The health service has changed but, in comparison to other services and sectors, not enough. There is plenty of room for improvement, says Stephen Dorrell.
It’s like climbing a mountain. When you need a rest, and a bit encouragement, you stop and look back and you are pleasantly surprised by the height you’ve gained. Then you start climbing again. So it is with anniversaries. It’s encouraging to recognize that public service reform has made progress over ten years. There is greater emphasis on outcomes; there is greater willingness to involve users of services in decisions which affect their lives; and there is greater willingness to be open-minded about who provides the services. But then we need start climbing again.
Public service reform is the heavy lifting of domestic politics. It is a process, not an event, and it is relentless. It is part of the process of continuous change which is at the heart of all successful societies. Public services are different from other forms of wealth creation because access to them is funded by taxpayers in order to ensure that it reflects our collective views about social justice. But in most other respects they are “just another industry”, and like all industries they face the need to change in order to respond to the changing needs of consumers. That is true of food retailing and car manufacturing. It is also true of healthcare – the public service in which I remain most closely involved nearly 22 years after I first became a junior health minister.
Many of the drivers of change within the healthcare sector would be familiar to managers across large swathes of the economy. Most obviously, new technologies continue to revolutionize the shape of care. New pharmaceutical products reduce costs is some areas and increase them in others – but in all cases they change the nature of care. As clinicians discover ways to treat conditions which were previously untreatable, the resources required to manage those conditions reduce, but increased resources are required to manage the consequences of increased life expectancy. Nor are the consequences of technology confined to the clinical sciences. Information and communication technologies open up opportunities for coordinating both data flows and clinical intervention which should be radically reshaping the way care services are structured.
Alongside challenges driven by technology come the challenges which are driven by wider social change. Patients whose parents were willing to accept “state charity” now expect to be treated as intelligent citizens who have a right to involved in decisions about their own care. And carers who willingly support friends and family members are more likely to have to reconcile their role as a carer with their own careers and obligations. It is these underlying long term challenges which are being crystallized by current economic pressures on the healthcare sector. For the first time in the history of the NHS, or any other advanced country healthcare system, a government is planning to meet rising demand for healthcare over a four year period out of a budget that is, effectively, fixed in real terms. It is this requirement for a four per cent efficiency gain, four years running, which the Health Select Committee refers to as the “Nicholson Challenge”.
None of this is unique to healthcare. Technology and social change have always been major drivers of economic change, and industries which have allowed the pace of change to slacken are always found out by recessions. The particular challenge in the public services arises because they are tax funded. Taxpayers expect those who impose their taxes to be accountable for the results with the consequence that decisions which in other sectors would be the accumulation of individual decisions require, in the context of a public service, a collective decision which becomes the stuff of political controversy.
This is the central challenge of healthcare reform. The long term drivers of change are well known and the short term imperative of the Nicholson Challenge is widely recognized. The question is whether there is the political will to make real change happen.
It is not a matter of management structures; the difficult questions concern the care model – the way care is delivered. Which services are best centralized? How many hospitals do we need? How do we achieve more integrated care? The good news is that there is a significant constituency for change. It is simply not true to characterize all care providers as “producers with a vested interest in the status quo”. The inadequacies of current structures are well understood by many who work in them. They are well aware that it is not only inefficient; too often it provides care which manages to be both expensive and poor quality. This is most obviously true of the care which is provided to people with multiple conditions for whom a high quality service requires care which fully integrates their needs as individuals, rather than passing them round the system from one specialist to another like a product down a production line.
This requirement for integrated services has, of course, always been there, but it has become progressively more important as the healthcare caseload increasingly reflects the needs of older people with multiple morbidities. This shift in emphasis towards the needs of older people is the result our increasingly ability to cure many of the conditions which affect younger people; furthermore changing technology allows more elderly patients to be managed in the community by generalists relying more on information technology both for patient data and for treatment support. Public health physicians have talked for decades about the opportunities to improve health and wellbeing through better prevention and earlier intervention. The idea is not new, but the priority which we should attach to it has changed as a result of these developments.
What does all this mean in practice? A clue lies in the report of the National Audit Office which concluded that 30 per cent of non-emergency hospital admissions are avoidable. They did not argue that the admissions were unnecessary, because by the time the patient is admitted their condition is acute and hospitalization is often the right response. But they did argue that they are avoidable if the system is enabled to take advantage of opportunities for early intervention and preventative action. If 30 per cent of non-emergency hospital admissions were avoided it would have profound implications for the shape of the hospital service – and the scale of resources that would be released to deliver improved community services.
Nor is this the only challenge facing the hospital service. Increasing emphasis on outcome measures poses some difficult questions for many hospital services. Local access is obviously important, but for a patient facing the need for hospitalization, surely the likely outcome is even more important? The recent reorganization of stroke care in London has been widely admired. It has produced dramatic improvements in life expectancy for stroke victims by insisting that the ambulance drives past the local hospital and takes patients to a specialist unit that is able to deliver high quality care. The result is 500 fewer deaths per annum in London, but also fewer local stroke services in London. Is it really that difficult to defend?
And all of this is without even touching on the difference between social care for the elderly, primary care for the elderly and community healthcare for the elderly, all managed by separate bureaucracies that are unable, and often unwilling, to talk to each other. Is it really true that the structures of community-based services which were established as a result of highly politicized negotiations in 1946 between Nye Bevan and the BMA are incapable of improvement?
I am often asked whether it is possible to deliver four per cent efficiency gain in healthcare four years running. I am an optimist – and not only because I prefer not to contemplate the consequences of failure. It is, for me, counter-intuitive to imagine that a system which is recognizably the same system as it was 60 years ago is ideally structured to deliver modern care to world which has seen unprecedented technological and social change. Every other sector of the economy has changed beyond recognition. Healthcare has, of course, changed too but not, I believe, enough. And I am not talking about management structures; I am talking about the patient experience.
This essay appears in The next ten years published today by Reform.