As future trends threaten to overwhelm the health service, the NHS must figure out how to deliver healthcare in a radically different way, says Michael Macdonnell
The case for radical change in the NHS grows daily. The scandal at Mid Staffordshire has been a watershed, highlighting care quality failures. The ongoing crisis in accident and emergency shows what little headroom providers have, and illustrates the dilemma posed by increasing demand coupled with fixed or declining resources.
‘It is striking how little we know about what citizens think the big problems are and what they want from the NHS’
And while cross-party commitment to maintaining health expenditure holds in principle, there is little doubt about the Treasury’s desire to encourage and bank underspends.
As if these challenges weren’t enough, future trends threaten to overwhelm the health service: a chronic disease epidemic, an ageing population and increasing costs of care.
So the NHS must figure out how to deliver healthcare differently. We need to change its physiology rather than its anatomy, to borrow Lord Darzi’s phrase.
Decision makers seem to appreciate this. NHS England has recently called for “ambitious and radical” service change, and the leadership at both the Care Quality Commission and Monitor have signalled a new direction designed to respond to the big trends in healthcare.
But, while there is consensus about the problems, there is much less clarity about the solutions.
Worse, strategic clarity is obscured by widely held myths. Like all myths, they contain truths about the world they seek to explain and the people who believe them. Consider five of the most prominent:
- By shifting services into the community we can address the NHS’s financial woes. This myth depends on the assumption that services provided in “the community” are cheaper. Yet since labour is the most important driver of costs, this would only be true if very different working practices accompanied the move. Achieving substantial savings also depends on decommissioning hospital services − something the NHS finds it nearly impossible to do.
- Integration would reduce demand for, and the costs of, services. The newest panacea; proponents of the integration myth tend to believe structural changes can keep people out of hospitals by creating incentives to treat more of them in primary care. But working models are scant (how many times have you read about Torbay?), tend to take decades to evolve (see: Kaiser Permanente) and are accompanied by other reforms such as capitated budgets.
- Investing in prevention would reduce demand for, and the costs of, services. This old shibboleth, still reverentially spoken of in meetings across the country, is true under two rare conditions. First, we need to know how to prevent disease − which is unfortunately not the case with the many important ones, such as chronic conditions where changing people’s lifestyles is still beyond our ken. Second, it is only true over the long term, since we still have to provide acute services while we wait for preventative efforts to kick in. And in the long term, as John Maynard Keynes said, we’re all dead.
- By getting older people out of hospitals we can reduce demand and costs. “Bed blockers” (a callous phrase) should be cared for at home so hospitals can close the wards whence they came. But how is increasing demand from an ageing population to be reconciled with the lack of investment in new homecare or step down capacity? How will we keep greater numbers in their homes if we can’t support them and their families?
- Centralising services would save money and improve quality at the same time. There’s no question this is sometimes true: stroke is the most well worn example. But for other services, like A&E and maternity, the evidence is ambiguous and the financial arguments are often stronger than ones about quality. This is a real problem when it comes to justifying reconfiguration.
Of course, each of these myths is only sometimes true, demonstrating that there are no simple solutions to the complex problem of how we should reshape the NHS. This is exactly why a serious strategy for the health services is so badly needed.
Today, NHS England announced its intention to formulate a new vision. To have lasting impact, this vision must satisfy three conditions. First, it needs to be bold and innovative, resisting the temptation to subscribe to any of the standard myths, at least as sole solutions. The NHS needs fresh thinking, which looks outward at best international practice and to new delivery models. A strategy, like any worth the name, must also make hard choices about where resources are best allocated, what kind of providers are needed, the shape of the modern workforce and much else besides.
Second, the vision must be radically collaborative. Not just with other bodies like the Department of Health, Monitor and the CQC − though this is important − but more widely. This is what makes the “big conversation” announced this week so important. It promises not only to engage the service and its stakeholders, but also patients and the public.
‘It is time to use our independence to build a vision about the transformation needed to put the health service on a sustainable path’
It is striking how little we know about what citizens think the big problems are and what they want from the NHS; typically we keep to comparatively safe questions about how “satisfied” they are. Real and meaningful engagement is likely to raise uncomfortable issues, which is why it’s worth doing.
Finally, the strategy has to be given time to work. Implementation must survive a potentially new secretary of state in two years’ time.
One of the happy consequences of the recent reforms has been to grant bodies such as NHS England a measure of autonomy. Now is the time to use this independence to build a broad-based vision about the transformation needed to put the health service on a sustainable path, and one that will deliver public confidence that it is fit for the future.
Michael Macdonnell is senior fellow at the Institute of Global Health Innovation, Imperial College London. Michael also begins as head of strategy at NHS England later this month.