Rather than distracting from the NHS efficiency challenge, the Health Bill could help achieve it, writes David Kerr.
We have a bloodied but unbowed Andrew Lansley in the dark blue corner and an ever consistent Stephen Dorrell in the light blue. The surrounding media is shouting “Fight! Fight!”, in the belief that the government’s NHS reforms are distracting the health service from dealing with the more pertinent problem of its unprecedented efficiency drive.
As always, scrape the surface and there is a significant degree of overlap between these pseudo-combatants. Mr Dorrell’s Commons health committee warns that efficiency savings are being driven by arbitrary short-termism without any intellectual underpinning or planning for the demographic challenge of increasing demand. The health secretary agrees that reform is needed to get the NHS on a sustainable future and repeats the mantra that service redesign can only be made by the doctors and nurses reshaping the NHS to suit patients. The missing element in both camps is failure to understand the concept of value-driven healthcare.
Value in any field must be defined around the customer, not the supplier. Value must also be measured by outputs, not inputs. Hence it is patient health results that matter, not the volume of services delivered. But results are achieved at some cost. Therefore, the proper objective is patient health outcomes relative to the total cost. Efficiency, then, is subsumed in the concept of value.
Since the publication of the NHS Atlas of Variation, and assuming that we would have to work to deliver quality care while funding remains flat, NHS chief knowledge officer Sir Muir Gray has been advocating the adoption of value to reduce unwarranted variation, patient harm, waste and inequities and inequalities in care
Increasing need and rising demand cannot be solved by more money, even if it were an option; neither can they be solved by reorganising the bureaucracy of healthcare, which achieves only change without transformation. Better value analysis and improvement will help organisations transform the paradigm from a focus on quality alone to a focus on value – the relationship between outcome and cost – for the decades of austerity ahead.
This seems a point of convergence between the various shades of blue and gives an agenda for sustainable reform that must be clinically delivered, the keystone of Lansley’s reforms.
The other seething cauldron of contention is anxiety in the Lords about the degree of embedded competition in the Health Bill. Yet the debate seems to have focused solely on the involvement of the private sector, ignoring that it has been integral to the NHS for over a decade. Lansley’s reforms will have a much more profound competitive effect through professional pride. The government’s commitment to publish clinical outcome data, so that citizens will be given insight into the performance of their local GPs and consultants, will provide a benchmarking opportunity. Comparisons will be drawn, delineating who does most good and least harm, whether as league tables or some more aggregated datasets. Patient choice will play a part, probably minor, in improving outcomes. The likeliest engine will be clinicians responding to their league table performance, doing all they can to gain promotion. These data-based disruptions have had very significant effects on the delivery of cancer care in Sweden and the Netherlands and improved outcomes.
This is where the bill is strong and clinicians should be seeking to understand its wider implications, which seem consistent with much of what is promulgated by the royal colleges on a quality centred NHS.
It seems possible to take the best of the bill, align it with a value-driven approach which engages frontline clinicians and seeks to minimise the unwarranted variation in outcomes that underlie so much of the current inequity in our NHS. As we prepare for relatively prolonged austerity, as the health committee comments, we need to take a more fundamental and sustainable effort to improve the efficiency rather than short term salami-slicing. The current bill could provide that capability if we change the culture of the service to embrace value, supported by tools like programmatic budgeting bridging primary and secondary care.
Finally, how should we judge whether the bill will lead to the “destruction of the NHS”, as some are arguing? Let’s look at the outcome from the perspective of the least assertive, poorest people. They cannot afford to travel 100 miles to get to a better service, so that choice is irrelevant. With very few exceptions, even the service commissioners and providers cannot tell them if the outcome or the quality of the service provided is better or worse than elsewhere.
That this is the case is a failure of professional duty. The bill offers the opportunity for clinicians – not just GPs – to put that right. Then all patients, wherever they live, can be assured that there is evidence that the service they are offered is of good quality and getting better each year without more money being switched from their child’s education or their housing support to pay for aspects of healthcare of low or negative value.