Disrupting health care
Civitas, 11 June 2009
The cat’s out of the bag. In an erudite and commendably candid paper, the NHS Confederation tells it as it is: the NHS will not be immune from the financial crisis, it will face real term cuts (Tory or Labour government, don’t believe either of their protestations to the contrary). And they will be of some magnitude; £15 billion over five years from 2011 set against rising demand, aging and an increasingly unhealthy population is no small fry.
So, what to do? The Confed do a good job of listing what shouldn’t be done: letting waiting lists grow; diluting quality; ‘slash and burn’ savings; letting pay get out of line; cutting training; and cutting prevention. They also suggest caution around a number of ‘money-saving’ initiatives: centralisation of support functions; mergers; structural change; demand management; price competition; and reducing staff.
Instead, they argue the NHS should focus on improving quality and efficiency (read reducing unfounded variations in care; adopting best practice; improving service design; releasing productive time; create flow through systems; and reducing complexity); cost improvement in support functions; strategic changes in provision through rationalising estate and reconfiguring hospitals; better resource allocation; developing organisational readiness and methods for delivering change; policy ‘alignment’ (largely focused on the inadequacies of the one-size-fits all tariff by which hospitals are paid); and local leadership.
All are pretty sound. The problem is can the NHS deliver? And who is going to drive it? ‘Leadership’ is a great word, isn’t it? But what does it mean?
It’s a nice thought that there are brilliant leaders out there in incumbent providers who are just itching to respond to the challenge and drive change the way the Confed advocates. Maybe there are, but many are schooled less in the art of customer service and running businesses, more in the art of playing the NHS ‘game’. Bumble along, meet the targets, ‘efficiency savings’ and everything will blow over. Not this time. As has been argued before on this blog, a sea change in organisational culture is required.
It’s an equally nice thought, too – as Andrew Haldenby of Reform writes in the Daily Telegraph – that we need leadership at the national level that ‘doesn’t mean ministers actually running the NHS… it means politicians daring to make the case for change. It means explaining to the public (and to the service itself) that a better service will look and feel very different.’ (Examples of this include that service will have fewer big hospitals and many more smaller units, both general (like GP surgeries) and specialist (like stroke units); that it will almost certainly have a smaller staff, in which the big pay rises go only to the best performers; and that it will be different in different places, as local leaders start spending local money better.)
Well, maybe we do, but, as Haldenby admits, it’s not the way things traditionally have been done in the NHS. The Department of Health prefers to think of itself less as a strategic body, more of a managerial one; and there is little sign of change. The NHS Chief Exec, David Nicholson, has already announced that the Department of Health will ‘really squeeze’ the NHS as soon as 2010-11 setting the task of ‘doing four or five things everywhere in the same way, at the same kind of time [through] regional support teams’.
My question, really, is this. We all know that with funding cuts looming, the current model of service is unsustainable. We all know there are huge efficiency savings that could be made without harming patient care. We all know quality is not what it could be. We all know silo-working is a huge problem. We all know huge cultural change is needed. But who is going to drive it? History teaches us the centre will try but can’t do it with any lasting or meaningful effect – how can you control an organisation that employs 1.3 million people and is fragmented into hundreds of different ‘businesses’ in this way – and experience from other industries suggests incumbents won’t do it alone. The latest health supremo in government Andy Burnham’s mantra that quality – getting things right first time, ironing out variations in care etc. – may actually be cheaper is surely true, but will incumbents work smarter?
It is more likely – as the Confed hints at but fails to follow through – that a seismic shift in quality and productivity will require huge disruptive innovation from outside the current makeup; new business models, new technology, new providers entering the market that threaten the status quo but ultimately raise the quality of health care for everyone. These are innovations that ‘sneak in from below’, while incumbents are focused on developing and improving existing products and services.
In doing so, they tend to miss the new, novel ideas, which enable a larger population of less skilled people to do things in a more convenient, less expensive setting that could be performed only by expensive specialists in centralised, inconvenient, locations. Think George Eastman’s camera, Bell’s telephone, Carlson’s photocopier, mobile phones, laptops and iphones. Only 27 companies in the FTSE 100 when it was founded in 1984 are still in it now. Most of the top companies in California didn’t even exist ten years ago.
And don’t think health care is somehow different. It isn’t. The Shouldice Clinic and the Texas Heart Heart Institute in the US and ISTCs in the UK have proved what can be achieved through specialised, streamlined care. Patients already pack glucometers with them and manage most aspects of a disease that previously had required much more professional involvement. Asthma is the same.
If speeches at an event hosted by The Institute of Physics this week on connected health care are anything to go by, the potential too is there to do so much more. Remote patient monitoring, in particular, offers the potential to save huge amounts of money in the management of chronic conditions (currently accounting for 72 per cent of inpatient admissions; 65 per cent of outpatient attendances; 52 per cent of GP attendances; and 69 per cent of the health care budget), enabling people to age independently, and in disease prevention. The biggest obstacle, it was garnered from innovators, is not technology, but getting existing providers to adopt it.
How, then, can such disruptive innovation come on stream? First, there must be absolute transparency in the costs and quality of existing providers and treatments; and the benefits proffered by the new. Ambiguity, as NHS Blog Doctor argues, is too easy to hide behind. Second, PCTs must be bold and open up to new providers, new ways of working, overcome the inertia of regulation and open up to market forces. And third, when it comes to the crunch, politicians must offer them their full support. Few, however, seem to have the capacity or the will to do so. Scampering around defending poor quality incumbents, attempting to ‘control’ costs and manipulating the tariff will not suffice.