The Changing NHS

Whilst I'm on a bit of an American healthcare riff I thought I'd share this with you. Kaiser Family Foundation (KFF) have supported the development of a side by side summary of the healthcare proposals of the 2008 Presidential candidates, Democrat and Republican.

You can quickly see the similarities and differences between Hillary Clinton, Barack Obama, John McCain and Mitt Romney for example.

The comparison tool is here.

 So now I know who is proposing to "provide individuals without employer-based coverage a tax deduction of up to $15,000 to make insurance more affordable". I should be popular at parties! 

usa healthcare

healthcare policies

I ran another 24 hour workshop last week as part of the work I’m involved in to help a bunch of NHS managers and doctors sketch out a set of ‘edge of plausibility’ scenarios for health and wellbeing systems in 2020.

I’ve talked before about this work and especially about the difficulty people often have in contemplating futures that differ from the logic of current strategic intent. That’s still the case, although the process is now better and people consequently get more help to ‘let go’ of the present’.

The starting point for constructing the scenario set is consideration of 28 ‘high impact / high uncertainty questions’ and I thought, in no particular order, you might like to see what they are:

1. What might the first 10 years of our lives be like?

2. What might the last 10 years of our lives be like?

3. What impact might new medical technologies have?

4. What impact might genetics and new pharmacological developments have?

5. What might happen if individuals became real consumers of healthcare and wellbeing services?

6. How might healthcare and wellbeing systems be paid for?

7. What might a prediction, prevention and promotion system look like?

8. How might competition and collaboration co-exist?

9. What form might leadership of healthcare and wellbeing systems take?

10. How might lower levels of social cohesion impact on healthcare and wellbeing systems?

11. How might information technology impact on healthcare and wellbeing systems?

12. What might be the ‘psychological contract’ between employers and their workforce?

13. Where might entrepreneurialism lead?

14. How might a more informed and knowledgeable society change healthcare and wellbeing systems?

15. What might happen if the search for better outcomes really drove behaviour?

16. What might happen to the balance between care and cure?

17. What might a truly efficient health and wellbeing system look like?

18. What might be different if all local stakeholders were facing ‘in the same direction’?

19. What might the future landscape for healthcare services look like?

20. How might climate change impact on healthcare and wellbeing systems?

21. What impact might the increasing globalisation of economics have?

22. What might be different if the priority was to reduce health inequalities?

23. What might be different if the priority were to maximise everyone’s health potential?

24. How might accelerating population migration impact on healthcare and wellbeing systems?

25. What key new roles might emerge?

26. What might be the impact of new diseases?

27. How might politics exert more of an influence on the nature of healthcare and wellbeing systems?

28. How might strategic commissioning evolve?

What you make of these questions? Do these seem like the best big questions to you? Am I missing some?

nhs

scenarios

healthcare

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?

I had an interesting chat with a clinical psychologist the other day. We were talking about what a really successful NHS might look like in 10 years time. A lot of the conversation was about the need for people to accept more responsibility for their own health status in general and for the NHS to become much better at helping people make specific changes in relation to diet, exercise, drinking, other risky behaviours etc.

In passing the clinical psychologist said…” the trouble is the NHS has 1.3 million staff but only about 25,000 know how to change people’s behaviour.”

Do you think this is anywhere near true? And, if it is, how many of the 1.3 million ought to be competent at helping people to change their behaviour?

• All GPs, District Nurses and Health Visitors – well yes, obviously
• What about all the therapists – again almost certainly
• Well what about Ward based nurses - again yes
• Doctors? Certainly all the medics. What about surgeons, do they need to know how to change people’s behaviour? - quite possibly
• Managers? - steady on their old chap. Next thing you know managers will be dispensing drugs and ordering tests!

The model I’m most familiar with is called The Stage of Change Model. At its’ simplest, this model suggests that people could be at one of five stages in relation to changing their behaviour (and then hopefully, their attitudes).

1. Pre-contemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance

The basic idea is to first identify what stage a person is at in relation to making an important change in behaviour and then to help them move through to the next stage. Each stage requires particular support and intervention. Eventually, hopefully, they'll make it through to and remain in the final stage. There’s a bit more to it and you can learn more about this model here – but that’s the gist of it.

Hopefully, whatever the number is, over the next few years many more people will get much better at helping people change their behavior. Otherwise I guess we could ask a Government to ban every unhealthy behaviour we can think of. That might just do it!

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behavior change

change model

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.

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practice based commissioning

payment by results

The NHS remains overwhelmingly a treat and care system, despite its’ long held espoused intent to shift significantly toward a prevent and promote system. Partly this lack of progress might be because national and local politicians exert pressure for a focus on issues that are most familiar / of most concern to the electorate (largely treat and care related issues). It also might be partly because NHS managers don’t feel terribly confident about the efficacy of the actions that can be taken regarding prevention and especially promotion. It's all a bit like trying to get this tractor to the top of the sandhill. But for me, there’s also something else here – something to do with the NHS’s inability to really believe in what its’ espousing.

What would be different if the NHS became really serious about becoming a prevent and promote system?

Well, for starters, local leaders, especially in PCTs, would clearly and effectively communicate (and re-state on a daily basis), the need for managers and clinicians to pay much more attention to preventing ill health and promoting positive health and – here’s the difficult bit - to consequently pay much less attention therefore to treatment and care. This is ground zero. Without this re-occurring message, clearly stated, and a significant reallocation of time and mental energy, the NHS has no chance at all of escaping the ‘stickiness’ of the status quo.

It also needs local leaders to be able to translate this strategic intent (to become more focused on prevention and promotion activities) into concrete, practical and measureable actions that make sense to staff. Examples might be:

• Measured over the course of one year, the executive team will spend at least 35% of its regular weekly meeting time discussing, sanctioning and reviewing prevention and promotion related activity
• We will spend 2% more of our revenue budget, year on year, for the next 5 years on activities that are genuinely classified, by researchers in the local university, as prevention and health promotion activities
• We will, in partnership with the local authority, successfully introduce a single health information system that’s focused on recording the health and social care needs of the 500 families agreed, by both parties, to be ‘most in need’ within our local geography
• We will help local councillors and senior local authority officers to better understand the relationship between improving health and local policy making. To this end, within 2 years, local councillors as a group will self-report ‘the health agenda’ as something that is absolutely central to their own organisation’s purpose and something that is amenable to significant impact as a result of more health conscious local policy making.

In addition to these largely process related measures, an NHS that really is serious about focusing on prevention and promotion will have successfully shifted its own culture in two important respects. First, at a local level, we’d have an NHS that was full of people positively enthusiastic about seeking out people with poor health, addressing both the causes as well as the affects and learning lessons for the future. Second, at a national level, we’d have an NHS that was confident enough to collectively seek to exert (or encourage others to exert) significant and concerted pressure on Governments to address the most important health issues in a serious, connected and sustained way.

Too often at the moment the NHS seems largely content to only deal with whatever is put in front of it. But maybe that’s largely what you’d expect from a treat and care system?

nhspreventionhealth promotion

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

It's 4am on a Sunday morning and my head is spinning around with questions. Usually I just 'bat these around' whilst trying not to wake my wife, but this morning she's woken up and kicked me out of bed, so here I am. 

Why should I suffer alone!

1. If Blairism was about the realisation that the vast majority of British people are now middle class why should Brownism be any different?
2. It's not a middle class elite it's a middle class majority
3. Is it possible to have a health and wellbeing system that operates in ways that delights the majority and  protects the most vulnerable or disempowered members of society from the consequences of making poor decisions? 
4. Why is the NHS (by which I mean the majority of people employed by it) so fearful of consumerism?
5. Defensive producer interests are so often strongly aligned with arguments about needing to sustain a system designed to protect the most vulnerable in society. Will the most vulnerable and needy ever become the most powerful voices for radical change? If this happened then 'the genie really would be out of the bottle' 
6. We don't have a National Food Service so why do we need a National Health Service?

What am I talking about. I'm as middle class as they come and I don't even know my Cholesterol count or how to find it out!

Steve

nhs

change management

By coincidence, the New Statesman (a left leaning political journal) and Pfizer have just published the transcript of an interesting round-table discussion on the theme 'Can We Afford Medical Progress?'

Amongst other things, participants touch on:

• Can the NHS get better at adopting new technologies and drugs?
• Might pharmaceutical companies get more efficient by stopping the more unpromising drug programmes at an earlier stage?
• Whether the research pipeline needs to be refocused on addressing diseases that are likely to be more of a priority for society?
• Whether expenditure on the NHS can ever be seen as an investment  (like it is in Education) rather than a cost drain on the public purse?

Reading the discussion has set me thinking about how we really need to get better at helping  senior clinicians and managers in Trusts and PCTs gain a better appreciation of 'whats in the pipeline' and how these developments might influence the need to signifiacntly reshape services and roles. At the moment it feels to me that all this 'stuff' is happeniing in a parallel universe.  
 
A packet of asprins is on offer to anyone with a good idea!

Steve

nhs

pharmacology

technology

innovation

The NHS currently has 65 Foundation Trusts (FTs), employing approximately 220,000 staff. The idea is that these organisations, usually secondary care acute providers, freer from central control, will be both more effective and more active 'players' in helping to reshape the NHS provider landscape.

In an earlier post I talked about 4 strategic mindsets that FTs might hold. I’ve now 'polished this up' a bit and so I'm re-posting, as I think the mindsets, as described in this post, are more accurate.

The 4 mindsets are not all mutually exclusive but I wonder how well a FT can pursue more than one of these successfully at the same time. They are as follows:

1. Compete with ‘Look Alikes’
This mindset is often the most prominent one amongst managers at the outset of a Trusts’ journey to FT status. Usually, by the time the application process is complete, views have migrated to number 2 below, but some still retain this mindset and many may well return to it once they feel more confident. Here, the FT continues to seek to provide a comprehensive range of local services whilst also growing quickly by winning market share from neighbouring acute trusts that are believed to be in a weaker position in certain service lines. To do this well it needs to act quickly, before other Trusts get their act together and before PCTs become better at ‘market’ management.

2. Refocus on Core Business
This is the most common mindset to be adopted once a Trust becomes a FT. Driven, in large part, by fear of becoming financially unstable and thereby falling foul of Monitor, the independent regulator, this type of FT quickly decides to stop pretending that it can be good at everything and seeks to re-focus on what it is good at or can produce a surplus from. To do this well it needs to be single minded in seeking to earn a deserved reputation for providing certain services that might, ultimately, lead to higher volumes of core business, possibly via brand extension into other FT and private sector facilities.

3. Be Entrepreneurial
Here the new FT wants to get off the mark quickly by enthusiastically seeking out large numbers of opportunities for creating or contributing to new services and/or niche businesses, often beyond its current portfolio of activity. ‘Let a thousand flowers bloom’ might be the motto. Managers within this kind of FT operate within an earned autonomy regime and, even if only a few ideas are ultimately fully supported, this should quickly give the Trust an interest in several new ‘businesses’. Some of these can then be sold off as going concerns, raising significant income. Ultimately the Trust will probably become a holding company with several operating divisions or it may merge with other FTs.

4. Dive Deeper
Here, the FT believes it can use its resources and talents to help the local health and social care economy become more coherent and efficient. Accordingly, it seeks to exert more influence within the local primary and social care sectors. In its most developed form this mindset suggests a high degree of vertical integration, with groups of GP practices contractually aligned to the FT and community service staff and possibly some local authority staff employed. Ultimately this mindset suggests an FT will have an interest in investing in new sub-acute community-based services, especially those that serve older people with complex co-morbidities, perhaps in partnership with new private sector providers.

Do you recognise these mindsets? Are there others around?  To what extent do you think a FT successfully pursue more than one of these mindsets at the same time?

Steve  

nhs

hospitals

strategy