Thursday, 7 April 2022

We are having the wrong debate about modelling the NHS workforce

It sounds intuitive that having a good model of the NHS workforce would be useful for solving many observable problems in the current NHS. But there are reasons to assume any such model would not be as useful as expected and could even be harmful. More importantly, the starting point suggested for the model is wrong in multiple ways that almost certainly guarantees the model would fail to solve the real problems.

When I first heard that a coalition of Labour MPs and the ex-NHS SoS Jeremy Hunt were proposing an amendment to the Health Bill to insist on regular publication of a workforce model for the NHS, I thought the idea was a good one. Better, transparent information about the staffing needs of the future NHS sound like a useful idea to test against government policy. 

But, when I reflected on some of the issues I have seen in the past when Strategic Health Authorities did workforce plans I started to have doubts. Then, after some further conversations and cogitation, those doubts grew. Considered alongside my analysis of what the biggest challenges are for the NHS (in short, the front line workforces is far from the biggest problem), my skepticism strengthened. 

So, I'm going to argue that, while a good workforce plan might help, the one we are likely to get is likely to be somewhere between useless and harmful. It is starting in the wrong place, has unclear goals that will likely make it far less useful than expected and has some risk of making things worse. 

That's a big claim. Let me walk through the potential issues I see step by step. 

Where the workforce model might go wrong

It doesn't start by considering productivity

The starting assumption in the debate is the almost universal belief that the problem is a shortage of front line staff. Commentators observe busy A&Es, overwhelmed GPs risking staff burnout, hospitals where waiting lists are growing not falling, and leap to the conclusion that the only way to address these is more medical staff.

But the problem framed this way distracts from any analysis that concludes anything other than "more staff" can influence the amount of work done. Concluding that only more staff matters rules out many known interventions that should be part of the debate, especially those that improve productivity..

Here is a simple example. NHS A&Es are currently catastrophically crowded and patients are getting treatment so slow it is killing them. But we know from analysis that has existed since the 4hr target was introduced that the number of A&E doctors has very little influence on the speed (for a fun review of the evidence on this and how little appetite the system has to listen to it read this BMJ piece and the replies). The dominant cause of long waits in the last decade has been slow access to free beds for admitted patients. The problem isn't even inside the A&E, so adding more A&E staff won't fix it. To be fair, the workload needs in A&E do increase sharply with the length of the queue. But they don't help to make the queue shorter. So any workforce model that ignores the external factors causing the queue will end up recommending far more A&E staff than needed if the external bottleneck causing the queue is ever solved.

Another example shows that not thinking more widely about the mix of staff required is a major problem in planning. A Royal College of Surgeons blog reported in 2017 that the productivity of surgeons had declined sharply as their numbers rose because numbers of support staff and nurses had not risen. It reports "Between 2010 and 2016, consultant numbers rose by 22%, compared to just 1% for nurses and 2% for all staff."  It Also pointed out that "... consultants in hospitals that invested more in infrastructure and building … are more productive". (it is worth reading the original analysis by the Health Foundation as well for much more detail). So, is a workforce model is built to forecast the number of surgeons required, but ignores the number of nurses and support staff or the capital required to create a productive theatre, it will vastly overestimate the number needed.

The point is that productivity depends on the mix of staff and other factors like equipment. Driving higher output across the NHS requires a good understanding of where the bottlenecks to productivity are so the right mix of capital and people can be deployed. Adding more of the most visible front line staff is often not that effective. But it is what a "more resources to the front line" workforce model is likely to achieve.

It is unclear what decisions a long term workforce model is intended to support

The only point of any model is to support better decisions. If you are vague about what decisions, then the model is likely to be unhelpful and even misleading. 

So what decisions could a long term workforce model support? So far the discussion has tended to focus on the need for a model to inform the NHS about its workforce need in 5, 10 or 15 years. 

What decisions could such a model influence? Not many. If we know we need more nurses in 5 years time the NHS might just have enough time to increase the number of training places to increase the numbers qualifying in 5 years time. But it is unclear whether increasing the number of doctors in training right now would lead to higher available numbers in a decade's time. 

If the NHS is short of particular skills right now, it is unclear how a long term model can possibly help. What the system needs most urgently is some idea of what the options are today

If the model focuses–as much of the discussion about it has–on front line staffing need, then it also misses critical groups that contribute to the productivity of the front line (see the section on productivity for why this is important). The question that desperately needs an answer is what different mix of staff, equipment, buildings and new clinical processes would give the biggest increase in the number and quality of treatments delivered. Many of those questions are not workforce questions at all and even a workforce-only model needs a good understanding of how different staff interact to make the front line more productive. That understanding will only come from a significant piece of careful analysis that doesn't seem to exist. 

What the NHS needs right now is that analysis. It needs to know where the bottlenecks to higher activity are. It needs to know what mix of capital spending, front line staff, support staff and managers would lead to the largest improvement. Without that a workforce plan will be about as useful as a one-legged trapeze artist with an itchy bum.

A workforce model designed to tell the system how many staff it needs to put into training now will get the wrong answer because it ignores all the interactions and other factors that matter and, even if that wasn't true, could not influence any decision that will have an effect for 5-10 years at best.

Major factors that influence the workforce today are likely not part of the model

The NHS has a workforce problem right now. And many of the factors causing problems are not relevant to the long term supply of qualified staff. Or anything else likely to appear in the proposed workforce model.

Right now the biggest factors influencing staffing gaps are recruitment problems and high turnover (plus illness, if temporary pandemic-specific problems count). These problems don't just affect the front line staff groups but are common in the other groups where a lack of staff has a lot of leverage over front line productivity.

There are many causes of recruitment problems and high turnover. In some groups NHS pay is inadequate compared to other jobs the same staff can do. This is a big issue for nurses but a huge problem for support staff like data scientists. It is also a bigger problem in some geographies like London where the cost of living is much higher and there are more alternative well-paid jobs. But the NHS finds it almost impossible to flex salaries to retain the people it needs both because the pay scales are national and because some groups are vastly undervalued in AfC grading compared to the market.

Working conditions are also a huge factor for recruitment and turnover. If the space is badly adapted to the work being done (~14% of buildings predate the NHS!) then the environment will be poor. Badly maintained buildings add to this (the maintenance backlog is about £10bn). Old, shonky equipment is slower and harder to use than modern equipment. IT systems are often slow and not seamlessly integrated so staff waste time waiting to log on or logging in to a dozen separate systems to complete a clinical task. Front line staff end up spending too much time doing tasks that should be done by support staff or managers (where staffing levels have been cut to "put more staff on the front line") instead of caring for patients. 

Too much of the people management in the NHS is bad. Staff are treated badly and insensitively by managers but also by senior doctors and nurses (the Ockenden report didn't just blame "staff shortages", it clearly blamed senior staff of all professions for ignoring clear signals about problems and even suppressing whistleblowers). 

Very few, if any, of the factors that discourage recruitment and drive high turnover are part of any proposed workforce model.

So the model won't tell the NHS whether a big increase in capital spending, creating better buildings, equipment and IT systems, would yield rapid gains in a better working environment. Nor will it conclude that recruiting more support staff to enable the front line to focus on treating, rather than admin paperwork, would improve their job satisfaction. And nobody in NHSE would allow the model to conclude that salary flexibility might yield immediate benefits in both lower turnover and higher recruitment rates.

That means that the model is likely to have nothing to say about the major factors that could impact the workforce any time in the next 5 years. What was the point of it again?

A long term workforce model risks fossilising current mistakes and practices

More than a decade ago I was part of a team auditing some workforce models for SHAs (when they still existed). One of the problems the team spotted was that complex models with very large amounts of detail tended to be very hard to audit properly and often contained errors in their code. That's bad when you rely on their outputs. 

But that complexity also had a side effect that is, though not an error, worse: they fossilised current assumptions about the mix of the workforce. In particular, they made assumptions about the need for very small specialist subgroups of staff (humorously like the number of orthopaedic surgeons specialising in only left hands). The problem is that practices often change faster than the model. So, if the model spits out the demand for some small highly specialised group in a decade's time, it may have been overtaken by major changes in the way that specialty works. Once upon a time, for example, most cataract operations were done under general anaesthetic. Then it became obvious that local anaesthesia was faster and safer and the mix of activity changed rapidly. Any model built before that change was obvious would forecast a completely incorrect mix of staff or number of staff.

When you build complicated models there is always a big risk that the assumptions in the model persist long after the change as many models are even harder to update than clinical practice. Or the modellers just don't notice the changes and the NHS keeps relying on their model as the users of the model don't understand it well enough to understand the assumptions it makes.

In another case I studied a model built for NICE on staffing in A&E departments (see my commentary). The original report gained a lot of credibility when NHSE allegedly suppressed it. But it was leaked alongside the full documentation on a simulation model built by external consultants that had been a major evidence source for their recommendations. I read the documentation. I wept. The assumptions about how an A&E worked had almost no relationship to reality and ignored very clear, well-known, data about actual performance. It looked like it had been built by someone who had never visited a real A&E or mapped a real world operational process. I suspect that most people who read the report didn't understand the model or that it was a major part of the evidence behind the recommendations. But bad models make bad recommendations. Worse, complex models make those mistakes harder to spot.

Even when a model works it may fail to influence the right decisions

The debate about the need for an NHS workforce model seems to assume that models have a magical ability to change the decisions people make. Decision scientists know this isn't true. 

Many analyses and models completely fail to influence actual decisions even when they are reliable and the data behind them is correct. For example, the NHS has reported on the hospital maintenance backlog for years, including an estimate of the need for urgent action to limit the immediate risk to patients. Yet decision makers have repeatedly chosen to spend far too little on capital (the budget has been about half that of peer health systems for most of the last two decades). And the high risk maintenance budget backlog grows every year. Maybe bad decision making is very resistant to modelling or analytical data.

Models work best not when they give a highly specific and precise answer but when they help decision makers to understand the core issues behind the decisions they have to make. A complex and detailed model of the NHS front line workforce is unlikely to achieve this. Not least because, if its focus is just the front line, it will fail to help decision makers to understand the tradeoffs involved in between different decisions they could make today.

What if, for example, a small increment in the number of managers greatly improved the productivity and quality of the work done in hospitals? How would that choice interact with the future needs for front line staff? We already know that more managers do have significant effects (see this summary from the NHS Confederation) but the idea that a workforce model should think about them is entirely absent from the current discussion on workforce modelling.

Also missing in the discussion on workforce modelling is any hint of how capital spending on better buildings, equipment or IT could contribute to productivity. But decision makers have to make tradeoffs today about how to split the budget among front line staff, support staff (including managers) and capital spending. And for most of the last decade that choice has skewed towards the front line leaving the NHS with a chronic deficit of support staff, managers and adequate modern buildings and IT (for some data see my analysis here). Those choices have led to declining front line productivity, a much worse working environment and, arguably, contributed to recruitment problems and higher staff turnover. A model focussed just on the long term needs for front line workforce numbers will encourage continued neglect of those other factors which directly impacts the immediate workforce.

Conclusion: a long term workforce model is a distraction not a solution

It seems obvious that the NHS has a serious shortage of front line staff. But that observation is very deceptive. It is a symptom of widespread problems of productivity and blocked flow of patients. As with many medical conditions, there is a strong temptation to treat the symptom and assume that this cures the disease. In NHS language, focussing on the front line workforce assumes that investment in the front line workforce cures the problem. But, like trying to cure headaches caused by a brain tumour with stronger painkillers, treating the symptom doesn't solve the underlying problem.

A model that assumes that frontline overload is cured purely by adding more staff distracts attention from all the other factors causing overload of front line staff. So attention will be distracted from inadequate buildings, obsolete equipment, slow and badly designed IT, admin overload caused by a lack of support staff and managers, and poorly designed clinical pathways. And "more staff" doesn't fix problems where the issue is having the wrong mix of staff. 

Some of those problems might be fixed, in principle. We could, perhaps, build a model that takes into account the staff mix, not just the overall number of staff. It could even highlight the areas where extra staff would most improve overall productivity (eg, to fix A&E overload, invest in staff who can improve the flow through beds). Unfortunately the first step would be to develop an analysis of how the whole system fits together and therefore identify which incremental investments would most improve the productivity of the system. There is no such analysis, though there are plenty of hints that workforce isn't the biggest problem. 

The workforce model as currently discussed seems likely to further distract the NHS from other major problems. A focus on the front line risks distracting from even bigger staff shortages behind the front line. And from a long term neglect of capital spending (leading to major issues with buildings, equipment, and IT). Furthermore there is a big risk that a long term workforce model could ignore the short term decisions that might help the immediate problems with workforce and could encourage the NHS to build in false assumptions that fossilise bad current choices.

That's a lot of risks for an unclear outcome. Whatever the intuitive attraction of a transparent model of workforce needs, it is far from obvious that the NHS would get anything useful.

We need a more informed debate about what holds back NHS productivity, not a model focussed on the front line workforce.

Thursday, 31 March 2022

The biggest problem holding back NHS performance is a lack of investment in capital, innovation and management not staff or beds

In debates about what the NHS should do to improve its performance it is common to see benchmarks of staffing or bed numbers versus comparable health systems. The argument is that the system needs more doctors/nurses/beds. This is not the biggest problem. The NHS has suffered far more from a failure to invest in capital, innovation or management. 

Charts like the one below dominate the debate about NHS funding:

The message is simple: the NHS is underfunded and needs to have more doctors (or nurses or more money, depending on which lobbyist is producing the charts).

The implication is that the very obvious performance problems of the system would be solved if only we matched the same level of doctors/nurses/funding as the peer group of other health systems.

There is some debate on the strict comparability of these metrics and that is rarely mentioned by the lobbyists. In fact I once saw Nigel Edwards heckled for pointing out that a major revision on OECD metrics of overall spend on the NHS and comparable systems made the NHS look middling rather than an outlier on the low side. People really want the explanation for poor NHS performance to be simple and, preferably, a conspiracy they can blame on the Conservatives. It is frequent to see phrases like "Tory staffing cuts".  And that is the end of the debate for many.

But, even though the overall NHS budget saw unusually low growth in the decade after 2010, front line staffing increased significantly. The "tory cuts" in staffing led to ~30% more doctors and 15% more nurses:

I don't want to argue that the government is not to blame. I do want to argue that we are looking in completely the wrong place about where policy has been wrong.

There are far, far bigger problems than not having enough front line staff. And the real problems that front line staff experience are often consequences of those other failures. Worse, those other failures get almost no attention and the topics that do get attention distort the debate so much that the biggest and most important failures get essentially no critical attention.

Before I get to the other issues that I argue matter more than staffing, it is worth a quick review of why the staffing benchmarks are not that relevant to NHS performance.

One reason is a lack of strict comparability with the other countries in how they use staff. But a more interesting one is that the implied policy when it looks like the NHS is behind ("fix the staffing, fix the problem") very clearly doesn't work in specific cases. An example is A&E staffing. It has been repeatedly claimed in the last decade that the decline in A&E performance is a consequence of a lack of A&E staff. But the number of A&E doctors rose faster than demand every year since 2010 and the number now is >30% higher than it was in 2010. The number of A&E specialists grew faster than any other for most of the last decade. But performance has declined monotonically over that period. 

In this case it is easy to see why staffing was never the problem. Patients suffer long waits in A&E not because there are not enough A&E staff to treat them but because there are no free beds to move the patients to. This was known in the early 2000s when the 4hr target was set and has repeatedly been shown in detailed analysis of the causes of waits in the last decade (see, for example, this from Monitor). To put it simply, more A&E doctors can't magic up more free beds. They mostly can't even influence the number of free beds. So adding more staff doesn't fix the underlying problem. (I should add that the longer the A&E queue, the more staff are needed to handle it. So the apparent staff shortages are actually a symptom of a different problem elsewhere in the hospital, not the cause of the problem. Adding more doesn't fix the problem.)

So what other errors has the NHS made?

The NHS benchmarks that really matter

Let me tell you the answer before working through the details and arguments. 

The NHS might be slightly short of front line staff but it is catastrophically short of support staff like managers and has a long standing lack of investment in innovation and capital spending. If benchmarks versus comparable health systems are any guide, the NHS is a spectacular outlier in investment and management. 

The NHS is very undermanaged

When the Lansley Reforms were in draft form and proposed severe cuts in management numbers there were several analyses that criticized this goal. The King's Fund concluded as part of its commission on leadership and management that:

"If anything, our analysis seems to suggest that the NHS, particularly given the complexity of health care, is under–rather than over–managed."

And this was before the drastic cuts in the Lansley reforms were implemented (see the staffing chart above for their immediate impact). A more recent analysis (in a report by Ian Kirkpatrick and Becky Malby for the NHS Confederation) said:

" is hard to argue that the NHS is ‘overmanaged’. At approximately 2 per cent, managers are a very small proportion of the NHS workforce. By comparison, ‘managers, directors and senior officials’ in the UK as a whole make up 9.5 percent of the workforce." 

And, in another report in the series they argued this: 

"We found that even a small increase in the proportion of managers employed (from 2 to 3 per cent of the workforce in an average acute trust) had a marked impact.

Up to a certain point, larger management functions in trusts were associated with higher patient satisfaction scores, a 5 per cent rise in hospital efficiency and a 15 per cent reduction in infection rates. Further tests revealed that it was primarily higher levels of managers employed that drove these improvements and not the other way round."

Both NHS management numbers and total administration costs are far below international norms and have fallen sharply since 2010. Given the clear evidence from Kirkpatrick's work that more managers make hospitals function more effectively, cutting management looks like a bad error. Adding more managers has a lot of leverage over the performance of all the other staff but the NHS has chosen to cut their numbers instead.

Both manager numbers and total administrative costs are far more out of line with international norms than the number of doctors, nurses or beds. Although good comparable metrics are hard to find, the IFS claimed this in 2018:

The OECD has compiled data on administrative costs of different health care systems at the ‘macro’ level – which captures the amount spent on planning, funding and monitoring care, but not administrative costs within individual hospitals. 

They found that the NHS spends relatively little on overseeing and planning care, relative to other comparable systems. In 2014, the UK, Portugal and Ireland all devoted 1.5% or less of their government or compulsory health care expenditure to administration. This compares with an average of 3.1%, with 4.1% in France, and 7.9% in the United States.

Investment in innovation and capital is grotesquely low 

Another area where the NHS is an outlier is spending on capital and innovation. In fact it is an extreme outlier.

This is somewhat ironic given Rishi Sunak's recent spring statement where he diagnosed a major problem for the UK economic productivity as being largely caused by a lack of investment in innovation and capital. As he argued:

"Over the last fifty years, innovation drove around half the UK’s productivity growth.

…our lower rate of innovation explains almost all our productivity gap with the United States.

Right now, we know that the amount businesses spend on R&D as a percentage of GDP is less than half the OECD average.

Weak private sector investment is a longstanding cause of our productivity gap internationally:

Capital investment by UK businesses is considerably lower than the OECD average of 14%.

And it accounts for fully half our productivity gap with France and Germany."

The NHS is the largest part of the UK economy controlled by the government. So exactly how has the government sought to control its spending on the key factors that determine productivity in the rest of the economy? 

It won't surprise you to know that it is the opposite of the Sunak recipe for productivity in the private sector.

The Health Foundation did a (little read) briefing on this in 2019. It starts by pointing out the obvious:

"Capital spending is a critical input in health care, with new technology able to transform services and improve workforce productivity. 

The DHSC has proposed a more technology–and data–driven NHS. New technology and IT could improve patient services and increase productivity, but both currently make up a small proportion of capital spending."

So the DHSC has an ambition to exploit technology and IT (which needs investment). But the Health Foundation analysis of 20 years of NHS capital spending compared to peer health systems looks like this:

Only during the late Blair/Brown years did NHS capital spending come close to international norms and it is often the lowest or next to lowest in the whole dataset. The Health Foundation  argue:

"For the UK to move up to the average for OECD countries, capital spending would have to almost double as a share of total health spending"

The National Audit Office also reviewed capital spending in the NHS in 2020 and some of their analysis tells an even more sorry tale. 

They start by pointing out part of the current situation with buildings and other capital assets:

Parts of the NHS estate do not meet the demands of a modern health service. NHS hospitals include Victorian-era buildings, and 14% of the NHS estate predates the formation of the NHS (1948). 

The growth in backlog maintenance indicates that there is an increased risk of harm to patients … the backlog of maintenance work to restore buildings to an appropriate standard was around £6.5 billion … High-risk backlog maintenance currently stands at £1.1 billion, and grew by 139% between 2014-15 and 2018-19, indicating an increased risk of harm to patients.

It isn't just the lack of modern IT and diagnostic equipment that holds back the NHS. It needs more modern buildings to do a good job but frequently doesn't have them.  Worse, in some cases, maintenance problems in the existing buildings are so bad they risk immediate harm to patients.

Given this already disturbing background it might be a surprise when they point out that in many years of the last decade the already inadequate capital allocation to the NHS was underspent:

"Between 2010-11 and 2012-13, there was an average underspend of £677 million (12%) against the capital spending limit. In 2017-18, £360 million (6%) was unspent."

And their story gets worse:

"Since 2014-15 the Department has transferred £4.3 billion from capital to revenue spending"

So not only does the NHS start with an inadequate budget, which it underspends, it is then encouraged to pilfer the capital budget to cover operating costs. The reason this has been encouraged is because it is a convenient short term way to cover up operating deficits. These are embarrassing. And, obviously, avoiding embarrassment is more important than the roof of an operating theater falling in. Better still, while operating deficits are visible every year, most of the catastrophes from the maintenance backlog will appear slowly over a decade.

It might seem strange that the inadequate capital budget should ever be underspent. But the NAO explain that too by pointing out that the paperwork and bureaucracy of applying for capital is so baroque that many hospitals can't even get their cases for urgent maintenance past the system. And, even if they do, they might lose the allocation if they can't spend the money in-year as next year's allocation may be arbitrarily different. Short term changes to the budget every year make long term planning of capital spending impossible.

The buildings are inadequate for modern healthcare activities. There is a huge and rising backlog of maintenance to keep the show on the road that is limiting the capacity of the system to do more work. The system frequently steals from capital to employ more staff who will have to work in an environment where their work will be harder and less productive. The NHS is close to bottom on international rankings of the amount of high-tech equipment it needs to do the diagnostics necessary to tackle long elective queues. And there is little budget for investing in better IT to enable front line staff to work faster and more productively without the burden of coping with decade-old kit.

It is lucky that investing in capital or innovation doesn't matter for productivity. Oh, wait, that's exactly what the chancellor blamed for low productivity.

As an ironic coda to this section the following story appeared in the HSJ the day after his spring statement:

"Tech spend under pressure as NHSE told to ‘cut core funding’"

It hasn't taken long for the promises in the last spending review to invest more capital in the NHS to hit the buffers of old Treasury munchkin habits.

The government's goals for an improved, more productive NHS are directly undermined by its choices about how to allocate resources.

There are several important messages here.

Problem 1: the government itself has correctly argued that spending on capital and innovation are vital for driving up productivity. So much so that they are increasing the incentives to encourage more such spending in the private sector. But, when they control the budget, they do exactly the opposite. And, at the same time, continue to demand even higher productivity gains from the NHS. Whipping a dead horse doesn't cover it. It is more like whipping the reliquary containing the ashes of the horse cremated a decade ago after being euthanized for breaking a leg.

The second huge problem here is the lack of attention this analysis has had among commentators and the media. The news is full of stories about how the NHS is struggling because it has 10 or 20% fewer doctors than comparable systems. Lobbyists for nurses and doctors demand higher levels of staffing to fix the overwork, the current catastrophic waiting lists and A&E delays. But there is little mention of the fact that the NHS has perhaps half the capital employed per worker than almost any other health system. The NHS is a far more extreme outlier on this than it is on staffing. And the day to day work the front line staff have to do is much harder and less productive as a result.

The third problem is management. NHS management does make the news more often than capital spending, but almost always to disparage it. Stories often argue that we could cut management even further to put more resources to the front line. These stories usually fail to note that NHS management has already been sharply cut by the Lansley reforms and is currently another major outlier in comparisons between the NHS and other systems (I made the case about managers and their importance in the NHS here). Nor do they mention that very clear work shows that more managers make productivity and medical quality better. 

In short, there is a fundamental mismatch between the government goal for a more productive NHS and the way it provides the tools to the NHS to achieve that productivity. The government and NHSE are like an army who recognises the need for bullets but forgot to allocate a budget for the guns required to fire them. 

The perpetual failure to invest enough in capital, innovation or management is a far bigger problem for the NHS than any shortage of staff. It is about time the commentariat, the media and the government realized this. We won't fix the NHS until they do.


Tuesday, 5 October 2021

GP prescribing is one of the few areas of NHS spending that is under control

Last week the government released a report on overprescribing that suggested perhaps 10% of prescriptions issued by GPs were unneeded or harmful. The media headlines tended to frame this as another reason to attack GPs. The Telegraph, for example, had this headline: "GP's needless prescriptions push drugs bill to £9bn…"

This framing was wrong but also led to a huge story being missed and an important lesson being ignored.

While GP overprescribing is a problem that deserves to be tackled, it is a far smaller problem than hospital prescribing and is already being tackled (for example, the report highlights the campaign against antibiotic overprescribing in the mid 2010s that led to substantial reductions). 

The GP prescribing budget is one of the few areas of NHS spending that has been under control. It has been between £8bn and £9bn for longer than a decade and has shown as many falls as rises year on year. Overprescribing by GPs is not driving spending up.

Hospital prescribing, on the other hand, has risen from £4.2bn in 2010/11 to £11.7bn in 2019/20 and is rising at a rate of between 8% and 16% every year (see the NHS Digital data here: ). See the chart: 

(the numbers above the bar are the annual growth rates in the spending)

This is out of control and, unlike GP prescribing, is a big problem.

We have a good idea why one budget is under control and the other is not. Detailed data about what is happening in GP prescribing in England is available and has been public for more than a decade. Analysts like me can count the number of prescriptions for, to give an example, 20mg simvastatin pills, in every GP practice every month. This hugely rich dataset covering more than a billion annual prescriptions can be interrogated to reveal the differences among practices for every one of the 20 or 30 thousand items they can prescribe (Oxford's EBM Datalab even provides a free interactive tool allowing anyone to analyse the data: ).

We don't yet have anything like that for hospital prescribing (the Datalab is working on one but it isn't complete). For many years the only source the NHS had was data bought from an external firm which had restrictive clauses preventing detailed use or dissemination of the numbers (that external firm's primary purpose for collecting it was to sell it on to the pharmaceutical industry for sales analysis, not to help the NHS get a grip on its spend). The NHS has no mandatory collection of data that would give it the same level of insight it already has for GP prescriptions.

Given how little we know about hospital prescribing, there is little mystery why the budget is out of control (and rapidly approaching 10% of the whole NHS budget). When the NHS has exquisitely detailed data about what is happening it can get a grip on both quality and spending; when it doesn't, the budget is out of control and the system has no idea about the quality. For all we know hospitals are wasting gargantuan amounts of money and overprescribing on a massive scale.

We should be praising GPs running one of the most well-managed areas of NHS spending. And we should be scandalised, instead, by the NHS's failure to collect the data necessary to get a grip on out of control prescribing by hospitals. That's what the headlines should have been last week.

Wednesday, 25 August 2021

Andrew Lansley would have lost the Battle of Britain

In a gobsmacking interview with the Institute for Government, Andrew Lansley revealed his reflections on his notorious health bill. He doesn't seem to have learned much. Had he been in charge in 1940 Britain would have lost the Battle of Britain. This is important as his mistakes are still prevalent in government thinking about how to run the NHS. And we need to learn from his mistakes or we will lose the battle for the NHS.

Introduction: thank you HSJ

The Health Service Journal had an interesting juxtaposition of reports in its regular The Primer column on August 23

The column reviews commentary on the NHS that hasn't otherwise appeared in the journal. On that day it mentioned a gobsmacking interview where the Institute for Government has asked Andrew Lansley to reflect on his time as Health Secretary. But it also reported an opinion blog by me published the previous week on the utter lack of any attention to management in the latest health bill. In doing so they also reminded readers of a much older opinion piece I wrote in 2015 about lessons the NHS could learn from the Battle of Britain (the original blog was written in 2015, the HSJ version–thank you for describing it as "legendary"–was published in 2018). 

The juxtaposition of the Lansley interview, my opinions on management in general, and the Battle of Britain in particular set me thinking. My immediate thought was that, if we applied Lansley's thinking on management in the NHS to Britain's air defence strategy in World War 2, we would have lost the battle.

I think it is worth explaining why. Again.

Lansley thinks management gets in the way of effective action

So what did Lansley say?

Not everything he argues in the interview is wrong. For example:

Because in the NHS, there was – and still is, frankly, and it is returning now – a dominance of the provider interest over the consumer interest.

In this, he was and is right. For example, NHS policy for many decades has been to try to move activity away from hospitals and into the community. But the dominance of decisions by big hospital providers has meant that, in decades of trying, hospitals have, if anything, a larger share of the budget than they started with.

And his method was to give decision making power to CCGs not dominated by acute hospitals. And, given the above, this might have been a good idea:

The essential proposition was that commissioning should be led by clinicians and should be the central focus of NHS activity in delivering better outcomes within budgets.

But then he lets his core beliefs out of the bag:

But what you have to understand is that in the Department of Health, many senior positions were filled by NHS managers. And they, of course, had a completely different approach. They hated it all. They hated the reforms; they were the enemy within. Because they saw the reforms as handing power to clinicians, and by extension removing jobs and control from the hands of the NHS management.

His view of managers is something like the Kafkaesque bureaucrats running the world of Terry Gilliam's Brazil.

This is a Daily Mail fantasy rant, not a serious assessment of NHS management. I'm not arguing that nobody in NHS management is like this, but Lansley's view both overgeneralizes and makes a huge error about the role of most managers. The leadership in DH are not like the ward manager who tries to improve patient flow by coordinating the activities necessary to discharge a patient. They are not like the managers who coordinate and schedule activity in operating theatres so all the equipment and people are available at the same time to ensure the surgeon can operate without silly delays. Those managers–the majority of the managerial caste–are more like the transmission in a car: sure, the engine provides power but the wheels don't turn if some of the gears in the transmission are missing.

When it came to his bill, Lansley dealt a severe blow to the managerial caste, attempting to impose 50% cuts in their–already inadequate–numbers by including a limit in the bill for how many managers a CCG could have. 

He still seems to think this was a good idea, claiming in the interview that he saved the NHS £1billion a year in management costs. Which he did, but at the cost of both organisational chaos and the ability of his new decision making clinicians to decide how best to spend their budgets and to implement the changes they wanted. CCGs got a new engine but most of the gears in the transmission were now missing. The general consensus was that the new bodies were the equivalent of a friday afternoon Austin Allegro that got through quality control when the QC team were still in the pub.

He wanted CCGs to think differently (I'm sure his grammar is better than Apple's) and to do differently. But, in his naive defenestration of the NHS management caste, he left organisations with no capacity to think or act differently. And it isn't like he wasn't warned

This thinking would have lost the Battle of Britain

This is where it is worth reviewing the lessons I reported in that piece about the Battle of Britain (originating from military historian and management expert Stephen Bungay).

Bungay's key point is that the myths we tend to be fed about the battle deeply misrepresent the reality. We often assume that Britain won because we had better planes (Spitfires!), clever new technologies (Radar!) and more heroic pilots (Douglas Bader!). These make a cool national myth but one which is close to the exact opposite of the truth.

The Battle of Britain was won because the RAF had by far the best organised fighter defence in the world. The Luftwaffe had great planes, radar and equally heroic pilots. But they didn't organise them well.

Organise is the key word here. The RAF had spent years developing a sophisticated operational process to manage its fighter defence. The management system that coordinated the defence was what won the battle. As Bungay remarks:

In their ‘finest hour’ the British behaved quite differently from the way in which they usually seek to portray themselves. They exhibited a talent for planning and organisation which, in its Teutonic thoroughness, far outstripped that of the Germans. They left little to chance, planned for the worst case and did not rely on luck. Given all this, it is hardly surprising that they won. It is, on the other hand, quite extraordinary that they should imagine they could have won by doing the opposite.

But the people who designed and implemented that management system would be exactly the people Lansley would have fired so the front line pilots could make the key decisions. The very people needed to design and implement the processes that deployed the RAF to maximal effect against the Luftwaffe would be the people Lansley hated. I imagine him saying "We don't want bureaucrats telling the pilots what to do". The front line pilots, in his view, would be the experts who know best how to fight the hun.

But they were not. And we know this because a very similar argument actually raged during the Battle of Britain. The two most important men in "management" roles were Hugh Dowding (who designed the system and was in charge of Fighter Command) and Keith Park (who implemented it and was in charge of 11 group which defended London and the South East). Their flexible and selective way of managing the deployment of fighters was strongly disliked by some famous pilots (eg Douglas Bader, a well known public figure even then) and by the commander of 12 group (which defended the midlands), Leigh-Mallory. Bader and Leigh-Mallory believed that an idea called the Big Wing was superior to what they were being directed to do by Park and Dowding. 

Dowding and Park were both moved sideways towards the end of 1940 (luckily after the Battle was won) because the lobby for letting pilots do what they wanted (which included Leigh-Mallory) had better political connections than they did. This was a mistake as later evidence showed Park and Dowding to have been right. And, later in the war, Park did it again in the defence of Malta, thoroughly defeating the Luftwaffe attempts to crush the island's defence. As Bungay remarks: 

What Park achieved in the Battle of Britain is in itself enough to place him amongst the great commanders of history. But his performance in 1940 was not a one-off. In 1942 in Malta, Park took the offensive and turned Kesselring’s defeat into a rout.

He was as adept at offence as he was at defence, and, like Wellington, he never lost a battle. His record makes him today, without rival, the greatest fighter commander in the short history of air warfare.

Andrew Lansley would have sided with Douglas Bader from the start. He would have sided with the opinionated front line pilots rather than the people who had demonstrable ability to find the best way to organise Britain's defence. He would have removed Park and Dowding before the Battle leaving the very real possibility that Britain would have lost because of the inferior systems proposed by Bader and Leigh-Mallory. 

Why Lansley's naive view of management is wrong

Lansley's comments repeatedly demonstrate that he has no idea of the various roles of management. 

One role is to organise the deployment of front line staff. In the Battle of Britain this involved managing the information flow from radar and observers to understand where the German bombers were and deploying the fighters in the most effective patterns to combat them. The naive views of some of the more vocal front line pilots about how best to deploy their planes were wrong. And few, if any, of the front line pilots could have designed the intelligence system that directed them to their targets (Dowding and Park had spent years thinking about the system of deployment not just about how to win a dogfight). Though both had front-line experience, it was their focus on how to manage the battle that made the difference. Lansley seems to assume that front line experience is all that matters and there are no benefits from organising the front line more effectively. 

He also misses the role of management and support staff in implementation. (Arguably "support" and "management" are different but they work together to make things happen). He demonstrates this in this quote:

But there were things like the continuation of commissioning support units and the form that commissioning support units took that I would not have done were it not for David Nicholson protecting his own people in the NHS and in strategic health authorities.

Now I am no fan of commissioning support units, very few of which did good jobs, but Lansley doesn't seem to understand anything about what their roles were. Many took over essential roles like managing procurement and the provision of analytics to CCGs and hospitals. I generally think their ability to do such jobs well was deeply undermined by the compromised and confused way they were set up, but, surely, not bothering to do those roles at all would be even worse?

Were Lansley looking at the huge infrastructure necessary to operate Dowding's system for directing the RAF (huge numbers of observers, multiple control centres, many layers of middle managers interpreting and filtering information before making decisions and sending instructions to the pilots), he would probably have slashed it in favour of "more resources to the front line" and more pilots and planes. 

The key point here is that the role of management is both about deciding the right strategy and having the infrastructure to make it happen. Lansley's own words suggest he understands neither role. And his actions slashed the capacity of the NHS to do either. Sure, he could claim £1billion a year of savings from ruthlessly deploying an axe to managers, but the resulting chaos and performance degradation show that the "savings" came with catastrophic costs. Incredibly, Lansley claims credit for improvements in the system: it happened, we got waiting lists down to their lowest ever level in late 2012.  

which were delivered before his changes were fully implemented and ignores the catastrophic declines that started as soon as his ideas began to take hold (waits for elective treatment and in A&E departments are now worse than they were before the major Labour reforms of the early 2000s). Remember when fewer that 2% of patients spent more than four hours in A&E? Today's NHS in England struggles to get fewer than 2% of patients spending less than 12 hours in A&E.

Lansley would be claiming credit for getting more Spitfires in the air even after the UK had been invaded by the Nazis.

In the interview he demonstrates a stunning naivety about the role of management in the NHS combined with an adamantine refusal to evaluate the real consequences of his decisions. What is worrying is that his views on management are widely held both by critics of his ideas and current NHS decision makers. His structural ideas about the NHS are being dismantled but his naivety about the role of management carries on. The current health bill says nothing at all about management.

Lansley seems unable to learn from his own experience or from history. We desperately need NHS policy makers to do better.