On September 3 2015 I attended the Gloucestershire Clinical Commissioning Group AGM. The main feature of the day was the keynote speech from Professor Chris Ham, chief executive of the King’s Fund. This is my interpretation of the talk, all errors are my own.
He started by showing us a slide of the ranking of the health services around the world where we came out at number one. Before that we were in the middle. And until 18 months ago were were doing well. If we weren’t doing so badly why does the government want to constantly reform our health services?
One of the problems for the future is that there has been a cut in social care. Twenty-five percent fewer adults are receiving social care. Under the collation waiting times started to get longer again.
The government has put in the extra £8 billion, but the NHS still needs to find a further £22 billion in productivity improvements and social care needs another £30 billion. We have never achieved this before, despite previous challenges, such at the Nicholson Challenge of 2006-2012.
The Three Challenges
We have three challenges: sustain existing services; develop new ones; achieving both while engaging staff and reforming from within.
Chris outlined some of the important aspects of sustaining existing services such as patient safety, maintaining good performance on key targets like waiting times. Developing new models though the Five Year Forward view, expanding and extending Devo Manc, giving priority to prevention and population health, and embracing new technology. Although he mentioned that there were some unanswered questions about Devo Manc.
The focus on population health systems include integrating mental and physical health care, primary and secondary care, and social and health care. By bringing everything together we can improve the health and well being of the whole population.
To reform and improve from within we have to look at what does and doesn’t work. Increased regulation and the command and control approach has had little positive impact. Other countries work better by appealing to professionalism. To reform the NHS from within we have to go beyond the hierarchy, inspection and markets. Chris showed us examples from around the world, and he pointed out that this wasn’t just book learning, he spent time in all these countries. The common characteristics were high preforming quality of care, not just relying on inspection, regulation and targets. They didn’t have competition and choice, they invested in care and people.
The lessons to be learned from these other countries were that organisational stability was important. Their leaders were in the role for 10-15 years, creating a continuity in leadership. They also had a vision for safe high quality services, and they systematically measured how they progressed to those goals. They understood what matters to patients, and actively seek patient feedback. They had staff and leaders who listen and engage with patients and staff. Happy patients makes for happy staff, happy staff makes for happy patients.
So what does this mean in practical terms. It isn’t just a different approach. We need more time to make the changes. We need an aggregation of marginal gains; doing lots of little things better rather than trying to do one big thing well. We need politicians to stop doing harm and to stop constantly changing things. We need to make sense of the health and social care act. Chris said he was amazed by the different number of organisations, and how fragmented the NHS now is. We need to find a way to make sense of the mess.
We need systems of care, not a single fortress of care. We need to work in collaboration, but that doesn’t mean merging into larger organisations. He cautioned us to not merge unless there is no other alternative, mergers cost time and energy and are huge distractions. We need more collaborations, alliances between teams. We need to agree on how to share the risk, and ask the question, how do we get the most experienced teams to work together.
He mentioned several King’s Fund publications, one of which is The Practice of System Leadership Being Comfortable with Chaos. We need to lead from behind and bring people together to deliver improvements.
So what next for general practice?
It has a key role at the heart of new care models. He sees a future where practices work together in collaboration, federations. These federations will become the building blocks for providing out of hospital services. They will need technology support to allow care to be delivered in different ways. Federations can engage with specialists to proved more care out of hospital as argued for by the RCGP. Out of Hours (OOH) services and others should work together. Chris sees the solution to the seven day working that the politicians want as greater development for federations engaging with hospital specialities
Commissioning and Funding for General Practice – making the case for family care networks , was another publication recommended.
Also Specialists in and out of hospital settings – case studies.
The key to it all is to strengthen GP practices and strengthen the federations.
The previous night he had been at a BMA dinner, addressing the workforce challenge, how to attract new doctors and increase the number taking up general practice. If we ignore these issues we will lose general practice.
He feels that the government understands these things, but that there are governmental tensions. Control of spending vs quality of care; this will have a large impact as the treasurer is pulling the strings for funding but they aren’t experts in health care. Devolution vs centralisation; most regulation is about central control. But Chris wonders if they are trying to control people more so that they are likely to rebel and push for more devolution, which it move the risks from the centre to the devolved areas. The third is priority for prevention vs cuts in public health. The treasury has cut public health budges again, and they can’t reconcile that with the desire to improve public health.
The immediate prospects
Something will have to give. The Carter Review will be used to exert pressure on the NHS to use resources more efficiently. The current government will not want to preside over the slow demise of the NHS, so they may have to go back on some of the things they have said at the beginning of this current government. After the Olympics the people were more proud of the NHS than the Olympics, and the government notices surveys like that, it will have given them pause for thought. No one wants to be the PM that watched the NHS die. The public won’t want to be let down, so there will have to a solution.
A positive proposal
It should be about improving value, outcomes and experiences. Improving and changing clinical practice, not reducing management will be the answer. Also look to the past at what we did well, another publication recommended was Better value in the NHS – The role of changes in clinical practice
Whether this succeeds will depend on every clinician playing their part by reducing errors, reducing variation, and providing better care at a lower cost. Some things will need more money, like 7 day working, but that won’t be necessary in all areas. Like other countries, we need a programme of work to develop over 10-15 years, but we need to make these programmes start to happen faster than they have been done.
Questions from the audience
There was just enough time for a few questions, the first coming from Becky Parish, the associate director of patient experience with the CCG. She asked Chris to expand on the unanswered questions about Devo Manc.
Chris explained that he was excited about it, there had been limited success so maybe it could be developed to work better, but the question was how. He says that it could end up with more variation reflecting important issues locally, but this could result in a post code lottery. There is also the question of what the role of the national regulatory bodies will be. Will their remit be the same in the devolved systems as in the centrally controlled ones? There are debates going on in the house of Lords over the devolution bill right now and Lord Warner has been raising challenges. Much of this devolution idea has come from the treasury as they want to support a northern powerhouse. Maybe also a southern one too? But the treasury isn’t a good place to deal with health matters. We used to have Whole Place Community budgets but that was when the money was flowing. Now there isn’t any money, and this might be connected to the situation, they might blame devolution for the use of money.
A member from Public Health at GCC raised the issue of having a core vision and the time to make it work, asking how can we have the space and time to make it work.
Chris suggested that the NHS has done it with Salford Royal Hospital, but they started that while the money was still flowing. Now maybe the lack of money will prove to be a stimulus. If devolution means greater freedom, it may allow people to do what other countries have done. It is all about health and wellbeing, not just care and regeneration. If areas are given more control over things so that they can make things different for a wider variety of situations, it could stop people from getting too ill.
A GP had the next question. He wanted to know how we can do things without the excessive risk management. We have become so risk averse that we can’t be freed up for prevention, we tolerate risk poorly.
Chris said that the public and patients have a part to play in this. But if doctors engage in shared decision making and not the old paternalistic model, then patients will take a more conservative position. It is about engaging the patients.
Another GP asked what was meant by federations.
Chris said not the super partnerships, but bottom up volunteering, getting GP practices to get together so that they can share experiences, back office work and specialities. This is happening because GPs want it to happen, it hasn’t been directed to be done by the DoH. GPs want it to happen because they need to do it to survive.
It was a great privilege to hear Chris speak, and I am grateful to the CCG for inviting members of Patient Participation Groups who were able to sit alongside clinicians, commissioners, governors and others involved in health and wellbeing, allow us all a better understanding of each other and our goals.