Tag Archives: NHS

NHS Five Year Forward View: still no skin in the game

NHS England and other English health organisations have produced a five year ‘forward view’ [here]. The refreshingly short and precise document establishes a new approach to the

English: British National Insurance stamp.

“Skin in the Game” British National Insurance stamp. (Photo credit: Wikipedia)

English health service, something political reform has failed to achieve since perhaps the beginning in 1948, namely the realisation that top-down reform really doesn’t work. This is a bit surprising given how oftenNHS folk have travelled, particularly to the US, and other places, where the notion of a top-down approach is anathema. All these visits, reports and breathless commentary on lessons learned has really, it now seems, to have been for nought.

We also now have some explanation why the attempts to adapt lessons and approaches from other countries has failed — the heavy overarching deadweight of central control has stifled innovation. Given the additional volumes of studies of the NHS, think tank policy papers, round-table discussions and consultation, researchers, in the UK at least, seem to have been trapped within their own paradigm and failed to see the internal fault lines that pointed to this blind-spot.

Anyway, that said, we now see that Simon Stevens, head of NHS England, has not wasted his time in the US, as not only does the report quote Lincoln’s Gettysburg Address, but tacitly acknowledges that the US (and other countries, but not in the UK) favour decentralised experimentalisation with payer and service delivery flexibility.

Lawton Burns in his important book on healthcare innovation [The Business of Healthcare Innovation, 2005, @Amazon] notes that one reason the US dominates the health technology innovation space is precisely because of the flexibility to experiment, try new things in healthcare service development.

This report, together with the other surprising ‘discovery’ that the funding of healthcare and social care are also part of the problem, after decades of dysfunction, shows that there is now a window within which major changes can be achieved to remove perverse policy incentives, drop barriers to change and get rid of the zombie administriative rules that kill off good ideas.

So where might this all go? Yes there are some very good examples already in place and one hopes more to come. But putting the cat amongst the pigeons may have other rather interesting consequences.

If we see increased power shifting to cities, will we see Swedish-style county-council run healthcare? Such an approach has the merits of democratic accountability, and challengingly, puts funding options within local taxation strategies. Given years ago I advocated with the other big city in the UK a local-council run NHS which caused no end of criticism, I would be surprised if this doesn’t come back on the agenda.

The rising priority of prevention also highlights one weakness of the NHS.  Dating back to 1819, employers had legal duties imposed on them for the health and safety of their workers, a responsibility which the creation of the NHS in effect removed at least in respect of health.  The report notes that employers pay National Insurance as though that were sufficient motivation. What the report fails to add is that NI employer contributions are not experience-rated in terms of the health of the workers themselves. The NHS has flirted with workplace healthcare in the past, but the concept of “primary care in the workplace” has failed. Stevens will know (and others should) how many countries separate workplace health from general health. Some places call it “workers compensation” and it involves risk-based employer premiums, adjusted for actual workplace health, injuries and accidents. Countries with such systems include the USA, Canada, Australia, Japan, and others.  What taxation does is risk-pool, but that means it is hard to link individual behaviour to risk.

American Accountable Care Organisations and other similar approaches in other countries of long-standing, only work when organisations are free to associate in ways that make financial and healthcare sense. US ACOs are forming partly in response to the financial signals in healthcare legislation there, but these signals, coupled with systems of rigourous inspection (and a failure regime), focuses minds. Vertical or horizontal integration in the NHS is needed, and would serve to remove at a stroke the barriers that bedevil patients. I’ve seen how building primary care onto the ‘front’ of the hospital enabled speedy patient access to specialists (they simply came down from the wards) and avoided inappropriate admissions. Buying a nursing home added a step-down into the coummenity releasing pressure on in-patient beds. GP integration toward secondary care pulls diagnostic imaging and laboratory technologies toward the patient, and removes hospital monopoly control of what is the major cause of delayed diagnosis.

But, the end result is in the UK, consumers, patients, employers, have no real skin in the game, which in these days of behavioural economics means that it is additionally challenging in the NHS to activate the essential incentives to align patients around their care, or employers around healthy workplaces other than through moral suasion.

We may need to revisit how to use the NI contributions as co-payments to create the necessary financial incentives that serve to quantify risk to both patients and employers.

Of course, one should be grateful for small miracles, which is why this report is welcomed.

P.S. I suspect this can be done without new money.





Why the proposed NHS Reinstatement Bill is a bad idea

Right now, there is the proposed NHS Reinstatement Bill, a lobby document which lays out a way to reverse many NHS reforms.

This lobby document, which is what is it, is familiar reading, and brings back various structures that in the past have failed. You can find information on it at this link.

What is interesting about this approach is the aura of respectability that it wraps itself in, by proposing the changes as a legislative draft, almost as though it were ready to go to committee.  This is, obviously, an influencing tactic designed to force debate onto the topics covered in the proposed bill, and disarm critics who don’t agree that the points in the lobby document are the right starting points. In that respect, the lobby document polarises positions, particularly against current policy direction.

The whole lobby document’s comments and notes identifies proposed changes to a variety of existing legilsation. What we don’t find, though is any evidence that the authors were in any way persuasive  or influential during public consultations at the time. We call that ‘sour grapes’.

Approaches such as this suffer from the following:

  1.  a belief that the fundamental values underpinning the health service can only be protected in a particular way and these are the ways things used to be.
  2. a belief that the changes that have been made have violated these values; moreover, that the solutions have made things ‘worse’ as they see it.
  3. selective use of academic research to support the positions that one wishes to avoid changing.

New PublicManagement as reform of government itself must sit uncomfortably with this regressive thinking.

For the authors, they would no doubt point to market failure logic to prove that the NHS should not be ‘marketised’ as they put it, forgetting that a greater fear is ‘government failure’, for which there is ample evidence, not just with the NHS but a whole host of other public initiatives and legislation that has wasted public money.

Healthcare systems are complex and by trying to overlay what they see as simple solutions to the problems they claim arise from the reform agenda of past years, they misrepresent what the actual problems are. As messy, or complex/wicked, challenges, the authors believe that by taking away that messiness, they’ll also take away the problems. But they know just as well as anyone, that their solutions will only create, perhaps even recreate, the very problems that led to reform in the first place, except now they will be today’s problems, not yesterday’s.

One might argue that the authors are committing a type 3 error, of unintentionally solving the wrong problem well, but that would assume that they have are not clear in their minds what they are proposing. Therefore, it appears they are do know better and are committing a type 4 error, of intentially solving the wrong problem well because that fits with their policy preferences, or prejudices.

That’s why this is a lobby document, designed to intensionally convince, (is mislead too strong?) others of their definition of what the NHS problem is.

Regardless, the lobby document and the authors are caught by a fundament policy trap: of solving the wrong problem.

Want to know more?

Government failure in the UK is examined in Anthony King and Ivor Crewe, The Blunders of Our Governments, 2013 (@Amazon) and in Richard Bacon and Christopher Hope, Conundrum: Why every government gets things wrong and what we can do about it, 2013. (@Amazon)

New Public Management was originally conceptualised by Christopher Hood, in 1991, A Public Management for All Seasons. Public Administration, 69 (Spring), 3-19. Some (Dunlevey et al) argue that New Public Management is dead and that governance in the digital era requires greater, not less, government. That may be the case for some, but if you actually look at the tools that are available to government in a digital world, you’d find that there is little reason for government to own or run very much. See Christopher Hood and Helen Margetts, The Tools of Government in the Digital Age, 2007. (@Amazon)

I have found Leslie David Simon’s book, NetPolicy.com (Woodrow Willson Centre, 2000) an early, and compelling way of laying out the digital agenda in a policy context really well. (@Amazon)

I would also recommend Vito Tanzi, Government versus Markets: the changing economic role of the state, 2011. (@Amazon)


Cancer Services in the NHS are coming apart at the seams: time for a new paradigm

Measuring Up: the health of NHS Cancer Services is a report from Cancer Research UK.

I have no difficulty accepting much of what they have discovered and the report’s key points are sensible. But, two main conclusions are unsurprising and disappointing: more money and better leadership.

There will never be enough money, so we need to think differently about how we organise care itself. More leadership is a typical lament which says that the people responsible for the service haven’t done what they need to do. When I read reports such as this that call for more leadership I can only shake my head that they were not able to think further about the underlying causal landscape.

Their use of tipping point language is useful, though, as it does suggest catastrophic, rather than incremental, changes are likely. A tipping point means a move from one state to another (like tipping over the milk pitcher), where other factors come into play (otherwise it wouldn’t be tipping!). That suggests that there will be a change of state in which the old rules are unlikely to apply or be useful. After Kuhn, we call this a paradigm shift. Edward de Bono characterises two situations: one he called a problem, where you use existing rules; the other is a crisis for which you need new rules. My take is that the NHS is moving into territory where the need for different thinking is more important than problem-solving. That healthcare is a complex (wicked) and adaptive system should alert us and not surprise us that solutions create new problems and indeed crises.

Based on the report, though, we’re more likely to see hyperactive civil servants and NHS “leaders” rushing about with Powerpoint presentations full of exhortations and flow charts, accountability matrices and maps. We’ve tried that so often, one wonders if there are any other tools in the box. However, that the current state of affairs may have been caused by past reform and changes is an important insight, but to argue for essentially what is more of the same is plain silly. If past actions have destabilised cancer services and tipping is likely, then new thinking and new rules are needed. Did I miss something in the report?

If we take the simple flow of patients through the system, we are told the rate of entry is rising as GPs shift to ‘urgent’ referral, presumably the only way they know to get an oncologist’s attention, but the velocity through the system hasn’t changed. Why should that be surprising when resources are rigid and constrained by NHS structures (such as lack of effective transfer of patient information), and what appears to be performance measurement of the wrong things, creating perverse incentives.

The diagnostic phase is what appears to be rate-limiting across the patient and treatment pathway and hence is the primary blockage. While increased investment in diagnostics would be timely, how to do that is where a paradigm shift is needed. The delay in procuring proton beam equipment (so much in the news) illustrates the procurement logic that undermines service delivery. Entrepreneurial creation of free-standing diagnostic centres, providing on-demand services to oncologists and patients would be one way to deal with this. Does the NHS need to own the equipment, labs etc. or does it just need access to the service? By-passing the GP would also be another option, as the gatekeeping function appears to be another form of avoidable delay (ask women how long it took for ovarian cancer, for instance). Would it not be better for patients to access directly oncology diagnostic centres, which might also speed GP referral in turn?

The policy-down focus on leadership has clearly produced organisations of dubious purpose, but with evocative titles: Clinical Senate. Wow! But systems are judged by their performance, not what they’re called. A focus on leadership shifts cognitive priorities from a service orientation to one of lining up organisational structures, job descriptions, role definitions and mandates, meetings, minutes, but distractions if the challenge is where the rubber meets the road. The intersection of patient with system defines the leadership challenge, not the other way round.

So, what is to be done? I don’t buy the authors’ argument that change-weary people don’t need more change. They may embrace the logic of wholesale paradigm change if it got rid of the nonsense that stops them from doing what needs to be done. My take is that there is a strong case to be made for unbundling cancer services (this logic can apply in other clinical service areas, too) defined by the demands of the patient pathway. I would also look for ways to encourage entrepreneurial solutions, particularly in the form of investment in diagnostic technologies, and in enabling oncologists to work autonomously with each other and with patients. This would call time on the hospitals’ monopoly control of oncologists, cancer diagnosis, testing, and services, which is organisationally rate-limiting, and many of the identified problems are consequences of a system subjected to serious rate-limiting blockers, but lacking the ability to alter its structure to bypass, elminate, or reform those blockers.

In the end, the report is a narrative exhortation to get people to meet and plan to do what they are currently not able to do, or otherwise they would have done what needed to be done. Why not?



Being right when you’re wrong: on NICE and the Cancer Drugs Fund

Conceptual work by Yves Klein at Rue Gentil-Be...

When rules don’t work [Conceptual work by Yves Klein at Rue Gentil-Bernard, Fontenay-aux-Roses, October 1960, photo by Harry Shunk. Le Saut dans le Vide (Leap into the Void) (Photo credit: Wikipedia)]







Sir Andrew Dillon, the erstwhile leader of NICE as said that it is irrational for the Cancer Drug Fund to pay for drugs that NICE has turned down.


He’s right of course, it is irrational. But only if NICE’s logic is compelling.


The problem for Sir Andrew, and likemined people, is that there is another logic that trumps NICE’s rational world. Don’t get me wrong. NICE performs a useful, but technocratic, function with analytical assessments that any rational person would indeed want to know. Where we part company is believing that NICE’s logic is the final word on the matter. Which it isn’t.


Tasked, perhaps unenviably, with parsing the performance of medicines and clinical practice, cannot also mean that they are above challenge. Many of NICE’s rulings fly in the face, not of logic, but of our beliefs as humans. It is why we do things when the odds are against us, because not to do so would be wrong. If we think of the challenges NICE faces as wicked problems, that is complex problems with a multiplicity of solutions, it becomes self-evident that their logic is just one way of deciding and choosing. We could use other rules, other criteria. The Cancer Drug Fund is just such an approach. It is another matter whether we should have in place alternative funding approaches that individuals can avail themselves of (such as co-payments or co-insurance); for extraordinarily costly therapies, co-funding would not apply, so we’ll back to the problem anyway.


NICE has a troublesome relationship with the notion of ‘rule of rescue’ and so has decided to ignore it. There replacement, the “end-of-life premium” is really just a reweighting of the logic they use.


You see, the rule of rescue is what we might call a meta-rule — it is a rule that tells us if other rules are working properly, and importantly, as a moral imperative which tells us what to do. The rule is often invoked in a particular form: that people facing death should be treated regardless of cost. The rule as originally formulated is really about assisting identifiable individuals facing avoidable death (Jonson, 1986); the bioethicists and economists have shifted this to a cost-effectiveness approach, making it one about trade-offs instead.


The problem for healthcare systems is that all patients are becoming identifiable as medicines become personalised (medicines may become orphan drugs). The problem for the NHS is that it does not allow such people to rescue themselves because it prohibits any sort of co-funding or other arrangements. The only option is an opt-out (and private medical insurance has rules about pre-existing conditions). Given the funding priorities of the NHS, we should be reflecting not so much on how to make the pot bigger, but on using the money that is available better (there will never be enough money), and ways to introduce practical co-funding.


Since individuals have no other options in the NHS, the rule of rescue as a moral imperative will be violated and we will act, not out of analytical error (i.e. make a technical mistake), but unethically. You see, the NHS must be the healthcare system of last resort and therefore of rescue, otherwise, identified individuals are destined to a death sanctioned by public policy and is that a policy or healthcare system worth having?


We have seen a similar challenge to NHS/NICE logic recently with the King family and proton beam therapy, and the NHS will also use NICE logic to determine access. Whether beams or drugs, it is the same argument.


But why cancer? The main public policy question is why should cancer patients be given preferential treatment as against any other deserving group? This may in part be driven by the often astronomical costs of new cancer therapies themselves, which demarcate cancer patients decisively from equally deserving patients with less cost-contentious therapies. I have just finished some work on motor neuron disease, for which there is one specific medicine and life expectancy from diagnosis is 3 to 5 years, with median survival rates that are measured in months. NICE reportedly is developing guidelines for this disease. Costs are considerable, and at least in the UK, highlight the bureaucratic illogic of separate healthcare and social care, but that is another story.


The moral dilemma that the economists at NICE are trying to reduce to an equation is whether a new therapy is extending life, or delaying death. The Oregon approach collapsed when the hard choices emerged and people were unable to resolve this dilemma, which is not a quantitative issue, but one of how we value our humanity. Kierkegaard’s Concluding Unscientific Postscript speaks of the leap to faith as involving self-reflection and the emergence of scepticism. It is worrisome that NICE is so confident.

Further reading


Cookson R, McCabe C, Tsuchiya A. Public healthcare resource allocation and the Rule of Rescue. J Med Ethics. 2008 Jan 7 [cited 2014 Sep 4];34(7):540–4.
Jonsen, AR 1986, Bentham in a box: technology assessment and health care allocation, Law, Medicine and Health Care, Vol 14, pp172–4.
Richardson J, McKie J. The rule of rescue, working paper 112, Centre for Health Program Evaluation, Monash University

CHPI report on private hospitals

English: Broken glass

Sometimes, the system is the problem. Broken glass (Photo credit: Wikipedia)

This report on the regulation of private hospitals in England from the Centre for Health and the Public Interest is important, but 15 years too late.

The UK has had and continues to have a love/hate relationship with the private (or independent as it is termed) healthcare sector. This has created a significant fault line across all reform and policy making on the NHS for at least 15 years. Reluctance to create a level regulatory playing field has been evident for years, despite the obvious need for one. I think part of the reason is that creating a level regulatory playing field so that the NHS and private hospitals had to meet common standards would legitimate the private sector itself.

However, when I first worked with a colleague to suggest, around the early 1990s, that the NHS hospitals should undergo some sort of accreditation, resistance was clear. At the time, I noted to others that there were more deaths in NHS hospitals arising from substandard care than from road traffic accidents.

But the view at the time was to ring-fence the NHS from that sort of performance and quality scrutiny at an institutional level. Based on some of the work I was doing at the time, and my own experience with accreditation systems, I felt that the negative reaction reflected a fear that NHS hospitals would fail; using pretty standard accreditation standards from the US, Canada and Australia at the time, I perceived that many NHS trusts would indeed fail. Mainly on safety and quality control grounds (I was teaching NHS managers about quality and quantitative methods in healthcare at the time). Many hospitals lacked any quantitative analytical or operations management capabilities within their organisation and had rather weak data for quality control and performance management purposes. The Department of Health, it must be said, had such expertise on contract but that was to inform their own policy making, not to improve operational performance. I would suggest that such quantitative expertise for quality is still missing at the hospital level.

The consequence has been years of fiddling with quality assurance and inspection regimes. Government has been advised, I think badly, by people who also shared the operative underlying assumption that a single regulatory and inspection system for both the NHS and private hospitals would be politically a step too far. Consequently, the private sector and the NHS have moved in different directions. The private sector has been both an opt-out for patients through private insurance arrangements, and an overflow supplier to the NHS when it ran into capacity constraints. Only more recently, has it been a direct and core supplier of services.

The UK situation constrasts wildly with practices in other countries where ownership of the hospital does not exempt the organisation from regulatory oversight. Indeed, many European hospitals seek out US-based Joint Commission International accreditation, a very high standard. Interestingly, there are no private providers in the UK that have achieved this standard, while (with any type of accreditation) there are 26 in Ireland, 3 in Belgium, 2 in Netherlands, 4 in Germany, 26 in Italy, 15 in Portugal, 23 in Spain, 13 in Malaysia and so on. Perhaps they know something?

I agree with the report’s sentiments, though perhaps not so much how it characterises the private sector as exceptionally risky. Indeed, the past years have demonstrated that NHS hospitals can be exceedingly risky. For instance, the report notes the 6000 admissions per year to the NHS from independent hospitals, while also noting that such hospitals do not have emergency facilities. One might ask whether a common regulatory environment would have led some independent hospitals to invest in such facilities? But such a figure should not be a surprise any more than transfer between NHS secondary hospitals of patients who need more complex tertiary and quaternary care; not every organisation can do everything. In respect of equipment, NHS equipment, too, has failed, gone missing or not worked properly (I have had personal experience of a nurse using equipment that lacked recent calibation); so before we cast the net, let’s make sure we know what we’re fishing for.

The report notes that the private hospitals do not directly employ their doctors, as though this were a problem. Many countries do not directly employ doctors, using fee-for-service type arrangements for compensation. What the report failed to note is that the private hospitals in the UK employ a system called “privileges”, which requires doctors to prove competency in areas for which the hospital in turn grants them privileges to offer that service in the hospital; NHS hospitals do not use a comparable system. I have argued that the NHS should introduce a privileges system, which would bring a more rigourous standard of clinical performance management than the NHS consultant employment contract does and would have the additional benefit of increasing flexibility in the supply of doctors, and perhaps importantly, keep doctors within their scope of primary competency.

A few other points that struck me:

1. Clinical risk does not transfer to the private provider when treating an NHS-funded patient. I’m not sure how this is a useful restriction, especially if the patient chose the private hospital. It seems to me that part of a level playing field would ensure that clinical risk transferred, too. The report addresses this obliquely in terms of whether the NHS is the provider of last resort.

2. The observation that clinical workflow is different is interesting, but it does appear somewhat anecdotal. The private sector is excluded from the requirement to take trainees, and that may contribute to the lack of depth, but I doubt the public would feel reassured that the clinical depth the authors referred to was reliance on trainees! We know what that looked like with registrars. The solution is to ensure the private hospitals are included in the system for training the health professions as a consequence of a common regulatory regime. By the way, I’ve looked at the supervision and training of junior doctors and other health professions and one should not be complacent that it is done well. However, I share the authors’ concerns over the organisation of clinical work, but would not single out the private sector on this point.

3. The volume of work in specific areas is a point well taken. However, I would again suggest that is an artefact of the regulatory system, and lack of effective use of the clinical resources themselves. Proper contracts for suitable volume, rather than handling overflow, would shift workload closer to levels where higher quality standards apply. It might also enable the consultant, for instance, to integrate their clinical workloads, rather than adding the private patients on at the end of an already busy day. Again, organisation of work arises from the current rules and may perhaps be causative of may of the identified problems.

4. I note that only one of the two authors is a specialist in healthcare or health policy, particularly patient safety with grounded expertise.

Many of the report’s comments, with which I broadly agree can seem quite disturbing, really arise from the regulatory box that the private sector has been put in. Given that private hospitals use the same doctors in the main as practise in the NHS, do these doctors lose their minds when they practice privately, or something else is certainly wrong at a system level. My guess is that the box is the problem, and the private hospitals are quite capable of meeting care standards, given a level playing field.

My remarks are meant to focus attention on the important distinction between the NHS as an organising principle for ensuring (and assuring) healthcare to people and the mechanisms used to identify and engage providers who meet the requisite standards. Focusing on the latter, would necessite doing what the report recommends, but ’tis a shame it has taken this long, to say once again, what has been said for years.

Is now any different?

Further reading: Vito Tanzi’s excellent book, Government versus Markets The Changing Economic Role of the State. Then think again about this



1. I don’t have private health insurance.

2. I have received NHS-funded care in a private hospital.

3. My NHS trust has recently been reviewed as overall inadequate by CQC.

4. I know something about the issues I am writing about.

The problem of failing NHS hospitals and a way forward

Once again an NHS trust is highlighted as having poor, if not dangerous, care. See this item in the London Telegraph.

Are the problems a result of design flaws in the way the NHS organises itself to deliver care? Some basic elements of the UK’s NHS that are relevant to the argument I’m going to make:

  1. consultants/specialists have contracts of employment and clinical duties are agreed annually in “job plans” in use since 1991
  2. doctors, once qualified, and registed with the GMC, the professional regulator, are immediately employable in the NHS; their authority to act rests on this
  3. performance improvement and clinical professional development is still work in progress in the NHS despite GMC efforts over the years
  4. junior doctors in training rarely fail and marginal clinical performance is not recognised as such
  5. the Royal Colleges act on behalf of the interests of doctors, not in the public interest as that is the job of the General Medical Council, though they no doubt would argue otherwise.

One starting point is that CQC (Care Quality Commission) inspection may identify the problems, but hospital doctors, other clinicians (nurses, OT, etc.), managers and the board have a collective duty to clinical quality. CQC is not a system of accreditation, and so failing hospitals continue to be protected from the consequences of their actions. The only options are bureaucratic and invariably political (merge the hospital with another, shut the hospital), but this does not solve the problem of failed oversight and management. There is good evidence that hospital quality control systems are weak and rigourous quantitative methods are still needed. I have separately argued that hospitals need in-house operations management capabilites to model clinical care systems, for instance — exemplary hospitals providing high quality care use data-driven analytics in improving clinical work flow and patient outcomes. The Francis report is what I would say is a ‘team hug’ approach recognising individual and cultural factors. I’ll also take a starting point that job plans are not working to uphold standards of care. Putting all this together, we might conclude that we have either the failure of hospital management systems, or the absence of the right type of control system.

My suggested solution is that the NHS should introduce a system called “privileges”, by which appointments/employment and clinical work are subject to prior agreement and degrees of supervisory quality control and oversight. This is an evidence-informed quality control system:

  1. The responsibility of clinical quality rests primarily with the hospital, not the NHS as such, and hospitals need to put in place quality systems that check the quality of clinical work. The quality of clinical work is the responsibility of the hospital Board, as advised by the Medical Director
  2. Medical job plans of NHS employment should include explicit use of privileges or contracts should include privilege as the fundamental determinant with respect to the scope of practice in these job plans.
  3. Appointments to a hospital’s medical staff would require a review of credentials, training, fellowships, previous work undertaken by a medical committee with a recommendation to the Medical Director (and then to the Board, which would be the body granting privileges).
  4. The privileges system would introduce a system of control over what clinical work the individual doctor is recognised as qualified to do (say knee surgery but not hand surgery)
  5. Changes in what a doctor has privileges to do would require the doctor to produce evidence of specific training to establish their ability in the required area.
  6. All new medical appointments, regardless of their total time practising since being licensed, would be supervised in their first 6 months to a year, by a senior colleague acting on behalf of the hospital. At the end of this probationary period, privileges would be confirmed.
  7. Privileges are not forever, but are reviewed for substantive changes on an ongoing basis, and fundamentally reviewed every so many years.

I like the idea because I’ve worked in a system that used privileges, where I’ve seen how it acted to improve clinical quality and worked to the benefit of the doctors themselves. It brings order and structure to clincal work within the hospital by better aligning case mix with skill mix. New hospital appointments would be supervised, while monthly notices kept all clinical staff, importantly nurses on the wards and in the operating theatres, up to date to changes in privileges (who had an area added, or dropped).

Interestingly, the private hospitals in the UK use a system akin to privileges to decide whom to appoint to their medical staff, but it lacks substantive quality criteria or credentialling apart from the requirement of having an NHS appointment!

Some additional potential benefits:

  1. It would create a level clinical playing field between the public and private systems, now that the private or independent sector is becoming more important and perhaps better integrated into the care system in the UK;
  2. Thinking of the future, the privileges system would decouple to some extent doctors’ employment and the work they do. This might increase the likelihood that new ways of organising clinical services in the community, for instance, might become more common.
  3. Patients would have clear evidence that quality and clinical work are connected.

I acknowledge that much is done to create a quality environment within the publicly-funded NHS, and this is not ignored in my comments, which in no way need undermine efforts at team working, or cost control. Job Plans in NHS contracts do not discuss clinical focus in detail and actually spend more space on dealing with private practice and academic appointments than on direct patient care; in essence, they are only workload management plans. However, as employment contracts, they focus on the dimensions of employment (e.g. car allowances, maternity leave and employer responsibilities such as providing the necessary tools for the work to be done).

In my view, the problems have a genesis in these aspects of the system that taken together do not produce the desired outcomes when there are problems, and may actually mask poor quality care. Considering a system like privileges may serve to focus attention on what is really important.

Additional Notes

There are types of privileges: admitting, surgical, courtesy.

Hospitals can add conditions to privileges such as living nearby so the doctor can get to the hospital quickly in an emergency.

Hospitals would revoke or suspend privileges where there is evidence of danger to patients, unethical conduct, and disruptive of hospital operations (that last one’s tricky).

Is Simon Stevens the new NHS Wizard?

It is no doubt reassuring for many in the English NHS that Simon Stevens, the new CEO of NHS England, comes with new ideas — they don’t have to think so hard. I guess people have forgotten their criticisms when he left the UK to work for a commercial provider: UnitedHealth, in the US.

What apparently has happened while he was in this rather different environment is that he has returned to the UK with a box load of fresh thinking.

However, he must be wondering why all those people concerned with improving healthcare services had not thought of them already. Why he has to do this is really worrisome as it is just further evidence that the NHS is a permission-seeking culture that takes ages to innovate even the most mundane improvements. I have no difficulty with what Stevens is saying, and I hope he legitimates even more radical initiatives, if all it takes is for him, like in Star Trek, to wave his arms and say “engage!” for people to get on the with jobs we all thought they went to work everyday to do!

We’ll hear a lot about the small hospitals idea now that it has been reignited as a ‘big idea’ (little idea?). People will now say that it is a good idea, timely, insightful. Or as one person on the news said today, that this is recalibrating what the NHS does. Hmmmm. Methinks the lack of insight into the problems that Stevens highlights with his comments is not reveletory, but just more evidence that the NHS eats its young. Perhaps we should listen less to the economists who are trying justify expenditure models in the Department of Health, and more to people with imaginative ideas to improve healthcare with the money they already have.

What Stevens seems to have learned from his time outside the UK and in the US (and I expect he’ll pepper his comments with examples from other countries, but the US is the innovation engine of note) is the need for healthcare providers and payers to be able to use their respective roles to improve care. So-called Obamacare mandates payer-side reform with a pluralistic perspective yet the English NHS has limited payer-side instruments to really drive reforms (despite CCGs). The ability to repurpose money is really important.  Providers for their part are struggling with health reform in the US but it is driving innovation. What is stopping NHS Foundation Trusts??

Some examples from the US:

1. Virginia Mason Medical Center worked with Intel to develop a totally new approach to organising care with a focus on creating “the perfect patient experience”. The underlying logic builds on Toyota’s Production System and was used to rethink clincial work and patient care processes. (see Kenney’s Transforming Health Care, CRC Press. Forward by Don Berwick by the way.)

2. The Mayo clinic has been working on the focused factory/solution factory model to rethink the alignment of patient case complexity and clinical organisation. Given work I’d been involved in the late 1990s was the first structured patient segmentation model ever used in the UK, moving toward a segmentation model is hardly rocket science anymore. (check out the May 2014 issue of Health Affairs, article on cardiovascular surgery by David Cook and colleagues at Mayo).

3. Michael Porter, of Harvard competitive strategy fame, is applying his considerable analytical models to healthcare. He wrote a great book, Redefining Healthcare, about the US, and did a powerful critique using similar models on the German healthcare system. I just wonder why he hasn’t done the UK….

4. Patient activation is on the agenda in the UK, following a recent paper from the King’s Fund. But why did it take a decade for them to discover something that is old-hat as an operational strategy to patient adherence. The problem in the NHS is that there is insufficient priority to spending money to anticipate care needs. I had a project to assess a project on how weather impacts acute exacerbations of COPD; all it took was a telephone call to tell people with COPD risk to stay home on days when the weather was for them risky. This sort of good thinking wasn’t continued, despite evidence that it worked. Oh well.

5. Berwick’s work, first published in Health Affairs, on the “Triple Aim”, is coming up to 8 years old, and it seems Wales and Scotland are using it, and Darzi and colleagues did write about it in a recent issue of Health Affairs, but it wasn’t published in the UK (perhaps the UK is poorly served by academic researchers or are publishing in obscure journals with paywalls to ensure dissemination is limited to subscribers). Triple Aim is a powerful analytical model to probe wasteful, dangerous and unsatisfactory care. I’ve been using the Triple Aim in my own work constructing decision architectures of patient treatment pathways, but the ability to convert the results of the analysis into action remains the sticking point. Payers haven’t been commissioning the work, and they are really the problem owners as much providers.

6. The Evercare programme, which Steven’s ex-employer runs, has been around in the US for over 30 years and involves, in part, specialists visiting at risk people at home and works well. The NHS tried to translate it to UK practice, but the key benefit, of home-visiting specialists, was implemented. The results was sub-optimal and probably a complete waste of time and money. Gravelle and colleagues produced an evalution in 2007, published in the BMJ.

Don’t misunderstand, many people working in the NHS want to make things better. The problem I have is why good ideas need to be permitted. I guess it is all about the politics of healthcare, but I thought the new model NHS was supposed to bury the supertanker logic and create bureaucratic distance to allow that.

The NHS solution to challenges is to bureaucratise them (create entities and bodies with mandates) and issue guidance, which perpetuates the permission-seeking culture.

Having experienced healthcare in other parts of Europe, there are many important alternative approaches which do not require new bureaucratic organisations. A looser more flexible approach to pursuing innovation may be the trick. Oh sorry, the NHS tried that with the Innovation Institute for something or other full of people running around the country with powerpoint presentations.

Just think of Sweden — healthcare run by the local council, and with co-payments!

The logic of reform

Domino Spiral

Death spiral or solution? (Photo credit: FracturedPixel)

There is a flurry of alarmist writing on the financial state of the NHS at the moment. Solutions are usually three: spend more, spend less, find money from other places.

These are not solutions but facts of state involvement in healthcare. While I would not disagree that financing issues are important, they do not alone define the problem. Choices of funding mechanisms are essentially political in most countries and hence reflect the usual rhetoric of political positions. Is there another way forward?

Let me begin by saying that many problems arise because of the descriptive models used and which limit creativity. The NHS has been compared to a supertanker, hard to turn around — so change the story to a school of fish (in organisational terms: greater autonomy and decision-making within smaller functional units). Candace Imison at the King’s Fund wrote recently on her blog that NHS reform was like ripping up plants in a garden and then sticking them back (or in policy terms: reform was careless and presumably didn’t pay enough respect to the fabric of the garden itself). Models such as this summarise a position, without the necessity of intellectual substance. May we be delivered from this.

I prefer to start my policy analysis at the other end, so to speak. What results do we want from healthcare systems and what do we need to realise those results. Keep in mind the current underlying logic of the NHS policy stems from a period that the majority of the population have no experience of, when the UK faced existential risks and government had almost no policy levers to do what needed to be done, except to take over and run the whole show. While evolved over the years, the essential organising logic of the NHS has not changed. Today, though, we have more nuanced policy instruments available, including much better educated clinical expertise, public literacy, higher general standards of education, better ways of looking after the health of people (not perfect, just better) and importantly the ability (not yet realised) of using information better, in real time, predictively, and to anticipate rather than react to healthcare needs of people.

What we do need to do is avoid the death spiral into thinking healthcare is only about funding (“health economics does not equal health policy” hard though that may be for some). Funding is in fact a policy tool, not an outcome. Regardless of how the money is provided, how it is used is what matters.

My suggestion to avoid this dealth spiral is to think about why disconnects arising from financial handoffs cause such major problems with service, impact patient care so badly and contribute to poorer rather than better outcomes. Indeed, my view is that there is enough money (the evidence is pretty clear that outcomes do not correlate with percentage of GDP spent, but on the organisation of care itself) but it will never actually be enough, so we need to be creative, not profligate.

One way forward is to embed payment in the patient, who is the only person to actually experience integrated care (i.e. care that is not disintermediated by funding gaps). The logic of patient action triggers connectivity amongst disparate providers and the patient takes on the responsibility for the stewardship of their own care. The NHS trivialises the potentially disruptive impact of patient choice by financially disempowering that choice as policymakers fear the consequences of disruption more than poor care. Many of the disconnects in NHS and social care are constructs of policy logic constrained by untenable premises. This is not so much about patient empowerment, but the consequences to the structure of healthcare delivery when patient actions determine the funding flows. Berwick and colleagues Triple Aim, which I have operationalised into a decision tool [email me], depends on the ability to intervene and set priorities within a whole-system view of healthcare. This is not hard. The will to do this is.

Organisational logic and clinical will-power alone will not be sufficient to integrate care — if that were true, then the last 20 years in the NHS should be the golden age of integrated care! But what is necessary (but not sufficient) is the ability to redesign and flexibly innovate and introduce change in service structure locally. We will no doubt hear a lot about accountable care organisations from the US, and like in so many cases, UK folk will flock off on site visits to tour these (stopping off for some shopping along the way). ACOs are interesting because they are an organisational solution to care integration (they are also a response to how provider performance will impact their income so survival is part of the logic here). There is nothing difficult about merging health and social care, as long as the providers of these can merge. It is, in this case, not about the money, but about the logic of organisational design for purpose. Regretfully, for the NHS, there is a fear of disruptive new entrants into care delivery. Policy objectives are constrained by two rules: the first is that there is no real (by that I mean meaningful)  failure regime (which is really a set of rules about financial viability) and second that there is a general avoidance within NHS policymaking of the creative destruction of publicly funded institutions (which is a rule about the prudential use of taxpayers’ money).

One last point is about the patient’s entry point to healthcare itself and the logic of general practice as a policy instrument to deliver primary care. I am worried that there are untested assumptions about general practice. I have asked whether general practice is fit for purpose, taking into account questions about what purpose general practice is supposed to have. If general practice is to meaningfully achieve its potential, then we need to see greater care integration around the general practice itself. This is a simple logic that suggests that services should migrate to the point at which they are most used or needed. Obvious examples are at least three. The first is that public over-reliance on accident and emergency (or emergency rooms) reflects a lack of timely resource availability in general practice. (US research shows that emergency room users have insurance and could use their GP, but for the lack of being open). So there is some logic in anchoring around GPs emergency care services. Hospitals, with their own integration logic, can extend their services into general practice (I worked in a hospital that did just that) — this is called the innovator’s dilemma and reflects the inability of incumbents (GPs) to meet their own challenges but we are faced with the fear of disruptive new entrants. The second is that patients often experience a diagnostic revolving door between GPs and hospitals/specialists, until they get a diagnosis and treatment. UK evidence is stark here with delayed diagnosis for many cancers, and I’ll highlight ovarian cancer, cardiovascular disease, and neurological disorders. What we need in general practice is direct access to specialists such as oncologists, neurologists and cardiologists and break the monopoly control by hospitals of these services. The third is whether there is an appetite for general practice to unbundle acute services into primary care, or for hospitals to vertically integrate into primary care. Some wil say, ah, polyclinics, tried that. Well, they weren’t tried. In fact many innovations from abroad have been tried and failed because of the failure of the system to alter its underlying assumptions. The Evercare programme from the US failed in the UK because the test sites would not send cardiologists into people’s homes — the essential enabling logic of the Evercare programme itself. Failure dogs NHS innovations because of the inability to alter assumptions (perhaps the new CEO of NHS England Simon Stevens will reflect on how his former employer, UnitedHealthcare achieved such good results over such a long perid of time and why the NHS failed). (have a look at this for some evidence)

In any case, I hold little hope for disruptive entrants or solutions that challenge the NHS paradigm. The strenght of the funding glue is far too great to let that happen.

The commercial realities for NHS Overseas

The UK’s Department of Health and UK Trade and Investment are, once again, exploring how to commercialise the NHS ‘brand’ overseas. Drawing examples from where some highly recognisable UK hospitals have set up, notably in the Middle East (Moorfields, Great Ormond Street) the spectre of a steady income stream coming into the NHS from these commercial enterprises has apparently got some folks in government all excited.

It is not uncommon, certainly amongst naive entrepreneurs, to say that if they only got 1% of the market they would earn billions. It seems that some civil servant has run some numbers, and come up with some sort of business case that has big numbers at the bottom of the page — otherwise, why would the DH and UKTI be claiming there would be financial benefits to the NHS into which all these global profits will be ploughed. The DH has a poor track record with commercially-oriented projects, tried with a Texan, tried with local talent, and wasted so much taxpayers’ money on ideas that were obvious failures from the beginning: NHS University, Modernisation Agency, and so on.

Criticism aside, let’s consider the real commercial environment. Let me first say that I am not against this sort of activity, and there is considerable opportunities for success. So, let’s look at the world out there.

All countries in the world are grappling with the costs of care. Others are facing that plus the need to expand their healthcare infrastructure. Rising numbers of middle class taxpayers in many countries are now informed and affluent purchasers of healthcare from a range of sophisticated, domestic suppliers. The countries that are most likely to be interested in expanding the services on offer are also countries with high levels of profit-motivated healthcare, private clinics, extensive and often high patient co-payments. All these are a long way from the experience an NHS hospital would have with a fixed tariff, publicly funded NHS.

No doubt, setting up a hospital in China or India involves a degree of approval, but unless the services are particularly hard to structure, require considerable capital expense or rare expertise, these countries are quite capable of building their own clinical facilities, training their clinicians (many of whom had in the past emigrated to work in the NHS), and supplying the necessary equipment (much of which they already make, in Workshop China). Many poor countries incur substantial losses on buying healthcare from abroad, without creating any domestic value.  Nigeria, for instance, wants to increase tertiary care investments as this is where they most frequently must sent patients abroad. Commercial enterprises from the NHS could contribute to the problem if they are seen as remitting their profits back to the UK.

Medical tourism is something high on the agenda of many countries, such as India or Singapore and they are streets ahead of the NHS when it comes to the commercialisation of their clinical services. The Medical Tourism Association, based in the US, has no UK members, though organisations from France, Spain, Hungary and Poland are members. Medical tourism, of course, is offering less expensive care at world-class levels of clinical excellence (and not just a hip op in the sun!). Indeed, the Middle East used to be medical tourists to the UK, until they started buying in what they needed. It is clear, therefore, that there is some market for medical tourism, and it depends on marketing domestic excellence internationally, rather than necessarily setting up shop in these other countries.

The DH and UKTI refer to the success of US hospitals in exerting an international presence. These US organisations are highly commercial organisations, and have well-developed clinical costing systems, and access to capital, as well incentives to align staff. True, not all are overtly commercial though and Research Triangle Institute (RTI) in North Caroline is worth thinking about as a way of structuring NHS global objectives. In effect, the US is good at this sort of thing as are European counterparts where commercial hospitals are part and parcel of the public healthcare system.  The NHS has discouraged in the past this sort of entrepreneurialism, as counter to the values of the NHS (the Patients Association has used this argument).

The apparent lack of commercial entrepreneurialism by the NHS is likely to put NHS organisations at some risk unless they make greater domestic efforts to test out and understand healthcare markets, many of which are not planned or regulated in the way the UK market is. Take for instance walk-in clinics. a sensible idea, but why are the ones at the train stations private? US instincts to be responsible to consumer preferences has led to an explosion in retail clinics, for instance, to respond to co-payment and cash patients — many countries would see these as particularly interesting.

Now let’s look at these profits. As any company will tell you, they spend considerable time thinking of ways to manage taxation across many countries. If an NHS hospital were to set up in another country, and it generated a profit, then I would think that country would want to tax it. If the hospital has set itself up as a non-profit, they that country would most likely expect any such surplus revenue to be put back into the services available in their country. Think about it. Why should, say, India, permit an NHS hospital to generate profits there which would be sent back to the UK to bulk up NHS services? The NHS and the UK are hardly broke despite the hand-wringing of government, and have no real barriers to service development except those that are self-imposed. India, on the other hand, or China or Malaysia or whereever, are using the private sector to build domestic capacity to benefit their own citizens. How should the NHS feel about shifting overseas profits from a low income country with serious health challenges, to wealthy olde GB, simply because the UK government doesn’t want to spend any more money than it has to?

And just to close the circle at this stage, other countries have similar ideas, and had spectacular failure, or lacked the necessary domestic knowledge and skills to work in this international arena. Any proposed activities will be overseen by some new review board called Healthcare UK, and what will it do?

So what are some conclusions?

I would think the best approach is to focus on helping build a country’s domestic capacity; but this sounds more like an aid programme than a commercial enterprise which DH and UKTI have identified. I might focus on India, China, Brazil, and other countries in Asia where there is considerable investment available and the need for services a priority. It may be worth noting that in many countries, the real problems lie in primary care, as patients already have direct access to specialists on a cash/copayment basis. SInce citizens/patients are used to paying cash or large co-payments, governments tend only to be concerned with regulation, rather than owning or running their own facilities. In India, Tata Steel, for instance, run their own chain of hospitals to world standards. Well-structured commercial thinking that address a country’s economic and healthcare priorities would also help them stem the flow of money to 3rd countries for the costs of care of patients sent abroad — perhaps someone in the UK will try to understand Nigeria’s objectives and offer to set up a productive tertiary centre and perhaps link it to some training facilities so they can build domestic expertise (however, Nigeria’s ICU at University College Hospital, Ibadan, is described as the best in Africa for cardiac care and was built as a public/private initiative by UCH and JNC International, based in Nigeria).

Obvious examples where I have had some inkling that opportunities exist (and not engage in vampire economics) include Libya which needs a complete refit of its healthcare delivery infrastructure (not just ambulances though that is no doubt worthy), including higher education (some hotel chains are looking to expand into hospital construction…), and other countries which have emerged from periods of conflict, and then there are those in the throws of revolution to consider — post-conflict reconstruction would bring the added benefit of advising on building fully integrated service structures (primary and secondary/tertiary/quaternary capacity) which in the end is what we all preach, isn’t it.

There is some market for contract management of hospitals, but many countries are taking a more nationalistic approach with a preference for local talent, than imported talent to run hospitals — I run seminars for health managers from many countries and they were quite sophisticated in their knowledge). Health management training centres in the UK are not really addressing the blend of commercial issues with healthcare, in the way that other countries, are able to (I’ve taught in one in the UK). Expertise is the real issue and few UK universities offers a post-graduate qualification in commercial hospital management, strategic capital planning and all that (they do offer courses more suited to public officials managing state-run hospitals, e.g. Leeds and Anglia Ruskin University’s Hospital MBA; but there is no UK or European equivalent of AUPHA in the US/Canada, so standards and practices reflecting real-world requirements are weak).

Now, if the few that could do this do it well, then it would do wonders for host countries and build the reputation for excellence that the NHS has been losing. Whether it returns profits to offset NHS underfunding is another matter.

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Bad regulation, good regulation

Régulation de la machine à vapeur Merlin

If only it were that easy. (Photo credit: zigazou76)

There have been quite a few cases of late of regulatory failure by the Care Quality Commission [CQC] in the UK.  How can regulatory performance be monitored and improved?

The first thing to realise is that regulators are monopoly suppliers of regulation; that means, that if they don’t do a good job, the regulated don’t have a choice.

Regulators often find reasons to expand their remit (regulatory creep) and because they are prima facie trusted to do their work, regulatory overseers’ consent. Tight performance expectations coupled with effective oversight helps, as does conducting regulatory benchmarking exercises to assess comparative performance with other regulators. This helps keep regulators focused and not get drawn into expanding, like a gas, from what they need to do essentially.

The people who work as regulators invariably derived there expertise from the industry area being regulated. In the case of the CQC, people who had worked in hospitals. This creates an obvious risk in terms of ‘regulatory capture’ by the regulated. The NHS used to speak of being a ‘family’, all cosy, and as we all know, in families it is important to support each other and suppress dissent — paternal/maternal models of behaviour dominate.

But, regulators need to learn how to adopt new behaviours from what got them the job in the first place; much organisational failure arises from failure of people alter their behaviour as roles change. The relationship between regulatory and regulated cannot be chummy; it must be built on evidence that the regulator knows what they are doing and are not going to be compromised by past relationships or a need to be ‘liked’ by the regulated. The selection of the ‘great and the good’ to act as chairpersons and chief executives risks individuals putting their own reputation ahead of the need to regulate with vigour. Sometimes, as the NHS is learning, regulators have to have the teeth to do what needs to be done.

Perhaps more relevant is how regulatory inspectors use their knowledge when inspecting a hospital. While one hopes they use their knowledge well, they are not immune from making assumptions that something is happening (because in their experience seeing ‘A’ means ‘B’ is happening, when in fact it may not). I recall doing some performance work in a UK NHS hospital, and as I was walking through A and E and noticed that guideline posters were both out of date and not dated.  I was told they would change that immediately. Well, mundane stuff making sure guidelines are current, and dated as such, but pretty sloppy. Perhaps a regulator might assume that staff would know what to do. A risky assumption.

Regulatory inspectors need to be able to test all the systems to ensure the are working together. This means, for instance, taking a patient chart at random from the records and tracking the patient care through to discharge, and perhaps follow up at home.  I did a review of discharge on an NHS hospital and was looking at the charts and asked the ward staff about discharge plans for various patients. I was told for some of them that they didn’t have target dates, but that they made up dates for patients to keep them quiet. I asked what the patients thought of this and they said they usually forgot anyway. Needless to say, this sort of dishonesty is easy to catch (the staff thought I was ‘like them’ and would understand the need; I wasn’t and I didn’t); doing good chart audits of this sort are part of a detailed hospital regulatory inspection. Are the staff still dishonest, though? Let’s just say they didn’t do very good care planning as they had no target dates for discharge against which to calibrate resource use and then review when things didn’t happen as planned. Easy to pick up. With better care planning, it is easier to be honest with the patients.

I take a leaf from the nuclear industry regulatory inspection process. A basic assumption is that the regulated have good reasons to conceal, mislead and hide relevant information.  Since the stakes are high that poor inspection leads to system problems (think Japanese report on Fukushima nuclear site), starting from a position of doubt about the veracity of information enables a more robust approach to regulation.

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