CHRIS HAM: REFORMING THE NHS –
LESSONS FROM THE PAST AND POINTERS TO THE FUTURE
I am going to take about 10 minutes to give you a very high-level overview
and summary of what our new report says today. Lots of people in the
Fund and outside have been very helpful in offering their ideas and
advice and experience to contribute towards what we are saying in the
report. It is very much about the process of reforming and improving the
NHS. What have we learned? What needs to be done differently in future?
What is The King’s Fund saying, particularly advice for the next
government about the best way of building on progress we have seen in
very difficult and challenging financial circumstances?
So that is what I will try to cover. To do that in 10 minutes is obviously a
very big challenge and I do encourage you please to take a copy of the
report away, have a look at it in more detail, because there is a great deal
more than I can possibly touch on in my time this morning.
I want to review what the evidence says about the impact of different
approaches to the reform of the NHS; what we can then learn and what
has not been tried. I want to touch on that too. If we look outside the UK,
other countries have gone down different routes of reform. What have they
been? What impact have they had? What does that suggest around what we
should be doing differently to reform the NHS in England – and this is
very much a focus on England.
Starting from this position, if you look back over the last 15 to 20 years,
this will be familiar to all of us but just to recap, I think there have been
three main approaches, drawing on external stimulae or pressures to try
and prod and poke the NHS to do better and to use the substantial
investment
we
saw
between
2000-2010
to
bring
about
tangible
improvements in outcomes and patient care and they are: the use of targets
and
performance
management;
followed
by
inspection
regulation;
alongside competition and choice, often used in parallel, often used in a
very complex process of overlaid approaches to the reform of the NHS, as
different governments – Conservative, Labour and our Coalition – have
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done a kind of ‘mix and match’ between these three principal approaches
to reform and improvement.
The short version of a much longer story, looking at the evidence from
different
evaluations,
those
three
approaches
either
singly
or
in
combination have actually had quite a modest impact. The biggest impact
has been through targets and performance management. I would add to
that not just targets but the use of national standards through the NSFs; the
work of NICE in setting out a more explicit framework for the use of drugs
and other technologies. They certainly have contributed that approach of
targets and standards alongside investment to the measurable improvements
in performance that we saw between that 2000-2010 period.
There is much less evidence that inspection regulation has contributed
positively and there is very mixed evidence – and quite limited evidence
actually – about the role of competition and choice; those two big
econometric studies that seem to show that competition did improve
quality in some areas of care but the methodology and conclusions of those
studies have been challenged by other researchers, so I suppose to use the
cliché, “the jury remains firmly out” on the impact of competition and
choice.
Alongside the positive effects of targets and standards let’s note the negative
consequences too. When Ara [Darzi] was a minister in the Department of
Health, three important reports were commissioned from the United States
which I have summarised in the paper from IHI, from RAND and from the
Joint Commission, reviewing the approach up until that point, 2008, to
improving quality and performance. They were quite consistently and
uniformly critical of the approach that had been taken. The series of
overlapping
initiatives;
the
emphasis
on
top-down,
target-based
improvement; the development of what I think they called ‘a culture of
fear’ in parts of the NHS as a result of that. Of course, we should also note
the risk of ‘gaming’, cheating in relation to how targets operate through
performance management. We also know that although there have been
aspirations to shift the balance of power, create a self-improving NHS,
liberate the NHS – phrases used by successive health ministers – we still
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have a system today which relies very much on inspection and on
performance management.
So aspirations have not really been translated
into practice.
There are approaches, then, in other systems, to move on, which need more
attention, we believe, in England, bringing about reform from within,
looking at high-performing health care organisations outside the UK as
well as those in the UK, such as Salford Royal, and I have mentioned some
of them here. Then the second approach – devolution and transparency,
collecting, reporting, performance data, making that publicly available, if
you like – in the belief that reputational damage will stimulate leaders in
organisations that do not perform well to improve their performance. I
came across a phrase in New Zealand where they very much relied on this
approach. They do not call it devolution and transparency; they call it
‘ranking and spanking’! Maybe we need more ranking and spanking in the
NHS in England!
I also draw attention in the report to the experience of the Veterans Health
Administration (VA), fully understanding that the VA has been through a
very turbulent time and has been quite rightly criticised for a decline in
its performance, but I am talking here – let me be clear – about the
transformation that took place in the late 1990s under the leadership of
Ken Kizer, and effectively what the VA did during that time was to put in
place complementary approaches to change and reform, combining topdown leadership through standards and outcomes with much more
devolution to local leaders to deliver improvement within that framework;
relying on a lot of collaboration within the VA system; getting regional
leaders to share and support each other, while also simulating a bit of
competition between them; so comparing regional performance within the
VA transparently, in the way I have just described – and ensuring
continuity of services while bringing about, over five years, huge change.
For example, during this period there was a 50 per cent reduction in the
use of hospital beds within the VA system at a time when outcomes and
quality of care for the population served also improved. That is a non-
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trivial improvement in performance in a big, publicly funded healthcare
system, using these complementary approaches to reform and change.
The other key ingredients in the VA – because it is probably the closest
analogy we can find in the international literature that has lessons for
what we are trying to do in the NHS today – reduce our reliance on
hospital; shift care closer to home; development of the new models of care
that Simon Stevens and others have talked about. Here is the list: I won’t
talk about all of them but I do want to highlight that when the VA went
through
the
transformation,
they
moved
from
being
a
fragmented,
hospital-centred system to the creation of 22 regionally based, integrated
service networks; each network comprising a number of hospitals and out
of hospital services; each network having a capitated budget linked to the
delivery of outcomes in performance contracts; the VA’s headquarters acted
as a strategic commissioner; there was devolution and transparency within
the organisation and fundamentally this was based on changes, actual
improvements in leadership at all levels.
One thing was strongly
advocated, as you would expect from us, given our work on this, is much
more attention to the role of integrated networks of care in taking forward
the changes and improvements we need within the NHS.
Another
complementary
change
is
combining
a
greater
focus
on
innovation, something that Anna has been leading on, with also much
more attention to greater standardisation of care, reducing unwarranted
variations in provision. It is not inconsistent to advocate both at the same
time.
Tim Harford’s interesting work on innovation – we need to accept
experimentation and indeed failure because not all innovations will
succeed but we cannot mandate innovation; you cannot do it top-down;
you have to build the networks between providers and clinicians. So the
great improvements in stroke care we have seen, following Ara’s work and
with leadership from Ruth Kahn and many others were based on a
collaborative approach.
We have the potential of academical science
networks; we know that UCL Partners is already a pioneer in that regard.
Greater attention to innovation through collaborative networks feels to us
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to be a high priority too but alongside tackling these unwarranted
variations in care.
If you look at one of the case studies we focus on - Intermountain
Healthcare in Utah - Brent James is the Chief Quality Officer and I have
had the privilege of visiting Intermountain on two or three occasions,
talking to Brent about their journey over 30 years to become a really high
quality, high performing healthcare organisation; their belief, justified by
experience as evidence behind this - high quality care usually costs less.
Why?
Because you can reduce waste and variation and Intermountain
have many examples of improvements in clinical care which have
delivered precisely that result.
Underpinning this is a drive towards
organised care and by that I mean organised clinical care, because what
we are focusing on here is variations in clinical practice first and
foremost.
So, innovation alongside standardisation – we need both of
those.
Last couple of slides. What our report is arguing for in headline terms is a
fundamental shift away from external stimuli, external pressures from the
top-down; much more emphasis on bringing about improvement from
within and building the leadership and other improvement capabilities
that you see in these high performing healthcare organisations. It is a bit
of a cliché but it is one worth repeating: we need to focus on how we build
commitment to change and service improvement, rather than creating a
culture of compliance with externally defined and imposed standards of
care.
That I think is a fundamental shift: turning the aspiration into
something that is the reality; complementary changes.
So the next steps – this is the final slide – that we are recommending.
Let’s understand the time it takes to bring about the impressive changes
that you see in Intermountain and elsewhere. This is a long march over
time, not a series of ‘quick fixes’. I think it was David Brailsford who,
when asked about the Sky cycling team in the Olympics, said, “Well, we’ve
made
progress
over
the
last
aggregation of marginal gains.”
four,
eight,
twelve
years,
through
the
We need more aggregation of marginal
gains in the NHS rather than going for these big leaps, which is always the
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risk because of the – if you like - disconnect between the timescale for
policy changes and the timescale for political changes. The NHS does
indeed suffer from short-termism, too many disconnected initiatives.
Of course, we would all argue that we need to keep on saying it: no more
large-scale, top-down structural change, and we need a new settlement
and I would be very interested to hear what Stephen has to say on this,
because let’s be clear, Andrew Lansley in the Health and Social Care Act
tried to bring about a new settlement; to demarcate the role of politicians;
to
distance
themselves
from
detailed
involvement,
the
operational
management of the NHS. That has clearly failed so far and the issue is
why? Is it too soon to tell? Is it possible to imagine a more firmly lockedin, embedded settlement that genuinely does create some degree of space
between the proper strategic role of health secretaries in accounting for
these
public
funds;
in
setting
the
direction
through
the
mandate;
accounting for how the NHS is performing but avoiding that involvement
in operational issues which is often the default position when things get
tough.
Lastly, and I am not going to say much about this because we have David
Dalton with us today, I am delighted to say, how do we learn from what
David and other organisations, some other organisations in the NHS have
done? Focus on developing their staff; engaging staff, many thousands of
staff over time; giving them much more training and support around
quality and service improvement – those are the very simple ingredients –
very simple but hard to implement – of improvement from within. That is
the call we are making today: to bring about this fundamental shift and to
focus much more on what can be done in organisations and in networks of
care rather than what can be done in Whitehall and Westminster.
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