Traditional financial incentives have led to behaviours that serve the interests of organisations, not those of patients. It’s time to lead a revolution for change, and make healthcare a patient centered
The way in which we view our health service is quite naturally tempered by our own experiences.
We may think of the NHS with embittered and frustrated pride; we may associate it with images of tattered NHS logos flying defiantly above battered, once-noble NHS institutions (or somewhat snazzier PFI builds); we may feel rage at press reports on unscheduled Care Quality Commission inspections; or puzzlement at the complexity of the acronym-beset thing; or we may think of the NHS with quiet satisfaction that some of us (at least for a while) believe that we understand how aspects of it work, and believe that parts of it - probably our parts of it - are really very good indeed.
Our NHS is all of these things: it is an enormous institution on the one hand; and an amalgamation of little human acts that really matter on the other. It’s both, and it’s important that it is both, and yet it seems almost impossible to think about both at the same time. But we need to, and I’ll explain why I think this is so.
The problems on the institutional side are well-known. The NHS is really big - too big to be manageable in conventional ways. And it’s complicated, with echelons of policy and strategy posts; dizzying levels of authority shouting; and the ironic complications of centrally-applied and regulated decentralisation. The core of the problem is that, in spite of the enormous size of the NHS, demand exceeds supply.
With our booming population, increasing life expectancy, unhealthy lifestyles, rising medical costs and the inconvenient truth of a world economic downturn, demand exceeds supply by a whole lot. Anyone who thinks that £20bn savings over three years is the final answer is probably living in cloud-cuckoo land. It won’t be enough.
Many organisations are now facing significant problems making their cost improvement programmes deliver, and the QIPP agenda seems to equate on the ground - mostly, unfortunately - to even more unpalatable cost-saving measures than last time.
But the NHS is wondrous too, and in the midst of all of these challenges, many people receive simply amazing service. The dedication to service of all working in the NHS, and indeed around it, is both striking and inspiring. But at the same time I’m glad I don’t run a business of which Ipsos Mori reports 70 per cent customer satisfaction - that’s potentially a whole lot of dissatisfaction mixed up with the good stuff. And something has to be massively, massively wrong to make people dissatisfied. The results of the recent round of unscheduled CQC inspections were surely a wake-up call.
At a time when it is already clear that health organisations will need to reform completely - some to the point of non-existence - there are institutional obstacles in the name of competition and commissioning reform which prevent them from thinking in these terms.
The financial incentives of payment by results have fostered behaviours that are in the interests of organisations rather than of patients. Clinical commissioning groups may help, of course, and will be charged to do so, but they don’t all have the requisite scale or enthusiasm, they are not ready, there are too many, and clustering (nice term) and collaboration arrangements take time to implement.
The only way is to unite health communities and to ignite revolution - real change - in the name of the patient, which outweighs all the institutionalised stuff.
This is about bringing people together to think about what needs to be done, at local and regional levels, working across and between organisational boundaries. It is about helping us to think beyond what is currently unthinkable, and into the realm of the possible.
This is about making change happen. The level of change is revolutionary rather than evolutionary. It’s hard, really hard, and requires real leadership.
So how do you create a revolution?
- Get yourself a leader (that might be you)
- Get yourself a group to lead - CEOs and teams across heath communities, social services, commissioners, providers, mental health and ambulance trusts.
- Create a movement around stories - listen to patients in masses. This is not about patient satisfaction, or noble principles, this is about co-design. Make a vision for change which matters to all of us, and to you.
I don’t care about levels and labels of different organisations in health and social care. I don’t care who my commissioners are, who is in primary or secondary care, or who has which money. All I want is a safe and compassionate healing experience.
We know that technology is a huge enabler of both efficiency and improved health outcomes. The technology exists now. It works. Why aren’t you using it?
We know that the private sector can be transformational in delivery of public service outcomes. I know, how dare I say it, but the inconvenient truth is that it can, that such companies exist now and they are justly proud of their achievements elsewhere in the public service. I’m talking about the unthinkable here - outsourcing well beyond the realms of FM.
Get the hard, clinically-based evidence of the need to change. MCAP and Interqual are out there. Whatever the statistics locally, around 20 per cent of non-elective admissions are unnecessary. Up to 50 per cent of people in non-elective acute beds actually don’t need to be there.
Make a financial case which makes sense. There is evidence everywhere that safe, high quality care costs less. Putting the patients first is right at the heart of any approach to quality, will save money, improve health outcomes, and help you and your people think beyond the travails of working in one part only of one of the most remarkable institutions of state anywhere in the world.
You can bring people with you. The people that really matter, the over-worked, much criticised, highly pressured, change-weary, and utterly amazing clinicians, managers and staff, will pull with rather than push against you, as there is a vision both recognised in their heads and desired by their hearts. You’ve got them by the values.
Paralysis by institutional re-invention seems to hinder so many of the outstanding leaders who are there. I’d like us to think about putting the patient first as a means of bulldozing the sacred cows out of the way to create a patient centred revolution. Make change a mantra, don’t wait for a mandate, just create one. It’s your duty. Be militant.