My mission statement

The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

Read my statement in full »

What does a modern NHS need?

Filed Under (Reform of the NHS) by Paul on 24-01-2011

Number 1 It needs to be a system with strong incentives that keep moving it forward to ensure it incorporates the dynamism of health care and medical technology. It must pull innovation into its every part.

Last week I said that I would post regular blogs that would try to develop the debate above the daily cut and thrust of the politics and practice of the NHS. This would try to develop what are the crucial themes that I think anyone who wants to run the NHS has to answer. Over the next few months I want to frame these questions – and to develop some answers.

Last Monday I said that I felt this would be necessary because the Government will start to say that you are either in favour of their particular reforms or in favour of the status quo. In fact this turned out to be one of the Prime Minister’s claims throughout last week – and I feel that gives urgency to constructing what is clearly a different position from this false choice.

First some caveats.

My personal position on developing reform in the NHS is that I want to work through and carry out reforms within its basic principles. I am the same age as the NHS. I accept that there will be others that come after me that will want to change this, but as of the 2010 election a higher proportion of people supported these principles than ever before and I see that as one of the successes of the last Government.

So for me reform is within the idea that the NHS will

  • be paid for out of money collected through national taxation.
  • provide equal access for all in England to services that will be free at the point of delivery.

These were the principles that guided NHS reform between 2000 and 2007 and I would want them to be the principles that guide NHS reform for at least the next ten years. Let’s not forget that reform so far has created greater satisfaction with the NHS than ever before.

Why is this important? These statistics mean that as far as the NHS is concerned the middle classes have decided that it is not worth buying themselves out of it and will therefore add their voice to the shouts for improvement. The NHS, in practice as well as in theory, provides universalism.

Part of the aims of any reform programme must be to improve on that by the year 2020 since it is that support that ensures politically the prolonged life of the NHS

And my first issue is vital to that support.

Why is innovation and its universal application so important? Health care is a very dynamic service. For the NHS to maintain and develop support it needs to be able to demonstrate that it not only gets hold of the very newest ideas but that those ideas are promulgated throughout the system as quickly as possible.

This is a matter of saving lives and relieving pain and distress.

At the moment innovation in the NHS is patchy. In some parts of the you will find the latest idea that will relieve distress but it will be provided alongside something that was out of date a few years ago, and that in turn will be provided alongside something that was out of date many years ago. I have typified this as a geology of forms of provision with one overlaid on another overlaid on another etc.

The failure to drive out the old with a tough and universal application of the new causes real problems for public services. It does so because the model that other industries and services have – one where the consumer uses their money to drive change – looks to be very successful. The public look to the way in which innovations in communication have changed their lives and have changed the lives of most of the population – and they ask why can’t that happen in public services.

The enemies of the NHS can then point out that where individuals buy goods and services with money from their own pocket they can drive change throughout a service. Within this model of change what happens is that new ways of doing things become the norm because the old says of doing things are wiped out by consumer preference. The very big mobile phones of 15 years ago are no longer being made. The numbers of people who use the internet to search for insurance bargains has changed the industry works.

Consumer preference, plus consumers having the financial power to enact that preference, has driven these changes not in a few little places but throughout the industry or service.

People want to know why their hairdresser reminds them of their appointment but their hospital doesn’t.

If the friends of the NHS do not have an answer to this issue of speedy diffusion of improvement, then the enemies of the NHS will demand that the cash driving consumer preference as a proven method of improvement becomes the norm in health care.

There is an answer from the NHS of the past as to how innovation and improvement is spread. That is through people at the top of the organisation telling people who deliver health care that they should do something new.

A lot of those who represent the NHS of the past will argue that having a single organisation means that it is of course much easier to spread innovation. Having a single management hierarchy and culture means that all that needs to happen is that the people at the top get hold of the new ideas and tell the people at the bottom what to do. The reliance on authority and the management hierarchy is a major method of organisation for those that support the status quo and it will become one of the main debating issues in these posts about reform.

Some do believe that all you need to do is construct a powerful enough hierarchy, with clear enough communication, and change will inevitably happen all the way through the organisation.

The problem is that this doesn’t work. It can work if you are telling people not to do something. The simple message of “stop doing x” can just about get through a hierarchy and an organisation, but it doesn’t work if you are wanting people to do something different, new or difficult. And if you want people to innovate it is very difficult to shout at them down a management hierarchy to get them to do it.

In terms of innovation and improvement this is called the “push” method. You push it down into the organisation through leaflets, management directive tool kits – and nowadays web sites. Of course this has some impact. Those that are looking out for new things read the leaflets, get onto the web sites, and apply the tool kit. But what about those that are not looking for new things? Those who believe that the way they are doing things at the moment is OK. You can shout at them tell them to read the web site, but the push method doesn’t really influence them. Especially if they are working in organisations that find it difficult just to keep going every day – let alone to innovate.

Much of the work of improvement organisations in the NHS has been within the push method. The Modernisation Agency or the National Institute, work by getting together the very best new ways of doing things and broadcasting them. It gets some traction, but mainly the people who need to do this the most – the people, who are at the back of the distribution curve – just ignore it.

The next stage is to get the people at the top of the NHS to say loudly to “read this web site and do these things”. A few more do, but the push method doesn’t reach even a large minority.

Within public services we need to devise a pull mechanism which is different from individual patients reaching into their bank accounts and buying the newest thing. If that is the only method of pulling improvement into the NHS, then its basic principles are finished.

We therefore need something apart from the money from individual wallets to drag this innovation into the NHS. And that is why so many of us are talking about competition within the NHS. If organisations fail to innovate and others next to them do, then there need to be some plusses for the ones that do and some pain for the ones that don’t.

Given the correct incentive structure organisations will look to improve their services and will compete for patients. Within a reforming NHS patients don’t bring money from their own bank account. They bring money from the pool of finance raised by central taxation and organisations that compete for that patient choice.

Successful innovative organisations gain patients and gain resource. And they pull the possible innovations into their organisations. Unsuccessful ones lose resource because they are not pulling innovation into them.

Look at the productive ward – a great product of the National Institute. It’s a good idea. Every organisation should apply it to every ward. But some did and some didn’t. Then as the impact of the tariff on the economics of organisations runs through all organisations, the importance of improving nurse productivity becomes an issue for all organisations. The tariff, hospitals earning money and looking at their cost base, means that they become more and more interested in improving nurse productivity.

The productive ward is used by more and more hospitals.

Many of those that are against reform really don’t like markets and see that they have no place in health care. But it is these market reforms that have provided the incentives to organisations to drag improvement and innovation into the system.

Getting these incentives right ensures that innovation becomes universal in the NHS. All of this without individuals reaching into their bank accounts.

Having no incentives except shouting at people to be innovative ensures that innovation is kept in a small corner of the NHS.

Those in favour want to find the right incentives that will pull improvement into organisation by organisation and will punish those that do not do so have such incentives.

Those in favour of the status quo will imperil the NHS by not providing the incentives that will bring that innovation across the board.

The challenge to those who are wary of market based reforms in the NHS is to come up with levers of improvement that work as well.


7 Responses to “What does a modern NHS need?”

  1. Thanks Paul,
    I have 2 points. The point of the NHS is not to provide ‘equal access’, but to distribute healthcare according to need:

    Secondly there are different drivers of innovation. The NHS (my own practice included) has innovated for years without being subject to market competition and there are things we offer our patients like drug counselling and routine home visits that are necessary but not profitable. Evidence to demonstrate the efficacy of non-market levers is urgently needed.

  2. When resources tighten you have a choice: you squeeze harder from the centre and limit the freedom to innovate locally or you let go, liberate and hope it does not wreak havoc. I know it is not an easy choice and each approach carries a high degree of financial and political risk.

    You are right Paul there is no doubt that this government has chosen the first approach. So we can expect the NHS to break even this year and next by careful control of the main financial levers: it is not so difficult – you top slice, hold money back and then sprinkle around the system when holes occur. Not very innovative but job done.

    In the meantime we will not get providers or commissioners to innovate on any significant scale, the stimulus, incentives and more importantly the space is just not there. At a time when, more than ever, we need people to think differently and imaginatively to write the next chapter of the NHS, we will get silence and inertia for the next few years.

    Fiscal control and mass innovation appear mutually exclusive in the NHS. We can go round this a 1000 times but we still come back to that basic challenge.

    Unless you do two things. Legislate to keep Whitehall and the Secretary of State out of the day to day running of the NHS and you introduce more competition. Competition provides answers, pushes up quality and holds people to account. It will provide the answer to why elderly people lie forgotten in hospital, why the mental health services are such a shambles and why in 2011 I cannot e-mail my GP.

  3. Dear Jonathon

    I agree with your point about what the principle of the NHS should be. My equal access to health care that is not appropriate for me is not relevant. I will try and think this throgh and post a blog for discussion on it.

    I am pleased that your practice has been innovative and I certainly didnt’ mean to give the impression that competition is necessary to introduce new ideas. But I do believe some form of competition is necessary to pull those good ideas into parts of the NHS that did not originate them. The (good) problem for the NHS is that it makes promises to the public as a national syatem – which is why people admire it. And having made that promise it needs to find a way of delivering the best innovations everywhere, until others come along. We have been good at the ideas and very bad at the systemic diffusion


  4. Could I be so bold as to pose one of the question which you might want to address? What value does commissioning add? The cost of commissioning has now been quantified at somewhere around £20-£25 per head and direct comparisons are available with Scotland and Wales. What is its relation to provider innovation, competition, patient needs, access and choice, efficiency and equity and all the other demands which we place on the system? In short, what do we get for our money?

  5. Hi Paul

    Interesting article with some emotive language! I think there are some important things to consider.
    One, there is an assumption in the article regarding the ‘enemies’ of the NHS. The article states its an all or nothing scenario ie free at the point of access or digging into individual wallets and private resources.
    What needs to be explored is how the taxpayer can be involved to ‘spend’ the money (when it is needed) and obviously within given parameters. This does not change the fundamentals of the NHS but rather gives the individual a greater voice and choice. This would also help manage public expectations and ensure that the public has a clear understanding of what visits, procedures and drugs costs. I am puzzled as to why the NHS does not produce benefit statements as a private insurer would.
    The second model is the one you describe where there may be multiple funding sources. The question to ask is: in such difficult times, would it be unreasonable to apply some sort of means test and ask those who can, to contribute in some shape or form (and to a greater or lesser degree). This again does not necessarily need to undermine the fundamentals of the NHS, it does not have to be an ‘all or nothing approach’.
    NHS colleagues may have some key lessons to learn – even from Social Care for example. The second mystery for me is why we are happy to ration social care through means testing but not health care when they are so integrally linked.

    I am sure there are a few more debates to be had on this issue.

    Best. Caroline

  6. Paul,

    Really enjoyed your thinking in this article. Thanks.

    For me there is a blurred boundary between Improvement and Innovation, as in this definition: incremental innovation seeks to improve the systems that already exist, making them better, faster cheaper. Radical innovation is more focused on new technologies, new business models and breakthrough businesses.

    However, I worry that for some people Innovation is only about the ‘radical’ side, and the incremental, i.e. improvement gets overlooked. I believe that there is a huge amount of opportunity to improve value for patients and the NHS by focusing on the incremental improvement side of innovation.

    From Paul’s piece – “The reliance on authority and the management hierarchy is a major method of organisation for those that support the status quo and it will become one of the main debating issues in these posts about reform.” For me this chimes with a quote by Nicolò Machiavelli; “The innovator has for enemies all who have done well under the old, and lukewarm defenders in those who may do well under the new law.” So here we’re talking in part about resistance to change, but I wonder if dear old Machiavelli was TARDIS’d into 2011 he would add an additional constituency; ‘…as well as those determined lobbyists who may do very well indeed under the new law’.

    Anyway, I work in a hospital environment where I facilitate incremental improvement using Lean thinking. I see improvements being made, improvements failing, improvements not sustaining, and services standing still. It’s a mixed bag. This is all OK as far as I am concerned, as the important thing is for individuals and teams to understand their processes, experiment (i.e. innovate) to improve them, and ultimately deliver additional value for patients. This is learning by doing and it’s happening in pockets. The Productive Ward is a good idea, and it’s a good example of understanding, experimentation and improvement. But is it properly understood and supported in organisations, or is it just a tick-box, expected to deliver some senior manager’s cost improvement programme?

    Which leads to my point, which is about ‘reliance on authority and the management structure…for those that support the status quo’, and is critical in this struggle: I don’t believe that there is any improvement or innovation in the way that management manages. From my perspective, the ‘business’ of managing an operational environment seems to be ossified as if some command & control throwback to Management by the Numbers (, and I believe it’s this that is getting, and will get, in the way of any incentives to ‘pull improvement & innovation into organisation by organisation’.

    Regards, Bruce.

  7. Paul – A particularly interesting post. Wish this had been around when I was a management trainee! I agree that promoting faster spread of innovation has to be a key objective for NHS reforms/development. You are right to point out it is challenging. However, do not underestimate the collective impact of different diffusion methods; having worked in a DH improvement team I know they can have a positive impact – but not in isolation. Judicious use of targets/entitlements, systematic performance management, clear research-based quality/service standards, financial incentives (eg best practice tariff), national clinical audits, formal region-wide clinical networks (eg stroke & cancer) , information to empower patients: they all drive frontline change.

    Not only are there a range of levers, that ideally are employed in concert – but they must be given reasonable time. The fact is that Messers Blair, Milburn and Reid were in a great hurry, understandably, to “demonstrate results”, and prove the “funding for reform” deal was being satisfied. Reforms were pushed through very fast, accompanied by the funding the Tories had denied that had been desperately needed for years to raise us to EU average. The fast pace brought some impressive results and new infrastructure but also uneven development. Stroke and heart disease improved far quicker than frail elderly care, for example. And, in my experience, the pace of change meant Labour lost support of too many NHS staff – a bitter irony, and one which certainly slows down adoption of innovative practice.

    Some competition can be another part of this mix to promote more rapid spread of innovation – but it should be at the margins, as for the ISTC programme, when there was a need to tackle obstructive surgeons. Lansley’s reforms are very different as competition will be let loose across the range of care, and actively promoted by an economic regulator. It is impossible to accurately predict the outcome, but risks include a “race to the bottom” on price and/or loss-leaders leading to uneven avialbilit of services, depending on what is classified as “core”, increasing NHS provider instability costs as they struggle to cover their overheads, “internal medical tourists” moving between commissioning consortia to get the best deal, insufficient attention on driving performance improvement in primary care (handicapped by the NCB centralised structure) . There will be no enforceable standards (the NHS outcomes framework is toothless), and differential provision will increase greatly, I foresee.

    @ Caroline raises social care. The unfettered market in that sector offer important learning for the NHS. Now times are tough financially, it is a race for the bottom in terms of price, which trumps quality every time – unless you pay privately, including via a top-up, for a superior service. Providers are getting squeezed by commissioners who are under instruction to reduce unit costs. So vulnerable people are being moved to larger, less personal homes, with less staff support and fewer outside activities. Staff salaries, already low, are to be cut further. (This is happening at the charity where I am a Non-Exec). All this in a sector where the service (ie care) is less complicated to measure and commission than in health.

    The fact is the people behind the NHS changes want to roll back the state, not just because they have an instinctive view that “the market knows best”, whatever the context, but because they disagree philosophically with any kind of collective universal guarantee for key public services.

    If the NHS struggles over the next few years, how long before the right wing think tanks start resurrecting the idea of an insurance system for healthcare, covering the bare minimum, but with the ability to “top-up if you choose to do so”. Sadly, social care provision will have got their first.

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