If we can demonstrate that it is possible to provide access to diagnostics and elective surgery locally, it really would change the current public discourse
In 2012-13 Clayton Christensen’s book The Innovator’s Prescription was lauded in the NHS as holding the key to understanding how we might transform our healthcare system.
In his book, Christensen describes how his theory of spreading innovation applies to the healthcare industry.
‘The location of any healthcare service is subject to the ebb and flow of being centralised or decentralised’
He argues forcibly that, just like in other sectors, the location of any healthcare service is subject to the ebb and flow of being centralised or decentralised, depending on factors such as the underpinning capital outlay, critical mass of workforce expertise, and the limits of technological capability to standardise and commoditise the product.
These arguments are well understood in most other industries, and are applied rationally by investors at different phases of this ebb and flow innovation cycle.
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Understanding the concept
For some new services the customers will travel some distance, for others they expect the service to be available locally.
Christensen cites telecommunications and automotive as industries where customers experience and understand this concept well.
‘If we are to create a sustainable health service, I would argue that we have to turnaround public perception’
Even the healthcare sector can cite some examples, such as hyper acute stroke centres where lives are saved through the centralising “flow”, and home renal dialysis or chemotherapy as areas of decentralising the “ebb” where twenty years ago a patient would have to make a daily trip to a specialist centre can now be safely treated at home.
Yet it is interesting that the public discourse of health service change has focused more on the centralising force and the fear of losing local access, rather than the examples of how services could be provided closer to home.
If we are to create a sustainable health service, I would argue that we have to turnaround this public perception.
Embrace the ebb and flow
In this context, I am increasingly aware of how little creativity we have shown in dealing with the asset base which the NHS owns and deploys.
Too often we have been constrained by a centralising economic model for how and where services are located, rather than go with Christensen’s innovative ebb and flow. I can think of a number of examples of how services should and could be provided closer to home but are thwarted by current mechanisms and parochial thinking.
Among these numerous examples, I would cite the failure to exploit community pharmacies as a location for supporting chronic disease management in the community and post-hospital follow-up, preferring to stay with outpatient departments and traditional general practices, despite workforce and capacity constraints.
In other areas, the lack of universal systemic adoption of smart IT platforms to offer testing, patient information and consultation online has been left to the market, rather than being pulled into our mainstream NHS offer, where we continue to require patients to travel to our physical static locations.
‘Unlocking an alternative way of thinking on a more permanent basis would help the NHS meet its resource challenge’
Further examples include the scarcity of deployment of mobile diagnostic services such as endoscopy and colonoscopy where demands are growing and waiting times are in danger of lengthening.
It is even possible to utilise mobile operating theatres in local communities, either attached to smaller community hospitals or as standalone units on public car parks.
Yet therein lies the rub, because what is missing is the imagination of the NHS to think proactively about exploiting these opportunities as a means to maintain and improve local access.
Often these sorts of initiatives are utilised in distress, when higher pressure is placed on the system, yet rarely built into ongoing service configuration.
Unlocking this alternative way of thinking on a more permanent basis would also help the NHS to rationalise the costs of its sprawling estate and meet its resource challenge.
As providers and commissioners work hard to develop their plans for sustainable healthcare over the next 2-5 years, it would be worth thinking more about these strategies for improving local access while simultaneously reducing the cost base.
At present, the public expects centralisation and closures, yet if people are able to physically experience “hospital” services in their homes and neighbourhoods I am convinced they would have more confidence in our rhetoric about patient centred care, and ironically, our arguments about where some highly specialised services would be better centralised.
‘There is no time like the present to change the NHS one directional thinking’
Chronic disease and dementia management may well have featured strongly as the focal point for the current debate about out of hospital care, but if we could demonstrate that it is possible to provide access to diagnostics and elective surgery locally, that really would change the current public discourse.
We can all see in our daily lives that new technology allows us to experience commoditisation and localisation of goods and services. But can we show the mindsets in the NHS to adopt such approaches?
What is more, there is no time like the present, with all the difficulty the NHS faces, to change our one directional thinking.
Mike Farrar is former chief executive of the NHS Confederation
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