When I was asked by HSJ to reflect on what I have learnt about in my 12 years at the NHS Confederation, I thought I would specifically reflect on the constant process of reform including at least two which were billed as a once in a generation chance to change the NHS.
First, the policy making process is messy and this is true across time and different countries. While many of those involved are very talented and committed there are some persistent and repeating problems. The frequency of reform suggests impatience, unrealistic expectations about change and the urgent need of politicians to make a difference. It may be because far too much weight has been put on the ability of the centre to design incentives and policies that will elicit a precise response. The potential for adverse unintended consequences and the fact that policy may work differently in different areas are still too often ignored.
There has been an obsession with major structural and upheaval in spite of the well known fact that restructuring loses at least two years of progress. Except for trusts the half life of NHS bodies is now less than 5 years, this is particularly the case for intermediate tier organisations which are proclaimed as the answer before rapidly being condemned as too distant, too small or too big.
In policy there is much talk about structures, incentives and policies but much less about patient care or clinical practice. A lot is said about involving patients, putting the patient at the centre etc. but there are few policies to make this real. Policy makers lament problems with nutrition, pain control and providing compassionate care, but they do not address the root causes.
This reflects a fact common to health policy across many countries – that most of it is about trying to change clinician behaviour but without taking direct action about it or having any difficult conversations about what this means.
For example, the fact that GPs are going to being taking responsibility for rationing during the most difficult financial period the NHS has ever experienced is hidden way in the impact statement.
We have seen many cases where policy makers try to solve the problems created by the previous reform that were hobbled by poor design, inaccurate diagnosis or evidence-lite policy ideas. So there have been four attempts to design regulation and patient involvement machinery, eleven years of discussion of revalidation and a variety of approaches to try to make partnership work. Getting the policy right by being clear about what you are trying to achieve and using the evidence. If there isn’t any or it’s weak then allowing room for experiment and variation is a good idea. Unfortunately the words experiment and variation are rather unpopular with policy makers.
The ingrained habits of thinking (especially about hierarchy) added to the careful husbanding and acquisition of power by some parts of the system, the need to reduce risk and control innovations and the phenomenon of path dependency – in which current and future decisions are shaped and constrained by previous decisions - means that many apparently radical policies produce apparently very little change. This tempts policy makers back into the ‘the once in a generation’ reform or to try to create disruptive new forces such as ISTCs, PBR, GP commissioning and economic regulation.
Almost every change mechanism available to policy makers in the UK has been used in the last 20 years: including targets, improvement and capability building, attempts to shift power, top down management and markets. The lack of a coherent narrative about how the different reforms and the multiple, sometimes conflicting approach to managing change were supposed to fit together has been a real problem. Sometimes the story about what problem reforms are trying to solve is also unclear, a particular issue recently. This leaves a worrying impression of explanations being made up in a hurry after the event. But the truth is that this has often not been done well.
A key lesson is having some clear principles for reform, supporting evidence, a strong narrative about why it is needed and how it will work and that allowing evolution and experiment generally works better than ‘intelligent design’ and the one-off creation of policy.
So the conclusion I came to some time ago is that the best thing for health care organisations to do is to focus on doing the right thing. This is like the television programme Scrap Heap Challenge where contestants have to construct complex projects out of a variety of different parts that don’t fit together, were intended for another purpose and may be broken. Policies and incentives need bending, bolting together or otherwise adapting to make the local system work. But this is not an easy task. The definition of the right thing is often contested and the incentives and accountabilities are designed so that organisations, or departments have to look after their own interests. An optimal goal for a local system cannot be achieved by each of the participants trying to optimise their own position.
The chances of creating good local solutions is sometimes undermined by features of health care management that I have noticed in a number of countries – a very short time horizon and too little use of evidence. Ideas based on hunches and common sense are a poor guide to the management of complex processes. So we get attempts to shift care closer to home which cost more and require more visits than a one stop hospital appointment, demand management interventions that increase cost and demand, and a range of other faith based initiatives. This may be because while the importance of leadership has been recognised, the role of management has been neglected and is not sufficiently grounded in a theoretical and evidence base. The Modernisation Agency represented a brief flowering of a movement that, while it had faults, could have reversed this. But here we learnt that if those in power don’t understand something or it is slightly subversive it will be dismantled. This was a shameful episode.
The reason for all of these phenomena is rarely bad or incompetent people. Most of the people in policy or the service I have worked with have been smart and values driven. I think the difficulty is that many of the business models – our ways of organising services and some of the mental models that underpin how healthcare is commissioned and delivered are at least past their sell by date if not completely broken.
Hospitals are collections of activities that don’t fit very well together, they are often insufficiently specialist to deal with the most demanding problems but have too many specialist silos to deal well with patients with complex multiple conditions. They contain many mechanisms that stifle innovation and while they are too big to be agile they are often too small to create business model innovation. Successful organisations that have the financial and managerial resources to revolutionise their business model have the least incentive to do so. Models are often overly focused on institutional care and the need to sweat expensive assets.
Primary care has many strengths but is sub scale and without more federal working is unlikely to be able to respond to the changing demands of patients. It is insufficiently integrated with specialist care and often failing in more specialist areas such as children’s care. The division between primary and secondary care has its roots before 1900 and that between health and social care from at least the 1930s if not 1834 or 1601. Neither have any obvious logic. Mental health services face their own challenges of a lack of integration with primary care and a nagging concern that when users hold the budget they don’t chose what we provide.
I am concerned that if the current reforms represent the equivalent of telecoms deregulation then much of the NHS – public and private providers alike - are the GPO circa 1980. About to face a significant challenge which will require a fundamental rethinking of the business model, unbundling and rebundling of activities and a savage reduction in prices. I doubt the politicians are ready for how this may play out.
We do not yet know what new models will work or how best to organise services to respond to these challenges or the changes in the dependency ratio and workforce that the ageing of society will bring. Further mergers will take place but one key bit of learning is that this will at best delay the day of reckoning. Making a broken model bigger, does not make it less broken. Although everyone knows this they also know that their merger will be the one that bucks the trend.
The development of new models and solutions takes time and the interest in integration and co-ordination of care rather than organisations is surely where some of the answers are. Porter, Christensen and others who have been looking at these questions may have other parts of the puzzle. This is one of the most challenging question facing health services and the current reforms in this and many other countries doesn’t even go near it. Finding solutions and telling a much better story than governments have managed to tell is down to local leaders and particularly clinicians and I hope to spend more of my time in the field working with organisations that are at the leading edge of this thinking.
I have enjoyed my time at the Confederation and I have tried not to be cynical but there is one area where I have sometimes found it hard to stay objective. The huge scale of the changes and challenges facing the NHS require high quality leadership and management. The day to day workings of complex systems requires bureaucracy in the positive sense of the word. And yet, healthcare is the one area of the economy in which management is seen as a cost rather than a value adding activity.
I have become weary of countering the cheap lines and huge inaccuracies. It has been even more frustrating to hear secretaries of state talking, sometime contemptuously, about people who are their responsibility and upon whom, with others, they depend for the effectiveness of the system. They then wonder why it is hard to encourage clinicians to sign up. Defending management is not always easy and it sometimes doesn’t help itself, but as the King’s Fund’s recent report shows it has never been more important.
Perhaps we can weather the storm, maybe the pressure for change on our current business models will take more time to be felt, but we need all the time we can get - and it’s probably later than we think.