Health services in the developed world: not waving but drowning

ImageLike most healthcare systems in the developed world, the British National Health Service is under constant scrutiny. However, such scrutiny is just the beginning of a much larger debate likely to exercise the whole developed world in the near future; are current health services sustainable?

Irrespective of whether funding and services are provided by the State or private sectors, a number of challenges are coalescing in such a way as to resemble a ‘perfect storm’, and all will need to be addressed if we are to avoid such a cataclysm.

These challenges have to be seen in the context of the countries involved: populations are reasonably stable, average incomes are well above subsistence levels, and population health (in terms of basic needs such as housing and nutrition) is good. Deaths from infectious diseases are low and life expectancy is high, but the negative impacts of affluence (such as obesity and diabetes) are growing. In such countries, several truisms can be highlighted:

The population demography is changing: as life expectancy in the developed world rises and birth rates slow, the demography alters, putting the emphasis of health services onto older people, who have the greatest demands; the increasing prevalence of long term conditions, co-morbidities, and rising hospital admissions all put increasing strains on health services.

Moreover, most health systems (both state and privately run) depend on the insurance principle: the ratio between those paying ‘premiums’ and those make ‘claims’, and that ratio is changing for the worse as older people pay less and claim more.

Medical technology is accelerating: medical science has become steadily more capable over the years, with a growing ability to treat ever more conditions. Some are life threatening and affect millions of people (the improvements in cancer diagnosis and treatment come to mind), some are extremely serious but affect very small numbers of people (the ‘orphan conditions’ such as Gaucher’s and Tay-Sachs Diseases), and some (the so-called ‘life style conditions’ such as baldness and erectile dysfunction) are changing our attitudes to health care so that ‘dis-ease’ of any nature is increasingly being seen as ‘disease’.

In addition, there are other influences for change that may be less direct, but are often as powerful.

Rising expectations reflect the increasing medicalisation of health problems, fuelled politically and commercially; politicians generally win elections by promising more services rather than fewer, and commercial companies survive by marketing their services to generate business. Expectations have risen in terms of what services may be available, as well as where and when they may be delivered (the so-called ‘choice agenda’). Results are expected to be virtually guaranteed, and there is a growing emphasis on improving the healthcare experience as well as its outcome.

Comparisons are drawn between the delivery of health services and commercial ones such as banks or restaurants, even though these latter are self funded (with built in brakes once they become unaffordable), whereas health services are usually funded by third parties (at least in part), making the disincentives to demand much less visible or effective.

The way in which rising expectations have been driving demand exactly mimics the developed world’s wider consumerist philosophies: economies depend on growth which requires increasing demand, driven in turn by the public’s hunger for more goods and services, delivered more quickly, more cheaply, and with greater choice. Thus, just as next year’s smartphone has to be better than this year’s, so next year’s antidepressants have to be more effective, with fewer side effects, than those available now.

However, since health care is enormously emotive, and usually largely funded by third parties, the ‘can I afford it?’ question is rarely asked, either by individuals (for whom health is beyond financial measure) or by funders, for whom the penalties of reducing expectations and disappointing their clients (electoral defeat for politicians, and lost business for insurers) outweigh most possible future problems. As a result, efforts to manage expectations downwards have been few, and have generally failed to make much progress; experiments in prioritization, such as those in Oregon, have had little impact, so the only serious control mechanism to have been generally invoked is that of increasing efficiency: getting more bangs per buck.

The reality is that, whilst there is always room to improve efficiency in large systems, the pressures are such that society will have to challenge what services are provided as well as improving how they are provided. Genuine rising need, growing expectations, and medical technology’s ability to provide more, are creating a Tsunami of rising costs; once increasing risk aversion and reduced investment are factored in, then the notion of the perfect storm begins to make sense, a disaster that can be foretold but not avoided.

So are there ways of avoiding the storm? There are, but they assume that the human propensity for short term fixes can be overcome, which may be an assumption too far. Firstly, reducing public expectations would help; understanding that healthcare resources are limited, and that some things are more important to treat than others, would be an excellent start.

How one does that is harder to prescribe; raising awareness of the real cost of services may help, even if these were not actually charged. The UK ‘GP budget holding’ experiment in the 1990s was partly intended to increase cost awareness, and the current development of Clinical Commissioning Groups is an extension of this, but the funding mechanisms mean that the there is little alignment between effort and reward.

Actual charging, on a co-payment basis, is used in countries such as France and New Zealand to demonstrate the link between usage and costs, but this would currently probably not be acceptable in the UK. Creating ‘tiers’ of services has been partially implemented countries such as Canada, where everyone is guaranteed basic services, but more ‘luxurious’ products have to paid for separately; thus for example, basic cataract surgery is free, but the fancier lens implants are not.

Service rationalisation, as mooted by David Nicholson, is inevitable if hospital economies of scale are to be realized, and the risks of low volume services are to be mitigated, but this is an efficiency gain, and not the paradigm shift that is actually required. To achieve that, the obvious variables that could be adjusted are the availability of services, or their price; changing the third variable, demand, would require our societies to bring back a more collective ‘communitarian’ response to public need, which would imply a radical adjustment of the balance between ‘me’ and ‘society,’ a utopian aspiration, but unlikely to come in our lifetimes.

This is an expanded version of a piece published in The Conversation on 20 August 2013 at http://tinyurl.com/n62gloc

The NHS in 2013: plus ça change…

Just over three years aPlus ca change 1go, ‘Clinical Medicine’ (the journal of the Royal College of Physicians) launched a series of articles in which the history of the National Health Service (NHS) was reviewed, and several eminent commentators surveyed the health- care landscape that was expected to emerge once the dust from the 2010 general election had cleared.

Thus, there were articles by the likes of Mike Farrar, chief executive of the NHS Confederation, Michael Dixon, chairman of the NHS Alliance, and Mark Britnell, from the management consultancy KPMG, as well as contributions covering subjects as diverse as system reform to improve NHS efficiency (Jennifer Dixon), the risks and challenges for a new public health system (John Middleton), the future of patient and public involvement in the NHS (Jo Ellins), the role of the National Institute of Health and Care Excellence (NICE) in assessing new technologies and value for money (Andrew Stevens et al) and the then impending commissioning reforms (Elizabeth Wade).

We are now well into the current round of reforms and, with less than two years until the next general election, it is a good time to review the events of the past three years, and speculate on future possibilities and developments.

Political context

The first thing to say is that the initial White Paper presented by the then Secretary of State, Andrew Lansley, during the summer of 2010 took most commentators by surprise. In the lead-in to the election, it had been observed that there was a basic convergence in policy and even organisational style on both sides of the political divide: the concept of the purchaser/provider split was an integral part of both Labour and Conservative policy; the independence of acute provider trusts was taken as read; and the centrality of primary care in coordinating their local health economies had been generally accepted.

Thus, it was largely assumed that, if a Conservative Government did win the election, its policies would be aimed at tweaking and refining the pre-existing direction of travel, rather than overhauling it radically and, indeed, the tenor of the manifesto of the party gave no hint of major structural changes. Such tweaking could even be interpreted as being helpful in making the NHS increasingly able to resist political change, as the policies of the main parties began to resemble each other, even if only in principle.

In the event, when the Liberal Democrat–Conservative coalition was formed and Andrew Lansley was confirmed as Secretary of State for Health, the coalition White Paper incorporated significant restructuring, and a philosophical ‘decentralisation’ that was seen as almost libertarian in its extent. The key suggestions of the document are detailed in Table 1 at the end of this piece, and now look faintly ironic, even after only three years.

A difficult gestation

As with all White Papers, the document was intended to form the basis of a Parliamentary Bill, but during its gestation, there was perhaps more debate among the various vested interest groups than was the norm; nearly all of these groups, lay as well as professional, opposed parts of it, with the most strident criticisms concerning the transfer of so much of the NHS resource to the control of general practitioners (GPs), the apparent abrogation of their responsibilities by politicians and the intention to allow the NHS to be driven so locally, with the variabilities that that implied. The fact that all the debate was being carried out under the cloud of the ‘Nicholson Challenge’ (a call for the NHS to save up to £20 billion over five years that had been issued in 2009 by Sir David Nicholson, the chief executive of the NHS as a response to the increasing austerity being rolled out across the country) added to the tensions and mutual paranoia being felt both politically and in the service itself.

In hindsight, the outstanding lesson from the launch of the White Paper was less about its content, most of which was more or less in line with the aforementioned direction of travel, than the manner in which it was introduced. The Secretary of State seemed to show a degree of political naivety in his approach to the powerful lobbies with which he had to deal and he introduced a whole raft of structural changes that were both unexpected and unwelcome, as well as perhaps unnecessary to enact the proposed reforms.

Such was the level of ‘noise’ concerning the White Paper that an official ‘pause’ was introduced, during which a Future Forum was convened, led by Professor Steve Field, the outgoing chairman of the Royal College of General Practitioners. Its official brief was to carry out a ‘listening exercise’ to consult widely and to modify the White Paper in line with its findings; to this end, the Forum comprised primary and secondary care members, nurses and Allied Health Profession (AHP) members as well as doctors, managers and representatives from other groups, including various patients associations and the voluntary sector.

The unofficial remit of the Forum was to ensure that the White Paper could be turned into a viable bill, although there were also suggestions that mechanisms were needed to counter the centrifugal force of Lansley’s ideas with some centripetal pressures to maintain parity across the service and behaviours in line with central Government policy.

The Forum met for some months (and, indeed, at the time of writing, has yet to be disbanded) and, although its activities did smooth the edges of the original proposals, some might say it changed their original intent. Enough organisational restructuring was introduced following its interventions, for instance, to obviate completely the promise concerning the ‘radical de-layering and simplification of the number of NHS bodies’. Its findings were incorporated into a revised bill, which was followed by more political wrangling in Parliament before the bill was finally turned into the 2012 Health and Social Care Act, which was fully enacted on 1 April 2013.

The 2013 Health and Social Care Act

Its final intentions and structures include the following, although it is too early to draw any conclusions about their effectiveness.

The major structural changes mainly concern the commissioning or procurement side of the NHS. The primary care trusts (PCTs) that were responsible for commissioning the vast proportion of all care for their local populations have been dissolved and many of their functions devolved into the new clinical commissioning groups (CCGs), which are each headed by a chair (usually a GP) and an accountable officer (AO); some AOs are clinical, whereas others are managerial in their backgrounds.

CCGs hold most of the budget for traditional hospital services and have the responsibility for planning and procuring these services, as well as holding them to account. In this task, they are assisted by the commissioning support units (CSUs), which are able to provide a variety of support tools, including payroll and human resources (HR), information and communications.

The CCGs have two strands of accountability within the system. The services provided within primary care (mainly general practice) are governed by the area teams, each one overseeing several CCGs. The strategic oversight of this, as well as the accountability for hospital services commissioned directly by the CCGs, sits with one of four regional bodies linked to NHS England. Clearly, each is holding responsibility for a large population and needs to develop the notion of locally developed services that are in tune with national policy while also knitting together the various funding and delivery streams that encompass primary care and hospital services to create a seamless and effective service map.

The public health function (traditionally involved in the prevention and health improvement agenda, health protection (including immunisation and screening) and generic service planning) has been split in two, with the mainstream operational services being moved to the control of the local authorities and the more strategic functions that cover larger populations, being housed in a new entity called ‘Public Health England’.

The whole system is intended to sit at some distance from its political masters, to try and insulate them from the public and media pressures that often divert policy from its intended direction. This approach was first tried during the early 1990s, under a previous Conservative government, which created the ‘NHS Executive’, housed in Leeds, in a finally futile attempt to create a similar gap between policy and service delivery.

The basic aims of all the NHS reforms of the past 30 years have been to try to bring into line behaviours and expenditure in the acute sector so that they fit with national policies and budgets. In the current round of changes, the main overt objective for this sector is simple: to ensure that all acute trusts reach the standards necessary to become foundation trusts, or if they cannot, to agree some form of strategic alliance with another organisation, so that together they might reach viability in terms of costs and quality.

However, the current changes, both planned (through the new Act) and unplanned (through crises, such as that in the mid-Staffordshire Foundation Trust) have highlighted a new, and much more significant ‘elephant in the room’, and that is the overall future of the district general hospitals (DGHs). There are several reasons why their future is now in considerable doubt.

Firstly, there is an inexorable move towards increasing specialisation, which average DGHs cannot supply; their budgets and turnover are too small, and their ability to recruit ‘premier league’ super-specialists is limited. As a result, the more ‘high-risk’ illnesses (risk being defined by cost, technical difficulty, infrastructure support, staff availability and even litigation risk) are being referred onto the tertiary ‘super-hospitals’, thus depriving the DGHs of work, income and work-related satisfaction for their high-level staff.

Secondly, there is an equally inexorable move of lower-risk illnesses out of hospitals and into the community, where their treatment might be carried out in less formal surroundings that are generally preferred by patients, by staff who can still deliver excellent care, but perhaps at a lower cost. With the shrinkage of this market too, the core business of the DGHs will become significantly smaller and will threaten their viability unless they change their form or their function dramatically.

Thirdly, there are the issues of scale; in the constant tussle between ‘small is beautiful’ and ‘bigger is better’, the size and complexity of the NHS probably mitigates against the former. Interestingly, there is a clear dissonance between the move towards super-hospitals, and the value placed on local treatment ‘closer to home’, that probably reflects the increasing polarisation of healthcare to these two extremes, which once again puts the future of the DGH in doubt. This tension is not new; as Aneurin Bevan said in April 1946, ‘I would rather be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy in a small one.’ The difference is that the intensive interventions feasible today cannot easily be delivered in a small setting, reinforcing Bevan’s aphorism for the 21st century.

What next?

So what might we expect from the new system?

At a superficial glance, the new organisational structure might appear to be well placed to deliver what its designers wanted. It has attempted to separate the service from its political masters; it has declared a move to ‘localism’ and it will pass control of over two-thirds of the total NHS budgets to the CCGs.

However, there are significant structural issues that look likely to trip the system up. The first concerns the distinctions in funding of primary and secondary care.

Because the two streams are managed separately (hospital funding though the CCGs themselves, primary care through the area teams), there is no certainty that moving services from the acute sector to primary care will free up the resources to complete the transfer. However corporately minded GPs might be, they are unlikely to create extra work for themselves and their teams without the resources to manage this, and that process is entirely separate. As in so many previous rounds of NHS reform, the incentives in the system have not been properly aligned.

In the same way that the new system does not acknowledge the factors that motivate and drive GPs, the continuing emphasis on payment by results (PbR), which is a recipe for increasing activity and not improving results at all, is not helpful. In addition, the movement of the mainstream public health function into local authorities, although it might be appealing at a conceptual level (the drivers that influence the health of the population are largely outside the biomedical universe), the emerging reality seems to comprise mixed interest among local authorities, with some apparently not considering any of the broader determinants of health beyond repairing potholes and running sexually transmitted disease (STD) clinics.

So there are structural problems, but there are even larger and more significant issues in the processes that are now supposed to govern the NHS.

Lansley was probably unduly optimistic in his aspirations to have the NHS driven quite as locally as he intended, but in the intervening months and years that the Bill has evolved and become law, it has created a polarised dynamic between the CCGs at the local end and NHS England at the centre, with the power apparently settling increasingly at the central end. GPs and their PCT colleagues who took up the notion of CCGs are seeing their expectations and aspirations once again diluted and soured, with the result, even at this early stage, that there is already poor morale and reducing engagement.

Processes should not subsume outcomes

Clinical professionals in general, and GPs in particular, are in positions where they can make or break their local heath economy without ever doing anything wrong. Their motivation and enthusiasm are the only way that referrals and admissions might be reduced or prescribing improved and, if their zeal is missing (or worse still, lost), then the auguries for success are poor. Add to that the ‘Nicholson Challenge’ being pressed upon them and one can see the likelihood of short-term ‘fatigue’ in the new system and long-term disaster as new doctors consider their reasons for going into general practice in the first place, and begin to vote with their feet.

One final bit of soothsaying; if the new system was designed to preserve corporate memory while allowing new ideas and ways of thinking to emerge, then even that probably has not worked. As the CCGs and CSUs bed down, not only are they populated largely by staff who had worked in PCTs previously, but their growing ways of working, their modi operandi, also begin to look increasingly controlling, unimaginative and bogged down in ‘due process’. Tendering for service change, allowing experimental models of care, anything that rocks the boat of ‘doing things right’ is being frowned upon, even if it is at the cost of ‘doing the right thing’.

The road to Hell, they say, is paved with good intentions and it is easy to see how an Act designed by a committee that tries to please everyone is almost bound to fail.

In fact, the issues are remediable: if the accountability of the CCGs to NHS England was simplified into one stream based on outcomes rather than on processes, then the incentives for those in the CCGs would be more positive. The oft-cited ‘conflict of interest’ for GPs would be less relevant if they became responsible for delivering all health-care for their population, in any (appropriate) way they chose, ‘sub-contracting’ to others what they didn’t do themselves (and hence maintaining vicarious responsibility).

If the rules governing changes in the acute sector were simplified, and allowed more flexibility of function as well as structure, then some innovative and dynamic solutions to these ‘wicked issues’ would emerge. In addition, if those working in the NHS, especially at senior level, could see something positive about which they could be enthusiastic and in which they could invest their hearts and souls, then I suggest that this might be ‘another fine mess’ we could actually reverse.

Table 1. Summary of main suggestions in the White Paper Equity and excellence: liberating the NHS.

  • Shared decision-making: ‘no decision about me without me’
  • Choice of any provider, consultant-led team, GP practice and treatment
  • Hospitals need to be open about mistakes
  • Stronger voice for patients and the public
  • Focus on outcomes and quality standards. Reduced mortality and morbidity, increased safety and improved patient experience and outcomes
  • No targets without clinical justification
  • A culture that puts patient safety above all else
  • Money to follow patients across the NHS to promote quality, efficiency and choice
  • Providers to be paid according to performance based on outcomes, not just activity
  • Professionals and providers to have more autonomy and accountability
  • Greater freedoms and less political micromanagement; ministerial powers over routine decisions to be limited
  • Devolution of power and responsibility for commissioning to GPs and their practice teams working in consortia
  • More connection between local NHS services, social care and health improvement
  • An independent NHS Commissioning Board to lead on the following: achieving health outcomes, allocating and accounting for resources, quality improvement and patient involvement
  • All NHS trusts to become, or be part of, a foundation trust
  • Monitor to become an economic regulator, promoting effective and efficient provision, competition, regulating prices and safeguarding continuity of services
  • Enhanced role for the Care Quality Commission as a quality inspectorate across health and social care
  • Ring-fenced public health budgets, reflecting population health issues, with ‘premiums’ to reduce health inequalities
  • £20 billion efficiency savings by 2014,to be used to improve quality and outcomes
  • NHS management costs to be reduced by more than 45% over the next 4 years
  • Radical de-layering and simplification of a number of NHS bodies
  • Debate on health should no longer be about structures and processes, but about priorities and progress in health improvement for all
  • Implementation to be bottom up

This piece is based on an article published in Clinical Medicine in August 2013: 2013, Vol 13, No 4: 374–7

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

A&E departments and the M25 effect

I’ve just done a shorImaget slot on the local radio, talking about the ‘crisis in A&E’. It was based on the new report by the Health Select Committee that highlights the issues, but says very little that is new about their solution. We know that A&E is the ‘safety valve’ for the system, we know that the patients are confused about its role, and we know that fewer and fewer doctors choose to work there.

However, the solutions mentioned by the Committee are almost entirely structural and unimaginative: beefing up the Urgent Care Boards from small talking shops into larger talking shops really isn’t the answer; neither is a vague exhortation that Ambulance Trusts should become ‘care providers in their own right’.

Perhaps it would be helpful to reframe the issues, and consider them in a slightly different way. If we look at A&E from the perspectives of hospitals providers, of those working in the community, and of patients themselves, we might get a more rounded view of the problems and maybe their solutions.

Hospitals are under tremendous pressure; they have to see patients referred to them within eighteen weeks, admit acutely ill patients from Casualty in under four hours, and do it all within ever tighter financial and quality constraints. To deal with the front door issues posed by A&E, they have introduced more and more services there, so that for many patients, turning up at the emergency department offers a ‘one stop shop’ solution to their problems. The paradox is that the more that is provided at A&E, the more the service will be used.

Clearly, the corollary of reducing services at the front door is probably not a viable option in political or practical terms, but at least we should be aware of the dynamics of supply and demand in this setting, and think twice before we get seduced by more manifestations of the M25 effect.

From a community services perspective, it’s worth asking what the incentives and disincentives are to sending people to A&E: in the middle of the night, at an ill patient’s bedside, when relatives are panicking, no other care facilities are available, and the hospital light is on (to use Stephen Dorrell’s image), why shouldn’t the ‘on call’ clinician send the patient into hospital?

The presence in NHS111 of a telehealth service that seems to do no more than signpost the road to A&E doesn’t really help either; one of the reasons we have trained professionals is to cope with risk and uncertainty in a way that an algorithmic system simply cannot do, and offering a cut price alternative was predicted by everyone but the party politicians not to work.

From the poor benighted patients’ point of view, they are faced with the emotive issues of ill health, with little or no information, often on their own, fed by a media diet of Holby City on the telly, and instant gratification in all other aspects of their lives; they also know that if they call their GP they will have a battle to be seen promptly, and if they ring NHS 111, they will probably be told to go to A&E; so once again, what’s the disincentive for them?

Complex issues cannot usually be solved with simplistic sticking plasters, so whatever single concrete suggestions are made will not be enough; indeed, given our track record, playing around with the system (any system) in a ‘quick fix’ sort of way often compounds the problems, and puts different parts of the system under strain.

However, applying a deliberately opaque and undefined solution, whilst harder to quantify and assess, does allow the system (and particularly individual professionals within the system) to use such a solution constructively and effectively, and to feel more involved in that solution; ownership is a recurring theme in all the current manipulations of the public sector.

Thus, giving Acute Trusts a new process measure to meet, such as a new Trolley time target would merely stimulate a new ‘gaming’ solution (what is the real purpose of medical assessment units, for example, if not to take the strain off the A&E four hour target?).  However, contracting with the CCGs for an outcome measure of reduced admissions (and giving them control of the resources currently involved) would allow them to be inventive and innovative in their approach, involving their own professionals, and letting them see the direct benefit to patients, to hospitals, and yes, to their bank balances too.

The GPs who are involved in running CCGs aren’t bad at understanding health and illness, and the ways in which patients are involved (or not) in their care; they are also infinitely practical and pragmatic, so if given the tools to create a solution to a problem with which they empathized, then we might begin to see some progress.

Without their ‘buy in’, no single prescription can ever work, even for Bruce Keogh and Stephen Dorrell.

 

This piece is based on one first published in Pulse Managazine on 24 July 2013, entitled ‘Another sticking plaster for the A&E compound fracture’

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

CCG: friend or foe?

Friend or foe1Put yourself for a moment into the shoes of a GP; not an ambitious, management focused, media hungry go-getter, but a doctor who wants the best for his/her patients. Your list size is average, which means that around 1600 patients are registered with you, and depend on you to co-ordinate their care, and be their first point of contact, their main provider of care.

Do you happen to know how much the NHS spends on an average GP list each year? Using the back of an envelope (so the figures are approximate), I worked out that  in 2012, the UK NHS budget was close to £110 billion, which was available to look after about 60 million people; that works out at about £1800 for each person, which meant that for an average list, about £2.9 million was available. Scary isn’t it?

Now obviously, quite a lot of this was spent on fixed overheads like Public Health England, and redundancy packages for displaced managers, but let’s ignore these for the moment, because it’s always been the Government and ‘The Centre’ that have determined these. The important point is that since April this year, control of over two thirds of this budget has been handed over to CCGs, to spend on commissioning services for their patients.

The logic underpinning this move has been explicit since the 1990s: GPs co-ordinate their patients’ care, and their referral of these patients determines much of the activity in the community, mental health and acute sectors; so who better than these individuals to ‘own’ the resources associated with all this activity, and use their knowledge, common sense and autonomous professionalism to begin to move activity in ways that improve both the effectiveness and the efficiency of that care?

All the reforms of the past two decades or more have been moving towards this end. GP fundholding, GP commissioning, PCGs, PCTs, and now CCGs, all have been designed to wrest control of activity as much from politicians as from the large provider organisations, to stop them peddling their vested interests to the public (often through the tabloid media).

The logic of all the policies developed over this time (Working for Patients; ‘a primary care led NHS’, ‘the New NHS-modern, dependable’; Equity and Excellence: Liberating the NHS; to list but a few of the buzz phrases) have all been pushing in the same direction, albeit with different structures in place to make the policies happen.

So how does this link to the title of this piece? Are CCGs a Good Thing for GPs, or a Terrible Disaster? I started by pointing out that in theory, GPs each have the power to control the manner in which £2 million pounds or more should be spent on the care of their patients, so I’ll follow that up with two challenges.  The first is: who do you think better understands patient flows and needs: patients’ GPs, or middle managers based in whatever incarnation of health authority happens to be in vogue? Only GPs know what their patients’ medical needs really are and with the freedom to be innovative, they could probably think of all sorts of ways of doing things better, more quickly, in more user-friendly ways: it’s £2 million pounds, for goodness sake…

But my contrary second challenge is about strategy: £2 million may seem like  a lot to you and me, but it’s only a couple of trees in the enormous woods of the NHS; how do we a) maximise its impact and b) minimise the risks to individual GPs, their practices, and their patients? The strength of general practice lies in individual patient care.  If GPs are to be involved in planning and procuring services for entire lists, then they will need ways of working that offer economy of scale and provide insurance against unexpected events (imagine what a cluster of motorway crashes over a holiday weekend would do to the Trauma & Orthopaedics budget) without destroying the ‘can do’ spirit that has been so integral to their success over the past 65 years.

Where CCGs are genuinely ‘owned’ by their GPs, then the new organisations have great potential.  As in any successful corporate entity, individuals will need to accept that the needs of the group will sometimes trump their own local issues, and they will have to toe the corporate line a lot more often than they may have done in the past. However, they should then expect their CCG ‘corporation’ to offer support and act on practical suggestions often enough to show the practices overall benefit and maintain their loyalty. They could then be seen as ‘friends with teeth’, where the relationship needs constant effort and development, but where the gain (whether in terms of patient care, professional satisfaction, or even primary care development) justifies the pain.

However, if CCGs are either run in a top down fashion, or driven by political rather than care based priorities, then it will not take long for the cynicism to emerge; like the PCTs before them, such CCGs will quickly be seen as foe, whose actions are to be resisted and subverted.

In summary then, CCGs have the potential to be THE agent for change in the new world of NHS England, but only if their growth and development are carefully nurtured. The large scale leadership developments that seem to be emerging from the new Leadership Academy have never worked before, so it is hard to see how they will be more likely to succeed this time. What is needed is enough interest to be engendered amongst ‘working’ GPs to persuade them to invest some of their precious time and emotional energy in getting their show on the road, and make it a show of which they, and the entire NHS, can be proud.

And that won’t happen without effort or resources; but with the potential for every GP with an average list to really influence how £2 million is spent on his or her patients, isn’t that investment worth it?

This piece is based on an article first published in Pulse magazine on 24 June 2013

Kissing it better: beliefs in modern medicine

ImageI’m trying out a new medium today, using the University of Birmingham’s Ideas Lab, on which they’ve just posted a podcast from me about health beliefs. You can find it at:

http://tinyurl.com/nd5wql8

I think the issues are as pertinent to health care professionals as they are to patients and the public, and it’d be really helpful to start a proper discussion about ways of harnessing and influencing people’s health beliefs, rather than always trying to discount them.  Even the term ‘placebo’ now has negative connotations, rather than being seen as a useful tool in the clinician’s bag.

What do you think? Should we be sticking to the narrow and reductive route of evidence based medicine to the exclusion of all else, or is there benefit in looking at a more holistic view of healthcare that uses all the levers it can find, even (perhaps especially) the ones that reside inside our own heads?

The issues obviously matter in the determination and implementation of ‘best care’, but it may also be relevant when we consider professional knowledge transfer; how and why do professionals change their practice, and how can we influence that? Can it be done scientifically, by assuming that this week’s articles in the Lancet will translate into next week’s clinics, or is there something deeper that influences how clinicians think, how their beliefs affect their behaviour? If the latter is true, we may need to augment those scientific journals with ‘softer’, more fuzzy approaches, the kind of tools used in social marketing.

I’d be very interested in your views…

If you go down to the A&E, there shouldn’t be any surprise….

Teddy bearsOur increasing use of hospital services is out of control and unsustainable, and is contributing to the current crisis in accident and emergency (A&E). But the problem isn’t new and 30 years of NHS reforms have tried – and failed – to control it.

We now have figures that show a million more people went to A&E in England between February 2012 and January 2013 than had done the previous year – although changes in reporting may explain some of the increases we’ve seen in the past 25 years. There are also reports that trolley times are routinely reaching 12 hours in some parts of the country.

Now that GPs have been given control of some £80bn to plan and pay for NHS services (it’s what Clinical Commissioning Groups are for…),  many believe they should also be able to treat as many as 30% of people who come to A&E, more appropriately, and in a way that eases the burden.

The 1990s saw the creation of the ‘purchaser/provider split’, which separated those who planned and bought services from those who provided them – i.e mainly the health authorities and hospital trusts. With this came the half-hearted introduction of some elements of competition.

But only if we properly understand the underlying issues can we develop a coherent strategy to deal with them. And these issues can be encapsulated in three words: poorly aligned incentives.

A question of supply and demand

The dynamic between supply and demand drives many aspects of the human condition, and this applies to the NHS too. It has always been demand led, as it was created to respond to and meet our health needs.

There are elements of preventative care, but they’ve never been as prominent as ‘sexy’ acute services such as saving babies or heart transplants.

However, demand for any service is based on knowledge of that service, and in healthcare (as elsewhere), this kind of intelligence lies mainly with those who provide them, who use it to drum up business. Until we knew that 3D televisions existed, we didn’t realise how much we needed one. Similarly, in the NHS, until we know that treatments are available for heart disease/depression/impotence, we don’t ask for them.

As in every other industry, the supply of health services tends to drive demand. Hospital funding has moved away from opaque ‘block contracts’ – crudely, an annual allocated amount – to a system based on ‘payments by results’. As this is actually payment for activity, it tempts hospitals to increase supply to drive up demand.

In commercial industry, demand is largely regulated by price: “I’d love that 3D telly, but I can’t afford it right now”. But NHS services are largely free for us to use.

They are also free to GPs, who control most of our access to hospitals through patient referrals – except A&E of course, where we decide whether or not to visit.

Traditionally, GPs referred cases to their hospital consultant colleagues that were complex, or needed high-tech interventions. It’s always been assumed that referrals are driven purely by clinical criteria (what patients need) and specific skills (of a particular hospital specialist), not serendipity or whimsy. Patients’ needs and clinicians’ expertise are supposed to matter – not consumer choice or doctors’ golfing schedules.

However, if the balance between supply and demand has depended on these assumptions, they have been eroded over the years; it’s been assumed that patients seek help when they need it (though the tension between ‘need’ and ‘want’ increases as we’re encouraged to become consumers of a ‘free good’ like the NHS); we’ve also assumed that hospitals respond to demand (and are not incentivised to increase it) and that GPs are professionally driven only to refer patients when there is an absolute need.

But with GPs’  contracts now based largely on listed activities,  they are less prepared to absorb the grey areas where no explicit activities or payments are described – for example a home visit to a bereaved widow.

Apply these criteria to the A&E situation and the results are obvious:

  • Patients, now consumers used to instantaneous service in other aspects of their lives, are bound to prefer going to A&E than waiting for an appointment with their GP. Not only is A&E open 24/7 but tests that would take weeks to arrange through normal channels are instantly available. Sure, the care is neither continuous or holistic in A&E, but these concepts have been increasingly devalued because they are so hard to measure.
  • Hospitals receive payment for every attendance at A&E, and get addiitonal sums if patients are then admitted to the wards. They are also punished for keeping patients in A&E for more than four hours, so admitting patients becomes a no-brainer. It’s only now, when demand for hospital services is starting to outstrip supply – and the cash to feed it – that the cracks in the system are beginning to show.
  • If there are no disincentives for GPs to refer patients into hospital then why wouldn’t they do it, when they feel disenfranchised and de-professionalised by the reforms that have been churning round them for three decades?

This is all easy to analyse, but harder to repair. The basic precept underpinning the NHS has been that it’s free at the point of delivery, so the mismatch between consumerism and the welfare state is bound to expand, unless the notion of corporate responsibility in health can be re-introduced or until services cease to be free.

One mooted idea has been to increase public awareness of NHS costs, on the basis that this might make them think twice before (ab)using the ‘free’ service.

Activity-based hospital funding isn’t sustainable, and a return to some kind of risk sharing between service providers and those who commission services (the GPs) is a prerequisite to managing demand at an institutional level.

GPs’ incentives must be better aligned so that it becomes truly in their interest (professionally and morally, as well as financially) to restrict referrals to those that are really necessary.

The biggest issue is that of managing service availability; as long as we increase the supply of hospital services (particularly in A&E departments) this will feed demand. We have responded to the supply side constraints in clinics and investigation facilities by increasing that supply, so it is hardly surprising that this has in its turn encouraged higher demand.

The obvious corollary would be to deliberately restrict services, but that would be very hard to sell politically to an already disillusioned electorate. However, if GPs and the CCGs were allowed to do what they were first intended to do, their core purpose would be to extract the optimum health benefit from the public funds allocated to NHS Trusts.

Managing demand would be high on their list, and most of them would tell you that given the right tools, they would manage to do this in a much more coherent fashion, albeit at the cost of reduced health consumerism. The challenge is to loosen the stranglehold from central government sufficiently to allow this to happen before all the breath of enthusiasm for doing anything is completely cut off. And that really is a Political decision.

This is a modified version of an article published in ‘The Conversation’ under the title of ‘A&E is in crisis because we all take it for granted.’ That piece is available to view at http://tinyurl.com/mp8esp6

A snack that you can eat between blogs without ruining your appetite

I’ve been very busy this week, and haven’t had the time to do a full length entry.

However, I was involved in an interview with The Consultant magazine, part of a feature that they were running on commissioning.

The link to the magazine is: http://tinyurl.com/o25jxmo, and it may be worth a look.

Hopefully, I’ll be back on track in the next few days with a full blown article here.

Making CCGs work: three cardinal rules

jigsawClinical commissioning has arrived, but it will take a while before it becomes clear whether it is creating order or chaos. Now may be an appropriate time to revisit the underlying principles to see how it is likely to pan out.

Commissioning is not a simple notion, but an inclusive concept that covers a number of different functions. At the ‘micro’ level, there is the direct procurement of individual services, a process that has been called contracting: the customer pays the supplier for a service on which they agree.

Let’s say the customer is a home-owner, who wants a new kitchen; he has a rough idea of what he wants (the ‘output specification’, if you like) but as he doesn’t know much about building kitchens, he will need to capitalize on the supplier’s expertise and trust him to do the job well. Success will be measured in terms of overall quality and satisfaction, timeliness, and costs, and if these aren’t met, the buyer may have to use the contract to hold the supplier to account, and gain redress for any failure.

In NHS terms, such micro-commissioning is based on GPs’ referral decisions: GPs know roughly what they want, and they have a knowledge of the local expertise; their role is to organize specific procedures with the appropriate experts, and then check that they been carried out to the agreed specification.

They have the advantage over the home-owner that their knowledge of specialist provision, whilst not encyclopedic, is detailed enough to let them make realistic assessments of quality and perception, timeliness, and costs.

At this level, one would not expect the home-owner or the GP to make decisions based on strategic impact or links to a European Directive; it would be for the specialist expert in each case to keep their customers apprised of any legal issues, and it would be the experts who would be held responsible for any non-compliance.

At the ‘macro’ level, the parallel relationship may be that between the town planners and a major home-builder; as with the individual kitchen, there needs to be agreement based on a mutual understanding of the outcome of the job, and any necessary markers of its progress.

Thus, the planners may want the new estate to be carbon neutral, to fit into the existing architectural ‘mood’, and to be completed within a certain time, to a specified quality, at an agreed cost; if they are sensible, they will leave it to the technical experts to decide the precise manner in which they respond to these specifications. Not only does that involve the builders in the decision-making and so keep them engaged and enthusiastic, it also maximizes the benefits of their expertise and promotes a degree of risk-sharing that divides up the responsibility (legal, financial, perceptual) for the project, and ensures that both parties need to attain the same positive outcome to be satisfied.

Back in the NHS, this relationship mirrors that between strategic commissioners (the CCGs, Area Teams, and the regional offices of NHS England: do we really need all three???) and the acute sector pretty well. Like the town planners, the strategic commissioners will need to incorporate national policies and regulations into their strategies. They will need enough knowledge to ensure that their providers are not pulling the wool over their eyes, without getting bogged down in the level of operational detail that boomerangs the risks back to them whilst raising the transaction costs of the whole process.

At this level, the quantum being procured is much larger, and so it is harder to ‘contest;’ a local authority, having agreed for a contractor to build them a whole new housing estate, would find it much more complex to withdraw from their contract than if they were contracting for a single kitchen. However, a competent authority should have levers to pull, should the builders not fulfill their side of the agreement.

And it is here that we come to the nub of whether or not commissioning in the NHS will succeed.

While developing and monitoring contracts (like any other performance management system) should be based on the carrots of success, it should be backed up by sanctions that are appropriate and viable.

Such levers should ultimately be based on the ability and feasibility of withdrawing the contract, something that itself depends on the availability of alternative provision and the consequences of such action (be they financial, legal, and perceptual, with the added complexity of how they affect the health of the population involved).

When the notion of commissioning first appeared the NHS in 1990 in the guise of the ‘purchaser/provider split’, its main purpose was to steer the acute sector away from fuelling ‘supply-led demand’ in health services and towards a new responsiveness to the needs of the population.

In fact, several iterations of change have not really had major impact on the acute sector, which still seems to be relatively unaffected by the current organizational changes, although it is facing some highly challenging financial pressures.

As long as it remains impractical to offer real challenge to the acute sector, commissioning will be largely irrelevant, offering no more than minor political irritation to the vast and politically-aware acute sector.

The three key challenges for the new commissioners may be summarised as follows:

– At the micro-level, the development of more widespread alternatives for GP referrals needs to be encouraged; merely shifting referrals between different hospitals won’t be enough, as the ensuing Brownian motion is unlikely to promote any real change, just random movement.

What is required is the threat of removing activity from the sector entirely, which will depend either on practices being allowed to develop viable alternatives themselves, or other providers (private or otherwise) being given access to such provision.

– At the macro-level, the systems being developed (whether through contracts or other less tangible ‘currencies’) must not be allowed to become ‘too big to fail’. Keeping the quantum of exchange small enough to allow real contestability is going to be key if commissioning is to become an effective management philosophy.

Thus for example, it is much easier to challenge the provision of a single service (Physiotherapy? Pathology? Plastic surgery?) where real service delivery changes may be seen, than in trying to shut down an entire hospital, or even parachuting a new management team into a failing Trust, where direct patient care is unlikely to be affected (at least in the short term).

– And at the ‘meso’ level that spans micro and macro, it will be vital that the consequences of any actions be seen quickly and directly. If the GPs in a CCG want to repatriate a service out of the acute sector and into the community and it takes three years and a warehouse-full of bureaucracy to do it, then the GPs will simply give up trying. The links between input and effect need to be obvious and the accountability for both needs to be transparent and appropriate.

If commissioning becomes an ineffectual brake on demand, then we may as well abandon the whole concept now; however, if we manage these cultural changes, then the introduction of the new commissioning arrangements have the potential to be the ‘pivot point’ for changing the entire dynamic of the NHS.

A version of this article was published in Pulse magazine in the UK on 8 May 2013