Tuesday, 8 September 2015

Top-down changes won't bridge the NHS funding gap

It is all too tempting for the leadership of the NHS to assume that the top-down levers they can easily control will be the things that will solve the big problems facing the NHS. They won’t.
Few disagree that the NHS has to generate something like £25bn of extra activity in the next 5-10 years without getting the £25bn of extra cash required to pay for it if the costs of that activity remain the same. In other words: there is a productivity gap.[1]
Both politicians and the leaders of the NHS have produced plans to avoid this future crunch. And those plans look a lot like other plans proposed or implemented over the last three decades that have arrived with the promise they would improve the NHS. They all share some characteristics that make it unlikely they will actually help.
This is why I think they won’t and what the alternatives are.
Governments in particular suffer from a belief that the things they know about–which being made up largely of professional politicians and lawyers and having very few engineers, scientists or practical managers consists of legislation and top-down organisational changes–are that only things that matter much in driving change. They are like one club golfers or perhaps footballers who only know how to tackle and not how to kick the ball.
There are two reasons for this narrowness of vision. One is simply that that is all they know. Legislators know how to write laws, they don’t know how to manage an organisation. The other reinforces that ignorance by using legislation as a signalling mechanism with no intention of it actually doing any good in the first place (legislation limiting government freedom can always be abolished if it doesn’t work out unless it can be written into a rigid constitution limiting future government freedom to amend it; the UK has no such framework). So in the UK we have had laws to limit the size of the government deficit and laws mandating a reduction in child poverty. Neither has any credibility in driving action yet both wasted valuable government time that might better have been spent understanding the problems.
One consequence for the NHS has been a major structural and legislative change every 5-7 years since Margaret Thatcher won the 1979 general election. Given that many of the changes take perhaps 3 years to enact and implement and the system takes perhaps another 3-4 years to get used to how the new structures work, there has probably been no point in my adult lifetime when we could judge whether the long term effect of any particular organisational form for the NHS was likely to lead to sustained improvement.
The NHS faces many major challenges and many of these have existed for decades. The leadership, however, is perpetually tempted by one major immediate challenge that often squeezes out its ability to deal with the big long term challenges: the need to be seen to do something right now. This reinforces the temptation of all those top-down changes. “We know” the political and organisational leadership seem to argue “how to do structural and legislative changes and at least we will look like we are doing something.”
The core problem faced by the NHS as a whole is the mismatch between the demand and the capacity of the system. However much money we spend, it seems that demand will always outstrip capacity. But it is worth clarifying what this means.
Some argue that growing demand on the service could be curbed by better effort devoted to prevention. even if true, though, this plan might not pay back for 30-40 years. Even if we could make a significant difference by doing the right thing now, the benefit will fall to our children and the current NHS will still face the damning consequences of mistakes made four decades ago.
On the other hand there is plenty of current activity that isn’t that beneficial. Many very expensive cancer treatments lead to only small increases in life expectancy or only work on a small proportion of patients. Shockingly, many patients currently receiving aggressive treatment for cancer would live longer if we stopped aggressively trying to cure them and started palliative care so they could have a more pleasant death.[2] And it isn’t just cancer. Many routine NHS treatments seem on contribute little to the wellbeing of the patients being treated. Whether improved data (more PROMS[3], for example) combined with improved decision making would lead to a lower NHS activity without harming patients is not proved, but it looks promising. If it worked that would be an immediate contribution to the big challenges.
More important and less controversial is the idea that the NHS needs to get more productive. More treatments for a given spend. Nobody disagrees that would be a good idea (though some think it is impossible to achieve). But there is a very lopsided argument about the best way to achieve it. And we don’t always have a sensible definition of what productivity is. It isn’t just about more treatment; it is also about better treatment and fewer errors in treatment.
Major organisational changes are always justified by the effect they are supposed to have on productivity. But, while organisational structures can blunt the incentives to be productive, they don't have a big impact and they do disrupt the system for years every time they are implemented so, if done too frequently, they permanently distract the management capacity of the NHS away from a focus on what matters. This applies at multiple levels to reinforce some of the temptations of top-down management. For example, there are some economies of scale in many hospital services. This should lead to larger hospitals having lower costs than smaller ones. And this appeals to top-down planners (who only seem to understand top-down economics) and hospital managements (who always prefer a bigger empire to a smaller one). But the evidence that scale matters a lot for whole hospitals is scarce (to be fair there is good evidence for some highly specialised services like stroke or major trauma but not for many routine services). But hospital mergers have a poor track record of delivering improvement in the NHS (and NHS hospitals are already on average bigger than almost any others in Europe). One possible reason is that, according to one unpublished study I’ve seen, size only accounts for about 10%-20% of the cost differences in NHS hospitals. The rest of the difference is about local operational, organisational or geographic factors.
This is where I get to speculate. My hypothesis is that the majority of differences in productivity are determined by operational management. In other words, how you organise the work[4]. A well organised A&E department will treat more patients faster than a poorly organised one even if the poor one has far more staff. And the quality of treatment will be better. But the quality of operational management is not directly visible to top-down planners. Worse, top-down planners like campaigns to reduce bureaucrat numbers but lack the ability to distinguish between wasteful pen-pushers and good operational managers so place staffing limits on all management. In an organisation like the NHS where the management capacity is remarkably low to start with this is a catastrophe.
The thing is we know that when operational management is done right, productivity and quality improve. It isn’t all about the amount of resources available. The medical (or nursing) life isn’t all about being overwhelmed by uncontrolled demand. If you take control of how the work is organised, work can be made less pressurised, resources can be freed up, patients can be happier and quality can be transformed.
One of my favourite examples comes from here and it is about transforming the patient and GP experience in primary care by applying simple operational principles.[5] Those of you who follow @HarryLongman on Twitter will know the evidence already. You can search his website for the detailed evidence that his process works, but my simplified summary is below. Instead of assuming that all requests for a GP appointment are equal (and fit in a 10min slot) practices should assess all requests by phone or face to face. Only then should any appointment be booked and the appointments should be adjusted to the nature of the demand. What happens when this is done is that much of the demand goes away or is dealt with very quickly and often over the phone. This frees up so much practice time that it usually becomes possible to meet all demand for an immediate appointment on the same day and leaves some over leaving less pressurised staff and happier patients.
I’d go so far as to say that the success of his approach shows that the actual problem in primary care isn’t, as headlines and RCGP campaigns suggest, overwhelming demand and underfunded primary care budgets, but a chronic lack of the operational skills to design GP services that match the needs of patients. And a naive adherence to an inflexible model of how GPs should operate. Maybe the RCGP should offer operational training to GP practices before starting any more campaigns for a bigger share of the NHS budget.
Another example from the acute sector reinforces the belief that much of the NHS lacks the operational expertise to run its services effectively. In a recent HSJ article, Rob Findlay (@Gooroohealth on twitter) points out that elective waiting lists don’t demonstrate a fundamental lack of capacity in hospitals. If we were really short of capacity, waiting lists would rapidly grow without respite. They don’t. They rise at some parts of the year and fall in others with very small long term drift. He argues that the problem is they way hospitals respond to the pressure. Instead of smoothing the capacity to match the demand, many hospitals only adjust the capacity in a panic when things get out of hand in the short term. This increases the burden on staff and costs much more as much of the “extra” capacity is bought with expensive overtime and out-of-hours payments. He argues that much of this could be avoided (reducing costs and staff disruption and burnout) by fine-tuning capacity well in advance of the panic resulting in far better use of available resources (of staff and equipment). He argues:
...we could manage the main working week with the resources we already have, instead of continually incurring the high marginal costs, inefficiencies, and risks of relying on ‘extra’.”
Again, the point is that good operational management can greatly improve the productivity of a service in a way that is good for both patients and staff.
My main point is that real change in the NHS will come bottom up from operational improvement and not from more top-down changes. And they should be easier to sell to staff as they see the benefits immediately rather than having to wait years to see how new structures, incentives or tariffs work their way through the system.
I hope that the Vanguard programme launched with the 5-year Forward View will sneak some more of this sort of thinking into NHS strategy. But I know from some recent conversations that a great deal of thinking at the top is being focussed on the top down stuff that likely won’t have much effect like major changes to the way tariff works.
The NHS can meet its productivity gap, but bottom-up operational improvement is the key, not big top-down initiatives. Let’s hope that’s what we get.

[1] Some have described this as a budget cut. It isn’t. The NHS will--even under conservative plans--have more money in real terms in 5 years than it does today.
[2] See this article that argues: “A new study finds palliative care doesn't put patients out of their misery; it puts the misery out of the patients.” And there is a surprising disparity between how doctors choose to die and how they choose to treat their patients faced with the same conditions. See this article about how they often choose low-intervention rather than aggressive treatment and how their deaths are more pleasant as a result.
[3] Patient Reported Outcome Metrics: a systematic way of assessing whether some common surgical interventions actually lead to improvements that matter to patients.
[4] The bottom-level work in each ward and each specialty, not the top-down structure of the whole system.
[5] And, incidentally, not blaming the government for insatiable demand, a shortage of GPs, reduced share of the NHS budget etc.. Maybe there are things the government should do differently, but if GPs take no responsibility for managing their own workloads things are not going to get better soon.

No comments:

Post a Comment