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Proposals for reform of the NHS are often frustratingly vague in terms of how the sector should be improved. This highlights inadequate real-terms funding increases, unacceptable waiting times and poor comparative patient outcomes together with disparate IT systems and a lack of integration of health and social care administration – but rarely setting out a workable plan for change or even recognising the supreme challenge that implementing meaningful change within the NHS presents.
Integration of Health and Social Care Management
Clearly integration is a key element in any drive to reform the service. The BMJ in January 2023 highlighted these wider causal aspects of the pressure on NHS services:
“Reforming the NHS is often touted as the route to improving the nation’s health… but health and health inequalities are fundamentally shaped by social and economic conditions outside the NHS’s control… public services – like social care – are ripe for reform. Politicians looking for radical solutions to improving health could perhaps start there instead.”
Despite wonderful visions of the NHS as a fully integrated system being set out in the 10 Year Plan, 5 Year Forward View and the 2022 Health and Care Act, the system continues to operate in a fragmented way.
NHS England issues central contracts for Ambulance, Dental, Optician and Pharmacy services together with third party primary care consortia via Alternative Provider Medical Services contracts.
Integrated Care Boards issue GP General Medical Services contracts and primarily fund Hospital Trusts which in turn employ secondary care staff directly. Numerous other private sector and voluntary organisations pop up even in rudimentary analysis of treatment pathways, including urgent treatment centres, hospices, care homes and charities. The famous King’s Fund NHSE diagram has more strands these days than ever.
Do the new Integrated Care Systems show discernible signs of achieving the declared objective of integrating and rationalising health and social care or allowing adequate staff, public and patient view representation within governance structures?
The staff appointed to key positions within ICS secretariats are mostly former employees of the Clinical Commissioning Groups, superseded by the Integrated Care Boards. CCGs were strikingly described as “well versed in avoiding accountability” in a 2023 Good Governance Institute seminar. Further, the Public Accounts Committee is concerned about the lack of direction of the ICSs:
“The ‘Integrated’ element of ICSs as well as their accountability arrangements appear under-developed: there is a concerning lack of oversight…”
Integration and Management Skills
Ironically, NHS managerial staff, via the NHSE leadership model, are encouraged to adopt (inter alia) the following “exemplary” characteristics:-
Make courageous challenges for the benefit of the service
Develop new concepts
Work strategically across the system
Stretch the team for excellence and innovation
Create a mindset for innovative change
Integrate improvement into “everything we do.”
Has anybody seen this happening in practice? Have NHS managers become renowned for being radical agents of beneficial innovative change? Once the dust had settled it seems that ICB activity certainly soon reverted to CCG business as usual as the preoccupation with distributing 70% of the total NHS budget based on archaic resource allocation concepts resumed, with managers working for Providers within the ICSs quickly becoming entangled in the funding web.
Despite NHSE’s monolithic planning and budgeting systems, tinkering attempts to effect change are apparent. Terms borrowed from lean manufacturing theory (e.g. “Get It Right First Time” (!)) appear in NHSE circulars and are officially encouraged.
There are 94 NHSE quality, service improvement and redesign tools, including the leadership model, nearly all based on lean management principles and techniques, but there is no real drive to apply the tools and few signs of adoption of the most important of these, the creation of patient pathway value stream maps across the entire health and social care system:
“To treat patients more effectively, we need to start looking at end-to-end processes (the value streams) rather than just improving our isolated departments. Making isolated improvements within our own departmental boundaries runs the risk of suboptimization that helps the individual department but harms the overall system,” wrote consultant and author Mark Graban in 2012.
Graban distinguishes waste from cost:
“Healthcare organisations have focused on trying to reduce costs for a long time, but costs keep rising… Lean hospitals focus on reducing waste, not cutting costs. Lean organisations also focus on the customers (the patients) and the value that is being delivered to them.”
Lean methodology is underpinned by the key requirement to show respect for the employee – a value which the sector as a whole is always seeking to embed in “vision and values” statements. Lean also seeks to optimise the use of resources, including scarce specialist staff.
Structural Change
If NHS managers need to adopt a radically different approach to engineer reform from within the service, can anything be done in terms of structural change to help them in their quest?
A recent American National Academies report strongly advocates primary care as the key element of any healthcare system:
“High-quality primary care is the foundation of a highly functioning health care system. When it is high-quality, primary care provides continuous, person-centred, relationship-based care that considers the needs and preferences of individuals, families, and communities. Without access to high-quality primary care, minor health problems can spiral into chronic diseases, chronic disease management becomes difficult and uncoordinated, visits to emergency departments increase, preventative care lags and health care spending soars to unsustainable levels.”
Many GP practices and PCNs are disengaged from their ICSs, with GPs angry about contract provisions and seeking private work to supplement their income. Practice partners are likely to be preoccupied with running the business, not patient welfare.
There is evidence of tinkering with this aspect of the NHS problem also in NHS England’s May 2023 announcement of new primary care initiatives, but the real issues are set out by a practising GP in a Financial Times article in July 2023, describing the job as “essentially un-doable”. Few of the GP’s concerns appear to have been addressed by the NHSE proposals.
Elsewhere we hear the specialist clinical voice within the NHS collective calling for structural change and urging enforcement targets:
“Reassess governance, structure, and advice to government and NHS England for cancer. Reinstate the role of an independent National Cancer Director and office of support with authority to drive through changes and liaise between the government and the NHS to provide robust independent oversight,” Professor Fiona M Walter and others wrote in an article published in Lancet Oncology last year.
They added: “Substantially strengthen primary care and deliver on the target of 75% of cases diagnosed at stage 1 or stage 2 by 2028 through enhanced screening.”
This seems to dispel the myth that clinical staff will seek to resist the imposition of key performance indicators as part of any revision of NHS management systems.
Community involvement – Place and Neighbourhood
The third essential element for reform is community involvement, and the funding of the provision of community resources such as diagnostic centres and needs assessment systems. This idea is widely endorsed – in Chris Ham’s King’s Fund April 2023 report for example.
The vision of the ICS is founded on the concepts of “Place” and “Neighbourhood” as the basis for marshalling community input to ongoing health monitoring for early diagnosis and treatment effectiveness assessment as well as public health needs analysis, but although place directors have been appointed by the ICBs nothing much seems to be happening in terms of mobilising local activity.
GP practices and local councils surely have a crucially important role in this but seem excluded from the top-down approach imposed by their ICBs, so characteristic of the CCGs.
Staff, patients and communities can help solve the NHS problem, but only if given clear direction and authority via intense political will.
A starting point could be the value stream mapping of a category of treatment pathways such as elective surgery, where real value stream models across Integrated Care Systems could be constructed, highlighting gaps and inefficiencies in provision, including IT system incompatibilities and setting out service structures as the basis for transformation of the rest of the sector.
In view of the UKs dismal performance against cancer targets this pioneering work should be centered around cancer care, and improvements implemented as quickly as possible, even if this means diversion of resources to achieve this.
The entire focus of the activity of the sector could be transformed from governance and regulation to the patient journey, via the redressing of the prioritisation agenda, the establishment of a genuine culture of pathway-focussed, staff-driven continuous review and innovative improvement, together with reform and revitalisation of the primary care sector around properly funded community-based diagnostics and needs assessment.
