Chris ham: reforming the nhs lessons from the past and pointers to the future

I am going to take about 10 minutes to give you a very high-level overview and summary of what our new report says today. Lots of people in the Fund and outside have been very helpful in offering their ideas and advice and experience to contribute towards what we are saying in the report. It is very much about the process of reforming and improving the NHS. What have we learned? What needs to be done differently in future? What is The King’s Fund saying, particularly advice for the next government about the best way of building on progress we have seen in very difficult and challenging financial circumstances?

So that is what I will try to cover. To do that in 10 minutes is obviously a very big challenge and I do encourage you please to take a copy of the report away, have a look at it in more detail, because there is a great deal more than I can possibly touch on in my time this morning.

I want to review what the evidence says about the impact of different approaches to the reform of the NHS; what we can then learn and what has not been tried. I want to touch on that too. If we look outside the UK, other countries have gone down different routes of reform. What have they been? What impact have they had? What does that suggest around what we should be doing differently to reform the NHS in England – and this is very much a focus on England.

Starting from this position, if you look back over the last 15 to 20 years, this will be familiar to all of us but just to recap, I think there have been three main approaches, drawing on external stimulae or pressures to try and prod and poke the NHS to do better and to use the substantial investment we saw between 2000-2010 to bring about tangible improvements in outcomes and patient care and they are: the use of targets and performance management; followed by inspection regulation; alongside competition and choice, often used in parallel, often used in a very complex process of overlaid approaches to the reform of the NHS, as different governments – Conservative, Labour and our Coalition – have done a kind of ‘mix and match’ between these three principal approaches to reform and improvement.

The short version of a much longer story, looking at the evidence from different evaluations, those three approaches either singly or in combination have actually had quite a modest impact. The biggest impact has been through targets and performance management. I would add to that not just targets but the use of national standards through the NSFs; the work of NICE in setting out a more explicit framework for the use of drugs and other technologies. They certainly have contributed that approach of targets and standards alongside investment to the measurable improvements in performance that we saw between that 2000-2010 period.

There is much less evidence that inspection regulation has contributed positively and there is very mixed evidence – and quite limited evidence actually – about the role of competition and choice; those two big econometric studies that seem to show that competition did improve quality in some areas of care but the methodology and conclusions of those studies have been challenged by other researchers, so I suppose to use the cliché, “the jury remains firmly out” on the impact of competition and choice.

Alongside the positive effects of targets and standards let’s note the negative consequences too. When Ara [Darzi] was a minister in the Department of Health, three important reports were commissioned from the United States which I have summarised in the paper from IHI, from RAND and from the Joint Commission, reviewing the approach up until that point, 2008, to improving quality and performance. They were quite consistently and uniformly critical of the approach that had been taken. The series of overlapping initiatives; the emphasis on top-down, target-based improvement; the development of what I think they called ‘a culture of fear’ in parts of the NHS as a result of that. Of course, we should also note the risk of ‘gaming’, cheating in relation to how targets operate through performance management. We also know that although there have been aspirations to shift the balance of power, create a self-improving NHS, liberate the NHS – phrases used by successive health ministers – we still have a system today which relies very much on inspection and on performance management. So aspirations have not really been translated into practice.

There are approaches, then, in other systems, to move on, which need more attention, we believe, in England, bringing about reform from within, looking at high-performing health care organisations outside the UK as well as those in the UK, such as Salford Royal, and I have mentioned some of them here. Then the second approach – devolution and transparency, collecting, reporting, performance data, making that publicly available, if you like – in the belief that reputational damage will stimulate leaders in organisations that do not perform well to improve their performance. I came across a phrase in New Zealand where they very much relied on this approach. They do not call it devolution and transparency; they call it ‘ranking and spanking’! Maybe we need more ranking and spanking in the NHS in England!

I also draw attention in the report to the experience of the Veterans Health Administration (VA), fully understanding that the VA has been through a very turbulent time and has been quite rightly criticised for a decline in its performance, but I am talking here – let me be clear – about the transformation that took place in the late 1990s under the leadership of Ken Kizer, and effectively what the VA did during that time was to put in place complementary approaches to change and reform, combining top-down leadership through standards and outcomes with much more devolution to local leaders to deliver improvement within that framework; relying on a lot of collaboration within the VA system; getting regional leaders to share and support each other, while also simulating a bit of competition between them; so comparing regional performance within the VA transparently, in the way I have just described – and ensuring continuity of services while bringing about, over five years, huge change. For example, during this period there was a 50 per cent reduction in the use of hospital beds within the VA system at a time when outcomes and quality of care for the population served also improved. That is a non-trivial improvement in performance in a big, publicly funded healthcare system, using these complementary approaches to reform and change.

The other key ingredients in the VA – because it is probably the closest analogy we can find in the international literature that has lessons for what we are trying to do in the NHS today – reduce our reliance on hospital; shift care closer to home; development of the new models of care that Simon Stevens and others have talked about. Here is the list: I won’t talk about all of them but I do want to highlight that when the VA went through the transformation, they moved from being a fragmented, hospital-centred system to the creation of 22 regionally based, integrated service networks; each network comprising a number of hospitals and out of hospital services; each network having a capitated budget linked to the delivery of outcomes in performance contracts; the VA’s headquarters acted as a strategic commissioner; there was devolution and transparency within the organisation and fundamentally this was based on changes, actual improvements in leadership at all levels. One thing was strongly advocated, as you would expect from us, given our work on this, is much more attention to the role of integrated networks of care in taking forward the changes and improvements we need within the NHS.

Another complementary change is combining a greater focus on innovation, something that Anna has been leading on, with also much more attention to greater standardisation of care, reducing unwarranted variations in provision. It is not inconsistent to advocate both at the same time. Tim Harford’s interesting work on innovation – we need to accept experimentation and indeed failure because not all innovations will succeed but we cannot mandate innovation; you cannot do it top-down; you have to build the networks between providers and clinicians. So the great improvements in stroke care we have seen, following Ara’s work and with leadership from Ruth Kahn and many others were based on a collaborative approach. We have the potential of academical science networks; we know that UCL Partners is already a pioneer in that regard. Greater attention to innovation through collaborative networks feels to us to be a high priority too but alongside tackling these unwarranted variations in care.

If you look at one of the case studies we focus on - Intermountain Healthcare in Utah - Brent James is the Chief Quality Officer and I have had the privilege of visiting Intermountain on two or three occasions, talking to Brent about their journey over 30 years to become a really high quality, high performing healthcare organisation; their belief, justified by experience as evidence behind this - high quality care usually costs less. Why? Because you can reduce waste and variation and Intermountain have many examples of improvements in clinical care which have delivered precisely that result. Underpinning this is a drive towards organised care and by that I mean organised clinical care, because what we are focusing on here is variations in clinical practice first and foremost. So, innovation alongside standardisation – we need both of those.

Last couple of slides. What our report is arguing for in headline terms is a fundamental shift away from external stimuli, external pressures from the top-down; much more emphasis on bringing about improvement from within and building the leadership and other improvement capabilities that you see in these high performing healthcare organisations. It is a bit of a cliché but it is one worth repeating: we need to focus on how we build commitment to change and service improvement, rather than creating a culture of compliance with externally defined and imposed standards of care. That I think is a fundamental shift: turning the aspiration into something that is the reality; complementary changes.

So the next steps – this is the final slide – that we are recommending. Let’s understand the time it takes to bring about the impressive changes that you see in Intermountain and elsewhere. This is a long march over time, not a series of ‘quick fixes’. I think it was David Brailsford who, when asked about the Sky cycling team in the Olympics, said, “Well, we’ve made progress over the last four, eight, twelve years, through the aggregation of marginal gains.” We need more aggregation of marginal gains in the NHS rather than going for these big leaps, which is always the risk because of the – if you like - disconnect between the timescale for policy changes and the timescale for political changes. The NHS does indeed suffer from short-termism, too many disconnected initiatives.

Of course, we would all argue that we need to keep on saying it: no more large-scale, top-down structural change, and we need a new settlement and I would be very interested to hear what Stephen has to say on this, because let’s be clear, Andrew Lansley in the Health and Social Care Act tried to bring about a new settlement; to demarcate the role of politicians; to distance themselves from detailed involvement, the operational management of the NHS. That has clearly failed so far and the issue is why? Is it too soon to tell? Is it possible to imagine a more firmly locked-in, embedded settlement that genuinely does create some degree of space between the proper strategic role of health secretaries in accounting for these public funds; in setting the direction through the mandate; accounting for how the NHS is performing but avoiding that involvement in operational issues which is often the default position when things get tough.