When clinicians were asked to design their ideal service, common design rules quickly emerged. As Nigel Edwards and William Dunlop explain, these closely matched the views of patients
The medical profession has been adept at providing a diagnosis of what is wrong with the government's reform programme but not at prescribing treatment. Most commentary on the reforms has little to say about services to patients, their experience and the working lives of staff and how these would be improved.
Instead, they concentrate on structural, often abstract and high-level concepts of public policy in the hope that changes at this level will have an impact on patients and staff. This is like trying to revolutionise the car industry by choosing new showroom furniture.
The NHS Confederation and Joint Medical Consultative Council attempted to fill this gap by asking doctors about their vision of practising in a reformed NHS. We asked medical directors, chief executives, the British Medical Association and royal college presidents to identify doctors who had developed excellent services. Having found our targets, we then asked them to describe their current service and vision of the future.
Interviewees were bound by two main rules: the vision must be in line with the evidence on what patients actually want and no extra money can be assumed.
From the interviews, we identified a number of design rules and working assumptions that embodied the way these doctors and their teams had created their service. So rather than identifying the effect that reforms have on doctors - the usual approach - we asked: 'What changes are required to create the environment in which doctors can practise medicine in ways that best suit the needs of their patients?'
We were surprised at how quickly a common set of design rules emerged from the often inspiring stories we were told. All the doctors we interviewed had a very strong sense of personal values; apparent from what they talked about and the language they used. All this translates into a range of positive behaviours that makes their teams compassionate, motivated to change the systems around them, willing to lead or follow when necessary and optimistic about the future.
Caring for each other and maintaining a strong team ethos was also vital. The doctors we spoke to thought there were too many departures from these standards and such departures most typically resulted in a negative view of care in the NHS, a perception that was not challenged often enough.
Patient perspective
The first, and perhaps most obvious, design rule is to see the system from the patient's perspective.
There is much literature about what patients want and a review of this is available as part of the report. Our interviewees would often express their vision as the care doctors want for their loved ones; others more directly referred to the views and ideas of the patients they were dealing with. The basics of care and the other systems that patients encounter were seen as crucially important.
Even the highest quality clinical encounter can be quickly and irrevocably ruined by a poorly functioning system, poor administration, an unpleasant environment or a discourteous member of staff.
The doctors were clear that they want to work in a system as opposed to a disorganised and poorly co-ordinated set of services. Patients also want well co-ordinated care that works systematically.
Doctors want to be part of a system which allows them to spend as much time as possible treating patients rather than dealing with problems they feel get in the way.
Systems need to be purposefully designed with the involvement of clinicians, although most received no training in how to do this. Doctors wanted to see integrated systems which broke down the barrier between primary and secondary care. There were concerns that the barrier could become higher under the reforms. Systems also need to provide the tools for the job, such as appropriate diagnostic and other support, including direct access for primary care and the ability to refer to an appropriate doctor. They must anticipate care need rather than simply respond to it and it must be delivered in the most appropriate setting regardless of the current organisational structures or buildings.
A diagnosis and plan needs to be provided by the system as soon as is practical; the implication of this is that patients need to be seen rapidly by a senior decision-maker and that generalist skills are going to be increasingly important. Once in treatment, continuity is important for the patient and also for doctors, not just because of the need to track outcomes but also because doctors wish to be more than technical operatives in an industrialised process. Some of the current reforms were seen as fragmenting care and obstructing desirable outcomes.
A difficult issue is that systems require a degree of standardisation. Many doctors we interviewed had introduced measures to standardise elements of care, particularly to improve safety and adoption of best practice, but there is a concern that their over-use is undesirable. The ability to produce individualised care plans is seen as important. To resolve this, one informant suggested a straightforward answer: 'The purpose of medical training is to equip doctors to make a judgement about when to depart from the guidelines. They need to document it because accountability for these decisions is the best defence of autonomy.'
This requirement for data on which to base the system and to use to innovate and anticipate for change is another common feature. Like medicine, a reformed system needs to be based on continuous learning and the analysis of data. The design and operation of the sort of system that our interviewees want to create also requires much more information about performance, outcomes and patient experience.
Where doctors take responsibility for the collection of data the results are generally much better.
The relationship with patients in a reformed NHS will change. While national policy emphasises the importance of choice, our interviewees suggested a more subtle approach in which the relationship is negotiated to fit the patient's wishes. Spending more time with patients and being able to look at their complete needs was a common theme. This might mean having some patients seen by other professionals.
Both large and small systems require leadership and management. The closer the system is to the patient the more likely it is that it requires clinical leadership. Many, if not most, consultants and GPs have key leadership and management roles as part of their everyday practice.
Being valued
A striking finding was how much the doctors felt undervalued by their organisations, the NHS hierarchy and the Department of Health. The design rules for a reformed NHS need to consider how organisations make all their staff feel valued, give them appropriate control over their working life and pay attention to processes, symbols and small details that create the impression of an organisation that does not care.
Most had strong ideas about change management. Many of these are very different from the current approach. Goals and targets need to be communicated in language that talks about patients, the consequences of changes should be worked out in advance and more attention needs to be given to involving clinicians, the use of evidence and support for those who are leading change.
We also found that many doctors prefer empirical approaches, time to change and small-scale experimentation and so they were highly suspicious of big projects, jargon and central initiatives. This raises a question about how large-scale change can be achieved.
It is striking how far many of the levers needed for change are in the hands of frontline staff. Our work demonstrates that clinicians have the ability to create well-designed services that provide very high-quality and cost-effective care capable of outperforming any system designed in Whitehall.
But there are undoubtedly measures the government could take that would help. For example, this might include revisiting payment by results especially in relation to long-term conditions.
The general direction of creating a more autonomous organisation should continue with perhaps a statement of the values that underpin the NHS through, for example, a constitution.
There is one final question from our report. If the ability to change the system is largely in the hands of the people who run it, why have they not taken the opportunity?
There appears to be a fatalistic acceptance that change will be imposed from above and that attempts to make local improvements are likely to be unwelcome and unsuccessful. The solution is to strengthen the hands of clinical professionals working closely with managers.
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