The future NHS is out there
In the face of the Covid-19 crisis and the courage it has summoned up, it is difficult to find the time or headspace to think ahead or consider hard choices. But we must. The future of the NHS is out there today. We must grasp the opportunity to build it for tomorrow.
by Axel Heitmueller @axelheitmueller
I know many NHS staff who are in tears on those increasingly warm and light Thursday nights. We need to celebrate and never forget these sacrifices and achievements. I have been working alongside the team coordinating the response to Covid-19 in one part of London over the past few weeks and I’m in awe of my clinical colleagues.
The sheer brilliance of the frontline, not just in healthcare, over the past four weeks has been humbling and puts every single one of us in deep and lasting debt. Their unfaltering commitment despite the many dangers and obstacles, the long hours, the physical strains of working in uncomfortable, hot and heavy protective gear. The dentists who are helping out as intensive care nurses, the cleaners who keep us all safe. We owe them all.
It is precisely because of this effort that we must not shy away from hard truths. Recent weeks have uncompromisingly exposed the many fault lines of a starved and ill-structured health and social care system held together by commitment, not design. Shaky supply chains and lack of planning will sadly cost more lives due to the lack of appropriate protective equipment or test kits. Despite the many dedicated civil servants trying their best to hunt down supplies globally, the crisis has exposed the frailties of a highly centralised infrastructure combined with a highly fragmented delivery system.
The unwillingness or inability to own difficult decisions centrally has sometimes left local clinicians exposed. A case in point has been the ping-pong between local and national bodies in relation to ethical decision-making guidance to support clinicians when making a choice about whether a patient should or should not receive intensive care.
A defining characteristic of any crisis is the level of uncertainty. This uncertainty is reduced by robust and high-quality information and the last few weeks have shown the NHS to be data rich but information poor. Too much data is highly unreliable, partly because it has not been designed — and has never been used — for critical decision-making. It is mostly collected in the context of performance oversight from national bodies and lacks connectivity with operational purpose. Most industries would not rely on manual counts of equipment or stock; much of the health service still is and this crisis might be the catalyst to move on.
The NHS is good at change but slow at transformation. It has managed to absorb political and structural change every five to 10 years, yet, despite all the disruption in most areas, the nature of care has stayed broadly the same as three decades ago. Structural changes and the associated acronym bingo (PCT to CCG to STP to ICS) have too often displaced activity, leaving little room for genuine transformation. Real innovation is too often left stranded outside the doors of NHS organisations.
Like a character in a superhero film, the NHS is perpetually in mortal danger, yet we know deep down it will survive. At the last minute disaster is averted as it was on 2 April when the government wrote off the collective debts of NHS trusts to the tune of £13.4 billion. Ultimately budget constraints are soft, so why change?
Out of crisis comes change
But more transformation has taken place in the last four weeks than a decade of PowerPoint presentations and meetings to talk about change. Normally, there are around 1.2 million face-to-face consultations per day in primary care. Over the space of a couple of weeks, the vast majority are now phone and video consultations. The drop in A&E activity is stark. Attendance has fallen by up to 60% in parts of London. Some of this is concerning as it may mean patients with serious health issues such as heart attacks or strokes are presenting late or not at all. But it seems also that many people have found alternative ways of dealing with manageable healthcare issues, making use of video or phone consultations.
Home monitoring platforms for shielded patients are being tested in London, requiring not only new technology at scale but also significant redesign of care pathways. Meetings have moved to virtual platforms and become action focused. It is hard to see how this will be reversed and the most practical solutions have been a far cry from the AI hype, sending a strong signal to the overinvested digital health market.
Responding to the wave of demand for intensive care beds required true collaboration across geographies. The sharing of staff, equipment and ideas has been rapid and has helped to put organisational rivalries to one side. The need to not only focus on acute care but also community, mental health and care homes has highlighted the value of taking a systems perspective. The instinct among parts of NHS leadership is to accelerate this change. Already these conversations have begun in London and will intensify as we approach what could be a lengthy period between lock down and some form of normality.
Covid-19 hit at a time when NHS structures were being reinvented once again. The two-decade long experiment with internal markets (aka the commissioner/provider divide) had gone into reverse with a shift towards population-based planning. The aspiration of focusing on health outcomes through collaboration is commendable, but there are also risks. As in all systems and organisations, improvement is hard to sustain. In the absence of internal market mechanisms or other quality signals that would enable patients to exercise their choice of care provider, the impetus for change may decline.
The pandemic has demonstrated we have a relationship with the NHS that goes far beyond passive consumerism. The willingness to observe social distancing, the army of volunteers, the weekly clapping and the respect paid to frontline staff all highlight the scope for a fresh social contract between the NHS and citizens. The idea that good heath is a social outcome, not just a medical one, must not be forgotten when the emergency passes.
In response to Covid-19 many regions have been managing their estates, beds and staff across organisational boundaries, behaving effectively as one organisation. There are strong reasons to continue with this beyond the immediate crisis. But, integration like this has implications for patient choice and may raise anxieties about the sustainability of local services, such as access to A&Es.
A new NHS social contract
To turn a crisis response into long-term improvement demands a new social contract between the people and their NHS. This should comprise three broad pillars.
First and most basic, we will need to empower patients and the public by radically improving the transparency of information about service quality and outcomes. Getting this right will make choice meaningful and enable a shift of accountability from regulators to citizens. This can provide the impetus for improvement in the absence of market mechanisms.
Currently, patients in the NHS have choice, but it is an empty right as it is extremely hard to compare providers or clinicians. Great work has been done by International Consortium for Health Outcomes Measurement (ICHOM) to define meaningful outcomes. Providers such as the Martini Klinik in Hamburg, Germany have demonstrated it can be translated into operational reality. A key role may also be played by the National Institute for Health and Care Excellence (NICE) in making it easier for patients to understand what good care should look like and what they can expect. An example is the work done some years back for patients with chronic obstructive pulmonary disease (COPD) in London. The Education Endowment Foundation has shown how to provide teachers, schools and interested parents with highly accessible information about what works.
Second, empowered patients are knowledgeable citizens. There is now ample evidence of the benefits of engaging citizens in helping resolve difficult policy trade-offs. Deliberative processes have been used across the world, for example, shaping policy on abortion rights in Ireland and climate change in Texas.
At Imperial College Health Partners and OneLondon, we recently ran a Citizens’ Summit with 100 Londoners to deliberate issues around the use of health and care data. It was a humbling experience to see citizens from all boroughs of the capital wrestle with the complex technical, social, ethical and commercial issues over the four days. It was a resounding success that produced recommendations for the Mayor and national and regional NHS leaders. Deliberation like this can help the public engage with difficult choices and trade-offs and also see the importance of citizen responsibility. The alternatives are tokenistic and transactional public engagement, which only stoke distrust and opposition to change.
Finally, to reinforce the idea that the success of our health systems is about all of us, we should consider giving citizens a more concrete stake in the NHS. Foundation Trusts enabled citizens to join the governance of their local hospitals. The impact has been mixed and it always felt it was a halfway house. How about enabling people to invest in the NHS? Organisations such as Abundance Investment have offered investments in renewable energy via ISA schemes (we spend collectively £60 billion a year as a nation) and noticed that those investing were not only more knowledgeable about different energy options but also changed their consumption behaviour helping to maintain the sort of changes in patient behaviour we have seen over recent weeks.
I suspect that the Covid-19 crisis has cemented the value of the NHS and social care into the hearts and minds of a new generation. This should give us the confidence to ask ourselves the really difficult questions about how it will serve those people and their communities in the future.
Axel Heitmueller is Managing Director of Imperial College Health Partners.
The RSA is hosting online public events, podcasts and publishing a series of Fellows’ blogs and long-read essays — Covid-19: Building Brides to the Future — responding to some of the short, medium and longer-term implications of the pandemic.
