Transformation in 5 ideas

The UK’s Guardian has an article on 5 things from other countries that could transform the NHS and presumably offer lessons for other countries, too.

The approaches while each in their own way are worthy, also reflect cultural thinking. At root, these ideas could have emerged if there were mechanisms in the NHS for instance to encourage disruptive or non-conforming solutions. However, risk aversion, bureaucratic overhang, dogma, doctrinaire thinking, fear of making changes, and an overwhelming need for the NHS to keep ministers happy dominate.

But as long as the taxpayer is funding the system, the government will claim the right to pre-empt good ideas, to ensure the continuing politicisation of care, to the distress of the patient. The “5 year forward view” was presented as a set of ideas to galvanise decentralised thinking; instead fearful NHS managers turned it into a blueprint. The problems stem from there and lead to the current crisis.

This approach will only ensure feet of clay.

But let’s look at each in turn.

New Zealand: integrated health and social care

The NHS has been saddled with the failure in 1948 to resolve the disconnect with social care. Integration, though, is a good idea, but is hampered by the fact the NHS is free and social care is means-tested. However, other countries have succeeded in payment integration across health and social care through the use of co-payments, which remove the arbitrary fault line that dogs the UK (of course, Northern Ireland has integrated health and social care but in England, who pays attention…). The aversion to any type of copayment in part blocks new thinking as it challenges the ‘free at the point of service’ principle. As other countries achieve better outcomes, less waiting while having co-payments suggests that the government is willing to sacrifice service access for equity.

Of course, the real blocker is that the hospitals in the English NHS cannot extend their services without running into arbitrary barriers either from the Treasury (about intermingling statutory monies) or legal barriers that box NHS providers. There is no reason for a hospital not to work with social care providers to develop proper referral protocols and care pathways that extend across organisational boundaries and developed shared case management; it can be done, but not if doctrinaire rules lock providers into these boxes from which there is little chance of escape. Vanguard trusts opportunities to develop novel models of care according to the NAO has been what one might characterise as a spectacular waste of public money and probably frustrated a large number of people. Will Manchester be able to pull the rabbit out of the hat?

Solution: Remove all responsibility for social care from local authorities and allow charities, independent care providers and NHS organisations to simply build the necessary structures in whatever form is needed in their local area. Pool the money and let providers move money, people and facilities around as they see fit and if a hospital wants to buy a nursing home to deliver intermediate care then let them. The regulatory regime is probably unfit for purpose. This should also enable the emergence of more intelligent thinking from the insurers to develop suitable policies to enable people to buy appropriate supplemental insurance. How will people pay for this, though? That solution is to unbundle a component of the National Insurance and remit it back to taxpayers to be used to buy the insurance, but with an cost-inflater to ensure there is a reserve in place for inflation.

Sweden: paediatricians on the frontline

The use of gatekeeping blocks patients from direct access to specialists and is seen by some as a serious barrier to patient-centred care. All social insurance systems provide for much easier access to specialists.

NHS hospitals are monopoly suppliers of specialists as that is the only place they work and the only way to get to them is through a GP gatekeeping referral process. And one of the major reasons for a child being admitted to a hospital is parental anxiety because the paediatricians are only available through a hospital. Indeed, the UK is at the bottom of the league table for numbers of children’s doctors, and at the top of the list for inappropriate hospital admission of children.

It isn’t so much putting paediatricians on the frontline, as removing monopoly control of access, to free up specialists to work more flexibly. Areas where similar unbundling would be of immense value is cardiology, oncology, ophthalmology, rheumatology, physiotherapy, golly, this list will cover everything. Yes. A design flaw in the NHS logic is the use of hospitals to warehouse clinical specialist expertise and services. NHS hospitals are also monopoly suppliers of lab tests; GPs account for about 50 tests provided by hospital labs and about 40% of their workload, so community labs are a good idea. As for imaging services, the same applies; for example, an outpatient can wait ages for a CT/MRI whatever, only to be bumped at the last minute by an urgent inpatient imaging requirement. Better to have community based imaging, as this will have the added benefit of keeping people out of hospitals, as GPs will be better able to manage their case load with community based radiologists.

Solution: Enable freer access by patients to specialists and have specialists to set up their clinical offices in the community for direct patient access. Same for labs and imaging.

Israel: single patient record

This is not hard, but is complicated by the way the NHS approaches IT. Flexible patient centred solutions are very hard to achieve, when the bureaucracy spends vast sums on failing IT projects, indeed billions of pounds have been wasted. Solutions exist but not when you approach the problem from the top.

While regression models may have been appropriate a decade ago, new computational risk models (artificial intelligence) should be the preferred route for identification of patients at risk, including trawling through EHRs that do exist to find misdiagnosed and undiagnosed individuals (a common problem with 6% of patients with rare conditions).

Way back, Enthoven suggested the HMO model for the NHS. Perhaps Manchester is channelling that approach, which had the government taken Enthoven’s advice at the time, would have removed much pointless NHS reform, and heralded integrated care in the early 1990s.

Of course, this might be a small plurality of systems, but integration of information, portability of records are now much easier to do, and don’t require a massive public bureaucracy to achieve.

However, the fault line between public and private care and between medicine and dentistry and other therapies needs to be closed. Dentists account for perhaps 40% of antibiotic prescriptions yet where do we see integration of medicines prescribing here? And while the Department for the NHS may not like it, there is a large private healthcare sector, and patients move between the two over the years. Records must be agnostic with respect to who the provider is, otherwise all sorts of gaps don’t get filled. The ill-fated electronic prescribing plans of the past studiously ignored private prescriptions because the civil servant involved didn’t take a whole system approach to healthcare.

Solution: Take a whole system perspective on healthcare information that is agnostic to the type of provider. Ideally, the patient should own and hold the health record, as the patient is the only person who actually has an experience across the whole care pathway, so having data follow the patient integrates the information flow across disparate providers of care.

Canada: innovation procurement

The clue here is engaging industry with care providers to work collaboratively. Canada’s somewhat fragmented system (the article refers to Ontario) is a public and private mix, but providers can develop close working relationships with industry.

Relations with the healthcare, medicines and device industries is managed by the Department of Health and whatever it is called today, and not by the Department that deals with industry. Over the years, there have been ill-fated efforts to build relationships with industry, but these will fail if the NHS itself remains hostile to industry engagement. Seeing industry simply as a supplier won’t do. Value added procurement processes ensure that industry has ‘skin in the game’ and therefore will put its best plans forward to collaborative and even risk-shared approaches to solving major problems.

Solution: Re-think the prejudices that hamper adoption of innovation in the NHS as this may be the clue to improving care through a wider committed stakeholder community. But this is a mind-set problem for the NHS and is how value based healthcare will come about.

What Cognology would say.

These solutions all seem very ‘industrial era’. While each in its own way is instructive, what we are not seeing is the embedding of intelligence within clinical and managerial systems.

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