A peculiarity of much health policy debate is that whilst it has a great deal to say about structures, incentives, payment systems, market mechanisms and other parts of the machinery, it generally fails to address the detail of the delivery of healthcare by front line staff or the experience of patients. This is mirrored in the current debate on policy in the NHS.
Introduction
The DH have helpfully described their vision for a reformed NHS in the White Paper, Healthcare Reform in England and the NHS Plan. However, this is a view from a high level and describes how the system appears from the perspective of central government. The ambition is to create a 'self-improving' system and whilst this is entirely appropriate as a position for policy makers it does not address the problem that this is not how it will appear to front line staff and organisations - they will actually have to do something. The reform programme has progressively less to say about the action required across local health economies, in organisations or at the clinical front line. Consequently, the policies have not been easy to explain to local staff or the public. The complexity of the reforms, their technical and detailed nature and some of the language of markets, competition and business are also an obstacle to their being embraced by many people who find this terminology alienating. This seems to be confirmed by opinion polling that suggests that staff are increasingly willing to speak negatively to others about the NHS and that the public often interpret modernisation as being a euphemism for service cuts and privatisation. Recent events, including the changes resulting from Commissioning a Patient Led NHS, the problems of financial control, the difficulties with the tariff have made the situation worse and the reputation of NHS is now at quite severe risk.
The gap in the reform programme and the reputation problems will not just be solved by actions from Whitehall - indeed there is reason to suppose the contrary. Whilst there is good evidence that improving efficiency and quality could reduce costs and improve care this is not very widely accepted and there is more to do to persuade the public and NHS staff that this is the case.
There is a significant opportunity for the NHS, the professions and other interested groups to spell out what an improved and a modernised healthcare system would look like for patients, staff and the public in terms of the experience of healthcare delivery.
In 2001 the USA Institute of Medicine produced a report called Crossing the Quality Chasm - A health system for the 21st Century which set out how the IoM thought US healthcare should change to respond to the various challenges it faces.
Given what appears to be a loss of confidence of the public and NHS staff in the reform process there would be benefit in a similar exercise in England articulating how the people responsible for running the services and providing care see services developing and where they think changes are needed.
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The approach
The IoM developed a working group made up of a cross section of professionals, academics and other experts that tried to set out the new rules for the US healthcare system. The result was a document not unlike the NHS Plan. This is clearly too ambitious for our purposes and not entirely necessary as some of the national policy framework and agreement on key policy values is already in place in a way that is not true of the USA. We propose that we should focus on a number of levels of analysis, starting with the patient and clinician and working up through the organisation to the local system in which it sits. This might produce some ideas about how the national system should be configured but this should not be the focus of the work, there is already too much concern with this issue. The terms of reference therefore might be to:
- Define what a modern, safe, efficient, high quality and responsive system would look like from the point of view of front line care delivery.
- Set out the principles that would create improvement in the quality of care and services, reduce variation and improve patient experience.
- Examine the way that organisations need to adapt to support this new system and how local health communities need to work to support these changes
Following the IoM approach the emphasis would be on the development of principles, rather than detailed blue prints or instructions as these allow local clinicians and organisations to develop their own responses and avoid prescriptive solutions. In a few cases it might also be appropriate to be more directive and definite about issues of detail, particularly if the working groups consist of recognised clinical leaders and the issue was one of patient safety or improved outcomes.
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Methodology
Much of the thinking required to create this vision is already in existence and a great deal of opinion polling, focus group work and other consultation with patients and the public is already available. This means that the need for a large amount of original research can be kept to a minimum. We will use an inductive approach to develop the vision from the clinical front line up by asking the following questions for a range of conditions or types of patient:
What would be the characteristics of an ideal encounter with the service? This might include questions about:
- Clinical content e.g. compliance with evidence
- Experience
- Organisation of care
- Communication
- Environment
- What goes wrong with the current system which means that the ideal is not delivered?
- What sort of changes are required to ensure that this is delivered:
- At the clinical front line
- Within healthcare organisations
- In local healthcare systems
- At national level
Once these questions have been answered for a number of representative types of patient and condition it should be possible to identify a number of clear design principles for how the system needs to change.
A small working group would oversee this work and take evidence from a range of professional bodies, patient groups, etc. where there were gaps in the existing documentary evidence. A summit meeting would bring the key leaders together for a seminar towards the end of the year. A final report would bring all the strands together and set a range of ideas for discussion.
The following steps will be required:
Establish a reference group for the work
The key principles derived from the IoM Crossing the Quality Chasm and the NHS Confederation's Breaking the Rules briefing will be used to form the basis of the study. Results from the focus groups will be cross correlated with existing College, BMA, NHS Modernisation Agency, Specialist Societies and other policy statements for key principles about the design of healthcare delivery. This is looking, not at the detail of recommendations, but at the key principles which underpin the advice given to professionals and policy makers. This is to be used as a check list.
Identify the conditions/areas that we might examine. It would be best to deal with a range of conditions where there is already some substantial agreement on the clinical aspects of care, areas where there is reason to be concerned about current performance and relatively high volume conditions. These might include:
- Elective surgery
- Emergency care
- Complex condition (including mental health and physical condition)
Convene expert groups on these areas to identify:
- What being a clinician in a reformed system would be like and how this might affect the patient
- what will need to change if this is to be achieved
- how the required actions fit with the current policy
- what general principles could be applied to other parts of the NHS
Interview individual clinicians
Clinicians with a clear vision of what it would be like to work in a reformed system will be interviewed indvidually. We will particularly target clinicians that have already gone some way to building these models into their practice. The design principle underpinning these interviews will be identified, checked back with the individuals and incorporated into the analysis.
Bring the data together in a summit to share:
- the generic principles about how care and its organisation need to change to deliver the improvements
- how participants think the principles should be applied to other areas
- the implications for clinicians, the organisations and the local health system
- any changes in the reform architecture
Report
We will write a short report of no more than 15,000 words with short case study vignettes based on the work of the group to be issued for consultation and discussion. Hopefully this might be associated articles and editorial in BMJ and other significant journals.
Seminar and discussion groups with opinion formers
Timetable
| Time |
Task |
|
August
|
Set up reference group/Invite steering group members
|
|
September
|
Steering group pre-meets
Inform key DH and MPs
|
|
October
|
Steering group
Confirm key areas for examination/methodology/project parameters
Confirm sub groups
Start review of secondary material
|
|
December - mid February
|
Set up sub groups/Invite participants /Confirm dates
Sub group meets
|
|
March
|
Sub group meets
Results collated
Steering group
|
|
April/May
|
Final workshop/summit
|
|
June
|
Session at NHSC 07
|
|
July/September
|
Final report launch
|
