The government is in a tough spot at the moment, but it can be eased if it heeds the lessons of the NHS Plan era, argues House of Lords independent member Nigel Crisp.
The NHS was designed to meet the needs of the last century rather than this one. Like other developed countries, the UK has a health system largely organised to provide good care for one-off episodes and acute treatments – which is what was needed 30 years ago – but isn’t good at meeting the needs of the many people with long-term conditions who have now become the biggest users of the NHS and its greatest cost.
The balance between the two needs to shift, with the NHS becoming much more community based and learning how to utilise the skills and knowledge of patients, voluntary organisations, local authorities and businesses alongside those of the established heath professionals and institutions.
The health secretary has run into trouble with his proposals for making this change, so what can we learn from the last set of reforms?
They started very well. In 2000 then prime minister Tony Blair invited more than 100 people from all sectors and stakeholders to plan how to improve the NHS. The resulting NHS Plan was endorsed by many health leaders and launched with great enthusiasm and energy. This initial goodwill created momentum and helped enormously when subsequent reforms took the NHS out of its comfort zone.
This sort of “coalition of leadership” which brought together clinicians, managers and politicians to drive change was used many times throughout the NHS Plan period and was very helpful in buying in the many health stakeholders.
There is a great contrast with the current government’s approach of developing its plans in private and then, inevitably, finding itself on the defensive. All is not lost, however. It has already taken the difficult political decision to pause its legislation and acknowledged the tough financial position.
It could now convert the listening exercise into a joint planning one and invite others to help chart the way forward – and in so doing commit themselves to helping with implementation in the difficult times ahead.
The extra mile
The controversial policies of introducing more patient choice, greater competition and involving the private sector had an overall positive effect in accelerating improvement. Waiting times fell faster, for example, when these policies were introduced. However, what was equally apparent was that incentives can change behaviour but rarely motivate: many people changed reluctantly but were not inspired and motivated to go the extra mile.
It is important not to be over-reliant on economic approaches but rather to adopt a more nuanced approach which supports collaboration and integration as well as appropriate competition. Many people receive care from neighbours, carers and voluntary groups as well as family and professionals. How can competition alone – and access to European competition law – improve their care?
Targets, of course, were also a mixed story. At their best they were all about patients. When I became NHS chief executive, 4 per cent of people on the cardiac waiting list died before being treated. Waiting-time targets helped reduce this to zero. Targets helped tackle MRSA, reduce delays in thrombolysis and lower the suicide rate, for example, and benefited thousands.
The downside was there were initially too many targets; some were badly designed and had perverse effects but after 10 years enough has been learned about how to design and use them effectively as part of a wider approach to improvement.
I believe that some such mechanism is still needed in the NHS to maintain the gains made and ensure that falling standards don’t damage attempts to reform. A reduction in performance from 98 per cent to 90 per cent in the accident and emergency target sounds modest but means one million people will wait longer. It is patients that will suffer if targets are not replaced in some way.
There were also missed opportunities. The most obvious was the failure to create better partnerships with social care everywhere, although there were many good local examples.
As importantly, there was only limited progress in changing skill mix and restructuring the workforce. As technology improves there is great scope to change jobs and permit people with lesser training to take on new tasks safely. With staff costs being 60 per cent of the NHS budget, these approaches are more important than ever.
Public satisfaction with the NHS has almost doubled in a decade, fewer people opt for private treatment and waiting times have become practically a non-issue.
There is an excellent platform for further improvement – and for learning about what worked and what didn’t.
- Nigel Crisp’s latest book, 24 Hours to Save the NHS – the chief executive’s account of reform 2000 to 2006, will be published by OUP in September.
- Acute care
- Admissions and discharge
- Change management
- Clinical Leaders
- Conservative policy
- Department of Health and Social Care (DHSC)
- Emergency care
- Government/DH policy
- Health Bill 2011
- Health white paper
- Labour policy
- Mortality rates
- Patient experience
- Voluntary sector/third sector