Sophia Christie on NHS crisis and opportunity

Even the Department of Health has begun talking up radical change for the first time since the Wanless report on long term health trends - the embodiment of public policy trying to adopt the maxim “crisis breeds opportunity”.

In 2002, Wanless noted that if the NHS only maintained the status quo, the trend of increasing and unaffordable costs would outstrip our tax base and ability to pay. He described three scenarios of “engagement”, and only if we achieved “fully engaged” would we have a publicly funded service, free at the point of delivery within 20 years. This required a shift in focus from a largely treatment and rescue service to one that increasingly prevented disease and enabled people to act as partners in care.

This analysis motivated a deal between the DH and the Treasury for huge investment to increase health funding to match others in Western Europe, in return for increasing attention to health improvement and chronic disease management. In effect, the Treasury was redefining a national “treatment” service into a service genuinely concerned with health.

The Treasury committed growth averaging 10 per cent per year over the past five years, the DH established targets to tackle inequalities and reduce mortality, but the vast majority of the money continued to go into the traditional areas of high spending hospitals. Raised expectations of access and new funding also drove concerted campaigns for new pharmacology. In short, the new money funded us doing more, faster of the type of rescue we had always done; it contributed little to innovation in service delivery or investment.

During 2006-07, the DH challenged the service to break even, with the focus on tackling long standing deficits in certain hospitals. This was counter to the Wanless recommendations, but made sense in the context of huge investment and rising public expectations. It offers our most recent experience of how the NHS responds under pressure. We delivered the required outcome, but not by innovation. The focus was control of existing costs, primarily freezing vacancies and training and slowing developments, not development of new styles of service. We delivered the immediate goal, but in many cases to the detriment of medium term quality and resilience.

Dominant theories of innovation describe a process where insights and creativity pop up in expected places in unplanned ways, often as a result of long term brooding, tinkering and serendipity. These legitimise the massive national investment in primary research, enabling academics to labour for years in ivory towers or laboratories. During the 1970s, successive US governments set out to cure cancer and spent millions of dollars attempting to reproduce the scientific project management approach that put men on the moon. But in 1986 researchers concluded that “35 years of intense effort focused largely on improving treatment must be judged a qualified failure”. It was an entirely parallel process of genetic investigation that yielded the next breakthrough in understanding the disease.

More recently “blue ocean strategy” has provided tools to enable an organisation to map the relevant value curve of its products or services, consider which factors to eliminate or create and thus sail happily into the wide blue ocean of new markets. The analysis of how the iPod, Cirque du Soleil or the Nintendo Wii left behind the competition makes great reading. It should stimulate a better understanding of the perceived value of our traditional approach to healthcare delivery, and where radical changes could be made to reduce costs and foster patient satisfaction. But it is one thing to have a new idea, quite another to systematise and adopt it across an organisation.

The DH promotion of “adding life to years and years to life” as the purpose of world class commissioning is highly aligned to the Wanless report, and sets out a new direction for the service concerned with health beyond only treatment. But the PCTs’ strategic plans showed that most failed to connect the 10 planned health outcomes, which required a focus on health improvement and service redesign, with the planned expenditure, which typically assumed continuing to spend at slightly increased volumes in the same historical patterns.

If we find it hard to imagine investing in different ways during periods of growth, it is not surprising we are reluctant in a period of economic downturn; even where we know failure to take the risk will end in collapse.

It is not enough for the DH to legislate for innovation or task SHAs with delivering it, and it is even less use to believe it will happen spontaneously. Innovation arises in organisations committed to a strategy that values the principles of invention: searching, experimenting, learning, doubting and taking risks.

In this model, strategy emerges and evolves over time. It is subversive and at odds with those invested in the current state of affairs. It is not a comfortable space for governments - or those tasked with ensuring the will of government - to occupy.