Future NHS funding: kneejerk populism ≠ enduring strategy

This is an expanded version of a comment written in reply to an article in the Guardian of 19 June 2018 (http://tinyurl.com/yd5wcnp5).

Polly Toynbee is precisely right; not enough extra money, with dubious provenance, applied in a populist manner without any careful planning, will result in little change.

In system terms, the whole supply chain needs to be reviewed, and the incentives carefully applied to ensure any impact at all. There are four main stages in this supply chain, and they all need to be considered:

1. Demand is rising because of our increasing healthcare needs as we age and have to manage increasing numbers of co-morbidities (think of someone with diabetes, high blood pressure and chronic leukaemia who is (perhaps not surprisingly) also depressed, for instance), but there are also rising ‘wants’ as our expectations keep rising, often because of irresponsible political promises of ‘more and better’ services. These haven’t ever been addressed, with the result that health services are seen as a ‘free good’ used as we might use our cold water tap. As one might expect from politicians who depend on re-election to continue in office, there have rarely been any serious attempts to manage (for which read ‘contain’) demand, and the new rhetoric is no different, continuing to use the same language as before.

Screen Shot 2018-06-19 at 08.56.342. Primary care, in the shape of general practice, is the Unique Selling Point (USP) of the NHS, managing the vast proportion of most people’s diseases (and dis-ease), but perhaps more importantly, choreographing patients’ journeys through the intricacies of institutional care to ensure that their care is appropriate in human as well as clinical terms, and preventing duplication of investigation and intervention. GPs, who are seeing little recognition of, or encouragement to treat people (and not just physical symptoms), are currently leaving practice in their droves, and recruitment is becoming ever more difficult, as their sense of overwork and under-appreciation grows. Yet general practice is barely mentioned in the rhetoric about ‘increased performance’ and ‘reduced waiting lists’.

3. Acute hospitals continue to do what acute hospitals do, which is to treat diseases, not people. Their perspective on real life, and their ability NOT to intervene are both conspicuous by their absence; surgeons measure themselves by their operations, physicians’ fingers itch to treat, and the current markers of success generally drive activity ever-upwards, rather than measuring patient outcomes and (rarely sought on an individual basis) genuine user satisfaction. Giving new money to the acute sector will merely produce more of the same, yet that is precisely what seems to be intended…. and don’t get me started on the way that mental illness is considered as an entirely separate part of the NHS…

4. As patients become medically fit for discharge from hospital, many will continue to need some sort of social support, whether in the form of occasional visits from carers, or intensive support of their long term conditions (see co-morbidities, above), and not everyone can afford to pay for it themselves. Yet funding for social care has dramatically dropped over recent years, and the drive to balance the public expenditure books as quickly as possible means that these services are rapidly disappearing, without any apparent, viable alternatives appearing. The new initiative overtly turns a blind eye to this, expecting the health system to improve without any reference to this end of the supply chain.

Only if all these factors are taken into account can we have any chance of improving the health service, but we are not seeing any evidence whatsoever of a strategic approach to public spending in general, and health services in particular. Sure, more money is required, but more thought too, and an analysis driven by logic, empathy and long term thinking, rather than tomorrow’s headline in the Daily Mail.

The NHS in Lewisham: a victory for natural justice?

Vox PopuliLewisham Healthcare NHS Trust is a mid-sized organisation (turnover in 2010/11 was about £220m) that includes acute hospital and local community services.  It produced a surplus of about £1m in that year, having overcome recurrent deficits to achieve sustained surpluses over a relatively short time http://tinyurl.com/p9yvq93. It epitomizes the successful integrated NHS organization: financially stable, well liked by its users, and expecting to achieve Foundation Trust status until external events overtook it.

Its misfortune was to be sited close to the vast, failing South London Trust, which was put into administration in July 2012, with losses predicted to exceed £60m annually. In early 2013, the Secretary of State for Health Jeremy Hunt agreed with the administrator (Matthew Kershaw, from McKinsey) that the Lewisham Trust should merge with part of the dissolved South London Trust, with the downgrading of its University Hospital and the closure of its A&E Department http://tinyurl.com/oqn57lu.

This decision was challenged legally, and a judgement has overturned it http://tinyurl.com/pn27366 , although the Government is considering an appeal.

The judgment is important, not only for the Trust, but for the messages it sends out about the NHS, its drivers, controls, and self determination. There are at least three main points:

1  Externally driven NHS Trusts may as well be directly managed units

Over the past few years, the Lewisham Trust has shown the value and impact of self determination.  It successfully overcame its financial problems, absorbed community services, and built up a reputation as a thriving, effective organization, a significant ‘player’ in its local health economy. If these achievements are discounted, and its future determined by Whitehall, then staff (clinical and otherwise), users, and local organisations such as the Council, will all see themselves as entirely disenfranchised; how that perception is incorporated into a political agenda of ‘localism’ poses an interesting challenge.

2  Expectations raised and dashed are worse than no expectations at all

The current NHS reforms in England are based on a few simple foundations. The first acknowledges clinicians’ impact on the processes and outcomes of health care by involving them in driving these; doing so produces a degree of ‘buy in’ and responsibility amongst clinicians, and develops a new and appropriate line of clinical accountability. The second is an extension of this: as general practitioners instigate most NHS spending through their prescribing and their referrals, they should be involved in the strategic spending decisions as well as the operational ones. This allows more rational and coherent planning, with the ‘ownership’ needed for responsible, accountable working.

The Clinical Commissioning Groups (CCGs) currently finding their feet are the organisational embodiment of these simple foundations, with responsibility for around two thirds of the entire NHS budget of £108 billion, and some influence over the rest. The key tasks they face in their first year are not only to learn to walk (by getting themselves established, and their members engaged), but also to run (by producing considerable savings, and starting to plan their future, more strategic activities).

These tasks would be hard enough, but if the application of their new found skills were to be immediately overturned by Governmental dictat, then all the efforts that have been applied in overcoming GPs’ natural cynicism about involvement in commissioning will have been wasted; the noise of the ensuing disenchantment is likely to drown out for many years any attempts to achieve the same aims.

3  ‘Vox populi’ is not democracy

If the lay press is to be believed http://tinyurl.com/qx2xvve , the recent judgement seems to have been driven entirely by local activists trying to save their hospital. Whilst local support is helpful, it would be bad for any part of the welfare state if national policy was only the result of local pressure.

The NHS was designed to be both egalitarian and utilitarian, and as such, ‘broad brush’ strategy needs to be driven in a systematic, rigorous fashion. The recent Health and Social Care Act http://tinyurl.com/pj3j4v3 suggests that decisions about service configuration should be made by CCGs working together, with appropriate input from NHS England, under the aegis of overarching Government policy. Whilst patients and the public are obviously important protagonists, it would be a dangerous precedent if major reconfigurations were seen to be driven by public demonstrations.

Finally, it is worth considering how the reconfiguration exercise might have been handled better. Once the South London Trust had been disbanded, it should have been the CCGs working with NHS England who made the strategic ‘macro’ decisions about the overall shape of service delivery; the operational details, the ‘micro’ decisions, should (in theory at least) been left to the new delivery organisations to define themselves, in response to an outline brief (‘what is required’) rather than any overprescriptive, micromanaged approach (‘this is how we want you to do it’). Broad brush strategic management needs the high level players to be involved, but preferably not the politicians; operational delivery is best left to those who know how to do it.

This piece is based on an article published in The Conversation on 1 August 2013, which can be read at http://tinyurl.com/p6wom8j

Referrals by numbers: consultant league tables

table - June1What are the criteria you apply when you refer a patient for a surgical opinion and possible operation? How much of your decision is based on evidence, and how much on ‘gut feeling’?

The likelihood is that, as an informed professional, you base your consultant referral decisions on judgments that include a bit of both: some quantifiable data (e.g. waiting times, lengths of stay, readmission rates etc) with a number of ‘softer’ measures about the consultants concerned (such as how nice they are to patients, whether you get on with them, your kids go to the same school, and so on) and about the patients being referred (will they get on with the surgeon, how far will the relatives need to drive to visit, whom do patients actually want to see, and suchlike).

What you are unlikely to do is base your decision on any one of these factors on their own; the social skills of a doctor are important in diagnosing and treating patients effectively, but are not enough to predict good results. Similarly, any single technical measure is too reductive to be of much use; it is too linear in the same way that the price of a computer is too linear. In the case of the latter, I need to know more about the size, computing power, display, operating system, and software (to mention but five factors) before I can make any kind of informed decision.

Thus, I would suggest that new ‘league tables’ such as the National Vascular Registry are just as unhelpful on their own, because missing out on most of those other markers of complexity makes them impossible to interpret on their own: their bald figures give little if any sense of context. If Prof X in London has a higher mortality rate in his surgery than Miss Y in Leeds, is that because he is a worse surgeon, takes on more risky patients, works with less able junior doctors, or has recently had a messy divorce? Is she a better surgeon, or does she only do a few simpler procedures that are intrinsically less dangerous? On their own, the figures don’t tell us any of this.

And even if the figures do reflect the quality of the surgery itself, it is worth remembering that surgical statistics, like all statistics, deal in probabilities, not in certainties; using Miss Y’s figures tells us what happened in the past, but her future results can only be inferred from them. For that reason, one needs to challenge how much weight to give them against issues such as distance of treatment from home, hospital ‘hotel’ facilities, and other extrinsic factors that may influence the whole patient experience, to say nothing of the intrinsic factors such as age, gender, social situation and co-morbidities.

As professionals who spend their whole working careers dealing in ‘soft’ variables like these, GPs are better placed than most to make the appropriate interpretations; patients, whose experience is limited to events in their individual lives, and perhaps those of a few family and friends, are less well prepared. That being the case, how useful is it to publish such information in the public domain, politically incorrect as it may be to suggest such a thing? Publishing the surgeons’ ratings in the Daily Mail is probably the least desirable outcome of all.

In other areas of consumption where consumers are not experts, there are often guides produced to help them make more informed choices; thus for example, the Consumer Association will list the criteria they use in assessing the quality of any particular product, and even make explicit the weightings they give each one; they will (to mixed effect, it has to be said) try to contextualise their findings, so that any reasonably bright but uninformed reader can gain a more ‘three dimensional’ view of the product, and make reasonable, logical, and effective choices. Alternatively, shoppers can follow the ‘Apple Store’ route and go to a reputable shop, where the assistants are trained to offer advice and informed guidance to the customers (although this is usually biased towards making a sale….).

Whatever the ‘purchase’, the messages are the same; in areas of complexity, simplistic measures are not helpful, and may indeed be perverse. Expert knowledge is required, which may be learned by the dedicated consumer, or offered by a guide, that may be written, or embodied in a good sales rep, or an objective, informed ‘care manager’. In health terms, that person is (or should be) the GP, with a good working knowledge of the medicine, the local NHS Trusts and their consultants, and an ongoing understanding of patients’ context and needs (preferably both physical and social/psychological). It is the GPs who should be the main customers for the ratings, not the red top daily papers.

This piece is based on one published in Pulse Magazine on 17 July 2013