Hope springs eternal

Published: 12/12/2001, Volume II2, No. 5835 Page 20 21

Optimism comes easily to Modernisation Agency director David Fillingham, but even he admits that the challenge of bringing the modernising ethos to every corner of the service is a daunting one Modernisation Agency director David Fillingham describes himself as a 'relentless optimist'. An attribute, he is honest enough to admit, colleagues sometimes find 'very tiring'.

It is just as well this amiable member of the NHS top team is feeling so upbeat. Anyone working at national level in the NHS will be constantly reminded of the huge effort needed to deliver targets and service reform.

Indeed, as Mr Fillingham talks to HSJ in a basement room at the Department of Health, the wall behind him is plastered with graphs showing waitinglist trends. Those for waits of six to 12 months spike ominously upwards.

But Mr Fillingham is in good heart. He says the NHS is 'genuinely at a tipping point', referring to the book by New Yorker journalist Malcolm Gladwell. The book treats change as a 'social epidemic' in which ideas spread rapidly like a virus. In Mr Gladwell's words, the 'tipping point', a phrase borrowed from epidemiology, 'is that moment in an epidemic when a virus reaches critical mass'.

Critics of the agency's efforts might smile wryly at its director deriving inspiration from a book which claims that 'ideas and behaviours move through a population... like a disease', but Mr Fillingham is too enthused to discuss ironies.

'Over the last two years, We have had a whole range of improvement projects - such as work on booked admissions or the cancer collaborative.What we need to do now is to join them up at the level of local health community so we get whole-system change.

'Where We have got good evidence of what works, it must be encouraged to happen everywhere, ' he continues, citing the recently launched ear nose and throat good-practice guide as an example.

'After two years of the action on ENT programme in 54 pilot sites, There is been some really good change. The challenge is now to get that to happen in every single ENT department.'

Mr Fillingham has just finished a series of top-level meetings which have clarified the agency's new strategy. He describes the new approach as 'something that moves modernisation into the mainstream, moves it from being a staff advisory function undertaken by redesign enthusiasts into part of the linemanagement function'.

'There is a very clear fit with the DoH's Managing for Excellence document (news, pages 4-5, 10 October), which said the job for managers and clinical leaders is to redesign the clinical process.

To do that, modernisation must not be an add-on - it must become the mainstream way in which you deliver access targets, a safe culture, quality improvement and so on.'

For all of his 'let's look on the bright side' cheeriness, Mr Fillingham is enough of a realist to know that, in terms of reform, the NHS still has the hardest part to do. What is more, he believes that most senior managers are now beginning to realise the scale of the task, too. This, he says, is thanks to the recent capacity planning process which required trusts to review what resources were needed to deliver on targets and service improvement.

'It is been a road to Damascus conversion. It is really brought home to people that if We are going to achieve transformation - even with the substantial growth [in funding] We are getting - we need to radically change the way the system works; we need to radically improve productivity.

'It is made people realise that you can't do what the NHS has traditionally done - which is limbo dance under the target at the end of the year. If you want to tackle six-month waiters, you have to redesign the system.'

The NHS, he says, needs 'a stepchange' in the speed with which it is delivering change.

Mr Fillingham believes this is possible because he has seen it happen in select areas - whether it is the 12 per cent reduction in the lengths of stay as a result of the action on orthopaedics programme or the 50 per cent reduction in the waiting time to see a GP delivered through the primary care collaborative.

To deliver this kind of change on a nationwide basis, the agency is adopting a new strategy for 200304. New programmes, such as the hospital improvement partnership and the emergency services collaborative, will continue to be piloted at national level before their learning is spread. However, arguably the key driver of change will be the strategic health authorities which are to be given over£50m to deliver the learning of the agency's earlier work locally (see news, pages 6-7).

Mr Fillingham claims the SHAs' new role will mean they are no longer simply seen as 'monitors or performance managers of the system, but champions for improvement at local level, who can provide help and support to meet targets'.

When NHS chief executive Nigel Crisp first described this new arrangement to HSJ (news, pages 4-5, 10 October), he characterised it as giving the agency a 'customer'. With modernisation staff set to be directly employed by SHAs, it seems that thinking has changed in the last few months.

'We found a deeper understanding of that [arrangement] - which is much more effective.We could have gone for a trading agency model - with its notion of supplier/customer relationship - but That is not what the agency's been asked to do. SHA chief executives have made the point strongly that they do not want a bureaucratic service-level agreement. It is a partnership.'

Mr Fillingham is taken aback by the suggestion that anyone should think that the agency's new strategy is somehow connected to a failure to embed modernisation at local level.

'I haven't heard anyone - trust chief executives, SHA chief executives, clinicians - say the agency approach has failed. They might say they want investment in modernisation locally. But if it was failing, they wouldn't be asking for that. People haven't said 'let's get rid of the agency and spend the money on the nurses instead'. They want to get their hands on it [the modernisation process] - That is real evidence that It is worked.'

Mr Fillingham hopes that the resources being given to SHAs will mean an end to debates over 'turf, territory or devolvement' and the dawning of a recognition that modernisation can and should be delivered by a mix of national and local programmes.

He rejects the idea that the funds should have been handed over to primary care trusts. 'There is no evidence that simply putting development funds directly into an organisation, as We have traditionally done, generates the level of change we need. It must be linked to best practice.'

While arguing for the ring-fencing of modernisation funds at national and regional level, he is 'not a great fan' of it for individual trusts. Instead he wants to see more health communities following the example of places like York, where acute trusts and PCTs have a joint director of modernisation.

'They haven't relied on us handing out cash, ' he points out.

'The NHS is going to get£5bn more next year. It is a question for individual trusts as to how much of that they are going to dedicate to modernisation and improvement.'

With SHAs concentrating on local modernisation priorities, the agency will be focusing on the big picture.Mr Fillingham says he wants the agency to do a lot more work on reconfiguring services, such as the separation of elective and emergency workloads, chronic-disease management and shifting the balance of care further towards PCT and practice level. Human resource issues such as how to free up clinician time, which will be tackled primarily through the changing workforce programme, and IT will also be priorities.

The agency's style of work will echo what SHAs are doing at local level in joining up individual modernisation programmes. It is an approach that Mr Fillingham describes as 'themes, not teams'.

He will be looking for agency staff to collaborate across programmes and develop greater coherence between them.

In terms of the actual number of staff employed, the agency will lose some to SHAs but gain more through the launch of new programmes.

The agency claims to be engaging around one in 10 NHS staff with its work. But how many of these are clinicians, particularly those working in the acute sector whose reservations about the NHS direction of travel, were revealed in the consultant contract vote?

Mr Fillingham admits there is work to be done, but argues that 'once you can convince clinicians that modernisation helps to provide a better service to patients - you're appealing to something quite deep seated [in doctors]'.

'There is evidence that we can build momentum and engage clinicians much more quickly than you might think. Even I've been surprised, for example, by how much enthusiasm clinicians are putting into the see-and-treat streaming system for accident and emergency departments.'

The former trust and health authority chief executive believes that the rejection of the consultant contract springs from deepseated concerns about professional status and autonomy. He argues that 'the more we get clinicians involved in modernisation', the less nervous they are likely to be about the kind of changes proposed in the rejected contract.

But engaging more clinicians does not mean automatically responding to the age-old cry to cut administrative costs, thereby freeing up resources for clinical work.

'It is often the admin systems that are letting down the clinical care. If you invest in the admin properly, it frees the clinicians up to do the work they should do.'