fact that I was unconcerned that each letter only scored 1 point.

I held on to Senate for 3 rounds, hoping to play it, scoring no points each time. I didn't.  Eventually, with a heavy sigh, I laid down ‘ten’ whilst telling my fellow players that I had Senate, hoping to impress daughter in any case. It didn’t. In the meantime they both had been playing away, scoring points all over the board.

I think PCTs form and implement strategy a bit like I play Scrabble! The world (like the Scrabble board) is constantly changing but they are holding onto the words they hold dear (reducing health inequalities, strengthening the patient/GP relationship etc) in the hope that some time soon the board, sorry world, will allow them to play their hand. In the meantime all sorts of opportunities for scoring points are passing by before our eyes.

For example, last week I discovered some interesting facts about our changing world, including:

1. Alternative practitioners are now more numerous than GPs;
2. The UK Governemnt has committed to spend $1.3 billion on stem cell research in the next 10 years;
3. Cancer drug launches have risen from just under 1400 in 2000 to just over 2100 in 2007;
4. In 2005 the annual spend on Complementary and Alternative Medicines was estmated to be £4.5 billion and the market has grown by 50% in the last 10 years;
5. Estimates of UK gas reserves amounted to 412 billion cubic metres in 2006 14.1% lower than the estimate in 2005.

That’s a really interesting Scrabble board for a PCT to score some serious points on, don't you think?

nhs

strategy

primary care trust

Soon, nine Strategic Health Authorities will submit their visions for the future of the NHS as the formulation phase of the Darzi review process comes to a conclusion.

As outlined in an earlier post, eight clinician dominated and led review teams have been busy in each SHA area trying to articulate what various ‘service lines’ might look like in the future.

So far so good. But how does the process move on from here? That’s the tricky question. Will PCTs and Trusts embrace the recommendations made by the review teams and happily fuse these aspirations into their own commissioning plans / service strategies?

Somehow SHAs have to construct an approach to implementation that does justice to the work done by CPGs whilst also respecting the strategic independence of PCTs and Trusts.

I’ve been involved, to a limited extent, in the Darzi process in a couple of SHAs and I know that SHA strategists have been preoccupied with this question for a while now.

On the whole, despite supportive noises when necessary, most PCTs and Trusts have been content to sit on the sidelines and wait to see what ideas emerge. Meanwhile, about 200 clinicians in each SHA area have been getting all fired-up, hoping to see the changes they have asked for, come to fruition.

If implementation hits a brick wall then this clinical enthusisam may soon disipate and worse, leading clinicians might become even more disilusioned with the NHS (and managers in particuilar who will probably be seen as the problem).

There’s no easy answer of course, but in thinking a bit about this ‘adoption’ problem I’ve been reminded about Chris Huxham’s work on Collaborative Advantage. Professor Huxham identified a few traits that successful strategic partnerships exhibit. In very short summary they are:

1. Have clear, common aims
2. Build trust, start with easier issues 
3. Use collaborative leadership
4. Be very sensitive to power issues
5. Carefully construct membership structures
6. Learn together 

I was minded to think about stategic partnerships because this is , in effect, what SHAs will be trying to construct or at least encourage, between the local Darzi review groups/SHA, PCTs and provider organisations.

For me, reflecting on these successful partnership traits provides some strong clues about what an approporiate architecture for implementation of Darzi might look like at the local level – or at least it suggests some principles that all parties might agree to abide by whilst constructing such an architecture.

The seven principles that come to mind are:

1. Implementation of recommendations to be managed via PCT strategic commissioning processes wherever possible (excluding those recommendations that can be introduced easily by clinicians acting under their own steam or require formal public consultation or changes to nationally constructed policy);

2. No PCT or Trust to have to implement any recommendation that they don’t support. The choice is local;

3. SHA to act as a ‘Process Agent’ on behalf of all CPGs, seeking to get as many of their recommendations as possible 'into play';

4. All PCTs to agree which recommendations that are adopting, refining or ignoring with the SHA Process Agent - together with phasing year by year. Not everything can be done at once;

5. Each PCT to nominate an implementation lead(s) (probably but not necessarily the person who is responsible for developing and overseeing implementation of Commissioning strategy or the part of it that pertains most closely to each of the eight CPG areas of focus);

6. Each Implementation Lead to meet with the relevant CPG quarterly for no more than 1 hour to share progress on adopted recommendations and seek CPG member support to help remove ‘blockages’ to implementation - especially via informal clinician to clinician peer pressure. This update process to be orchestrated by SHA; and  

7. SHA to fund and orchestrate voluntary learning sets to encourage implementation leads and CPG Chairs to reflect and learn together about how best to implement recommendations.

What do you think? Do these seem like useful principles?

What other principles might SHAs wish to consider to encourage effective implmentation of local Darzi recommendations? 

nhs

Darzi

implementation

by Jeanne Hardacre - Guest Blogger

The paperback version of ‘The Fight of My Life’ has just been published. It is Barbara Clark’s personal story of how she won the right for all women in the UK to receive Herceptin to treat certain types of breast cancer.

I was invited to work with Barbara Clark last week in Westminster, where dozens of women with personal experience of breast cancer met with their MPs to press for further improvements to breast cancer services and treatment. These women all form part of an advocacy and campaigning network for a national breast cancer charity called Breakthrough.

I ran workshops aimed at helping the charity’s campaigners better understand commissioning and the health economics behind why and how some treatments are funded – and others are not. Of course, NICE was in the room. So were clinical representatives, academics and health economists. Senior politicians attended. Two large pharmaceutical companies joined in the discussions.

But there were no NHS managers to be seen. Two dozen PCT Directors of Commissioning had been approached, but no replies were received.

For those of us inside the NHS, there are, of course, lots of reasons why such events are not deemed a management priority. But from the outside, for many patients and health campaigners, NHS managers often seem a faceless set of bureaucrats working behind closed doors, who are difficult to engage in dialogue or discussion.

Health lobby and campaigning groups are raising their game. People who take on the NHS, NICE and the Courts – and win – know about influencing and will only get better at it. They have shown that their work can lead to policy change, with a direct impact on PCT decision-making.

There is lots to learn from the lobbyists. They are experts in their area of interest and are eager to engage with NHS organisations. But their frustration with the NHS ‘closed door’ can lead to more negative press for NHS managers. For PCT commissioners, it could well be an hour well spent to sit and talk to local health campaigners a couple of times a year. Keeping your ear to the ground can keep you ahead of the game.

And just think, how much more civilised and productive to be influenced over tea, biscuits and conversation than through headlines in The Sun followed by a court ruling.

nhs

herceptin

primary care trusts

Somewhat belatedly, I’ve just read the interim Darzi report, called ‘Our NHS, Our Future’, published earlier this month. The report recommends a range of actions intended to help the NHS move, during the next 10 years, from an improving system to a world class system.

The recommendations fall under 5 headings and these headings are suggested as the cornerstones of a new Vision for the NHS over the next 10 years. They are:

• A Fair NHS (improved access for disadvantaged groups, increased productivity, good outcomes for all etc)
• A Personalised NHS (more integrated care, more dignity, choice and personal control for patients, improved consumer responsiveness and access again!)
• An Effective NHS (faster adoption of new technologies / innovation, more integrated and evidence-based care pathways, a sharper focus on outcomes achieved etc)
• A Safe NHS (stronger regulatory powers to inspect and intervene, MRSA screening on admission, financial penalties and incentives linked to cleanliness of Wards etc)
• A Locally Accountable NHS (a clearer and more streamlined process for effecting big service changes, better leadership more often from clinicans and possibly a new/revised NHS consitution)

You can get hold of the interim report here (58 pages, pdf).

Stage two of the review, runs from now to June 08 and is more devolved in nature. Basically each Strategic Health Authority area has been instructed to set-up clinical review groups to make detailed recommendations about the future shape of eight areas of activity. These are:

• Maternity and newborn care
• Children’s health
• Planned care
• Mental health
• Staying healthy
• Long-term conditions
• Acute care
• End-of-life care

My guess is that given the membership and focus guidance given to the clinical review groups, the sum of all this work will add to or strengthen the recommendations associated with An Effective NHS in particular.

My initial reaction to the interim report is:

1. Overall, the report is clear and contains a number of very sensible recommendations, especially in relation to access to primary care services
2. The Locally Accountable NHS element is the weakest by far. There is nothing very exciting or visionary here with regard to the NHS’ relationship with local government or local people. Will the NHS ever be brave enough to seriously explore options and ideas in this regard?
3. The Personalised NHS element of the Vision, if pursued vigourously, is likely to conflict directly with elements associated with A Fair NHS and An Effective NHS. Under Blair I’d have expected the tensions to be resolved in favour of a more personalised NHS, but now I’d go the other way and suggest that ultimately the personalised element of the Vision will be ‘held in check’ in-order to allow the other two elements to take centre stage, especially the ideas associated with a Fair NHS. That’s what defines Brownism in my opinion.
4. Because exploration of funding options was ruled out before the review started, there are some big questions left untouched by the review process, especially in regard to how the extension of personal-budget holding might ‘play out’ over time.
5. The idea of a new/revised NHS constitution is potentially an important part of the process that could open-up a much needed national debate about the kind of health and wellbeing system that might benefit the country in future. Let's hope it does not, instead, turn into a self congratulatory 60^th birthday present.

What do you think about the interim report?

by Dr Jonathan Shapiro - Guest Blogger

Payment by Results (PbR) was introduced into the NHS to ensure that hospital activities (it was never about results, only activities!) could be linked to their costs. The idea was that hospitals would have to justify their actions to their paymasters (initially Primary Care Trusts, but ultimately Practice based Commissioning (PbC) clusters generally run by local GPs), so that the system could assure itself that expensive hospital services better matched the needs of the population, rather than the established tradition of hospital supply determining patient demand.

The system was predicated on having strong commissioners, not only at the strategic population based level (the intended role of the PCTs), but also at the more operational, individually focused level. Here clinicians (usually GPs) were intended to use their working knowledge both of individuals’ clinical needs and of local hospital providers’ strengths and foibles, to case manage their patients through the system effectively and efficiently.

So far, so sensible, but given that the notion was imposed by the Department of Health, and merely formalised the existing referral control mechanisms that had been in place since 1948, it begged the question of how to persuade the referring GPs to use the new tool, rather than ‘playing’ or simply ignoring it.

It was clearly not ‘owned’ by the GPs, and did not offer them any obvious personal or clinical advantage, but it did have the potential to introduce more control over hospital activity, itself potentially a powerful motivator.

Unfortunately, attempting to shift the locus of control over hospital activity to PbC has fuelled resistance from PCTs as well as from hospitals. A number of PCTs are resisting the introduction of effective PbC by diluting its key levers; either passively (‘PbC will work more effectively for you doctor, if we co-ordinate all your intentions’) or more actively (‘we can’t afford to let the GPs decide referral patterns, they’ll only do what’s in their own personal interests’), PCTs are finding ways of not letting go of the operational aspects of commissioning (what used to quaintly be called ‘purchasing’ in the early 1990s).

Consequently, PbC is simply not happening to any significant extent; you may argue with this point, but the reality is that PbR is still racing ahead, that hospitals are generating income by their activity, and that the intended brake on the system, PbC, is simply not strong enough or widely placed enough to slow down the express train of hospital activity.

The NHS has a tradition of muddling through (elegantly or otherwise), and in the absence of overt, clear controls, more opaque, Machiavellian, mechanisms will emerge, that are likely to reflect established patterns of power and patronage, rather than the real health needs of the population. If PbC is not clarified and strengthened quickly and radically, then the potential powerful, positive tension between PbR and PbC will be lost, to be replaced by a regression to an ineffective and unpopular mean that will help nobody, and further diminish the reputation of the public sector as a system that is capable of defining and managing its own destiny.

nhs

practice based commissioning

payment by results

I thought you might be interested in seeing this very comprehensive comparative study of healthcare performance across 6 countries – USA, Australia, Canada, Germany, New Zealand and United Kingdom. The study was done by The Commonwealth Fund – which is a highly regarded private research foundation in the States.

Drawn from 3 surveys that together cover the views of over 20,000 patients and physicians, the study has about 120 comparative ‘charts’ of data, covering lots of performance issues across 6 broad categories:

1. Quality of Care
2. Access to Care
3. Efficiency of Health System
4. Equity of Health System
5. Ability to Ensure Long, Healthy and Productive Lives
6. Views of the Health Care System: Physicians and Patients

You can see all 120 ‘charts’ here  From a quick scan, a few of the things that struck me about the UK system are:

1. We make much more use of nurses in routine care management of sicker adults (Chart 15)
2. We make much more use of multidisciplinary teams in primary care (Chart 18)
3. We score relatively poorly in measures concerning Patient Centered Care (Charts 39-44)
4. We are much more likely to set targets for clinical performance (Chart 46)
5. We can get much speedier access to a doctor than people living in the USA (Chart 56)
6. We have much better out of hours access than the USA (Chart 58)
7. If you have above average income then you are much less likely to have your blood pressure checked than someone with below average income, whilst the reverse is true in the States (Chart 105).

What ‘jumps out’ at you from flicking through these charts?

P. S. Many thanks to Paul Levy for drawing this data to my attention in his excellent blog - Running a Hospital

Steve

nhs

clinical performance

uk healthcare

Imagine you are a newly appointed CEO of a Primary Care Trust. It’s your first CEO post and you are keen to earn a deserved reputation as being innovative, credible and far sighted.

One of the most important issues on your new To-Do list is how best to engage with the Government’s flagship White Paper ‘Our Health Our Care Our Say’. The Government clearly wishes to encourage “more effective health and social care provision outside of hospitals”. More specifically, it wishes to encourage “more personalised care, services closer to people’s homes, better co-ordination with local Councils, increased patient choice and a focus on prevention as much as cure”.

You know that the Government will initiate a lot of activity itself (too much maybe) and your organisation will need to play it’s part in helping these central initiatives take hold ‘on the ground’ – but beyond this – you're really  keen to make your own mark by initiating local change projects that succeed in bringing about concrete and welcomed changes that are in keeping with the spirit of the White Paper.

You call together a few friends and brainstorm some ideas for getting started. Ideas include:

1. Ask an acute Trust CEO to lead a planning group to identify 3 great initiatives your organisation should support?
2. Bring 25 GPs and 25 acute specialists (paediatricians, geriatricians and general physicians) together for a day and ask them to come up with at least 10 ideas before they leave the room?
3. Hold back 2% of your organisation’s contracting income and only make it available to support new or redesigned services that are proposed by joint groups of clinicians and social care professionals where at least 50% of the membership comes from social care.
4. Host a quarterly 'Innovations Breakfast' – where you advertise for / invite private and not-for- profit companies with good ideas to come along and pitch ideas informally to you and senior managers and local GPs 
5. Find 10 ‘super-patients’, give them lots of support and ask them to redesign a key service (Super-patients = articulate, knowledgeable, motivated and time rich)
6. Invite the Local Authority to nominate someone to review all Commissioning decisions and insist that they block at least 3 proposals.

So, what's next? Tell me, how did you get to win that Award?

Steve

www.stevepashley.co.uk

nhsinnovationprimary care

How are PBCs and PCTs going to work together to identify, research, prioritise and then commission desirable changes to Services?

Presumably the strategic commissioning side of a PCT will want a clearly defined process, something that can not only be managed, but managed according to an annual timetable that allows future budgets to be (re)allocated according to the likely investment or savings that are thought to be associated with the proposed changes.

But how is this inherently disciplined and rational approach to be reconciled with:

a) the need to ensure that local GPs, through their PBC arrangements, have a strong voice in identifying such changes and prioritising them for action? and

b) the reality of all the in-year, small scale, more emergent type changes that tend to characterise our local health systems?

Perhaps on the first question, PBCs and PCTS will be able to agree to adhere to an annual timetable for all this to happen. Perhaps something like:

• Sept – Oct PBCs identify and prioritise desirable changes,
• Nov – Feb PCTs research feasibility of proposed changes and predict investment needed or savings possible,
• March – April PCTS procure new services or negotiate modified contracts with exisiting providers to secure changes to current services etc

But paradoxically, if they succeed in working in this way, what will happen to all the ideas that enthusiastic and capable people have outside of this disciplined process? Will someone who has a really good idea in March be willing to put in on hold until the ideas window opens for business the following September or will s/he just try and get on with it in any case, mustering whatever local resources are to hand, albeit without access to the additional support that a PCT might be able to offer? Is this what we want to see happen?

Perhaps PCTs and PBCs should also be seeking to create a parallel process that allows the quick allocation of small-scale funding and support for a range of in-year service change experiments, with those that appear most promising automatically getting near the top of the list for ‘official’ consideration in the following commissioning cycle? Or is this approach just likely to keep us too culturally rooted in our haphazard approach to managing change?

Steve

www.stevepashley.co.uk

A large part of the motivation to introduce more strategic commissioning, in addition to saving money, seems to be to encourage PCTs to focus much more directly on increasing the volume and/or quality of local primary care provider services through more explicit competition or contestability.

Whilst many senior managers can probably envisage how this might be done - for example by inviting various private practitioners, independent organisations and other NHS organisations to organise together and offer various services in competition with or instead of existing providers - I wonder how many are enthusiastic about this new core role for Commissioning?  

Is it more likely that most people will hold, as a default belief, the idea that incumbent public provision is always preferable - with other (new) providers being invited to offer services only as a last resort when services have already clearly failed? 

Are encumbent senior PCT managers, many of whom have worked in the 'old style' NHS for many years, able to create new identities for themselves and if yes, what kinds of support might they need to help them change? Presumably the selection process for new PCT roles will have an important part to play here. Candidates could be asked to explain how they envisage making this switch. But beyond this, can  'established managers' be helped to acquire new attitudes, learn new behaviours and let go of old ones that are now less approporiate or are they essentially 'on their own'? Also, if they can be supported, then how and by whom?

Steve

www.stevepashley.co.uk