Doctors' views about a reformed NHS

Doctors have been very good at providing a diagnosis of what is wrong with the government's reform program. NPfIT, Choice and MTAS - to name a few - have all been dissected and analysed. The problem is that this commentary has little to say about improving patient experience and how to better the working lives of staff.

With the Joint Medical Consultative Council, we aimed to fill this gap. With the help of college presidents, NHS trust chief executives, the BMA and others, we set about finding doctors who had developed excellent services and asked them what they had done, what guided their work and what their vision was for the future. There were two important constraints on setting out this vision. First, you were not allowed to assume limitless pots of public money and, second, everything had to be based on the existing and extensive information on what patients actually want.

Having identified our targets, we used what they told us to draw up a series of design rules that embodied how services had been improved. It was remarkable how quickly they emerged from our interviews from the often inspiring accounts doctors gave us. These rules were also underpinned with a strong set of personal values that helped maintain a strong team ethos and were focused on changing the systems around them for the better. Many of our subjects felt that too often such strong values were missing, resulting in a negative view of care in the NHS which was not challenged often enough.

The first design rule - and perhaps the most obvious one - was that the system should be centred around the patient, starting at the most basic level. The essentials of good quality care were seen as crucially important as even the highest quality clinical encounter can be irretrievably spoilt by poor systems, poor administration, an unpleasant environment or a discourteous member of staff.

Our interviewees were also clear that they wanted to work as part of a system rather than a disorganised, poorly coordinated set of services so they can spend time dealing with patients rather than things that get in their way. In the same way, we know patients want such systematic care. As a result, the barrier between primary and secondary care was viewed as very unhelpful with the potential to widen as reform policies currently stand.

The system also needs to be able to make sure the right equipment is in place and patients see a senior decision maker as soon as possible so that a care plan or course of treatment can start. Once treatment started, our interviewees valued continuity of care. This was not simply because they wanted to track outcomes but also because it made them feel like more than mere technical operators in an industrial process.

These principles of continuity and systematic care provide some context to some of the unhelpful recent positioning over the provision and funding of social care. Neither doctors nor patients are that concerned over where the funding comes from so long as systematic, continuous care is provided. Structural or accountability changes will at best be meaningless to patients and staff and at worst could actually damage delivery.

Another key design rule was standardisation of care through the use of pathways, guidelines, and care bundles. Many of our doctors felt that variations in care could not be explained away by differences between patients. In this context standardisation is the most sensible way forward as it ensures patient safety and aids the spread of best practice. Too much standardisation, however, becomes part of the problem rather than a solution. A powerful answer to this dilemma was provided by another interviewee. He made the point that, 'the purpose of medical training is to equip doctors to make a judgment about when to depart from the guidelines.' In short, the training of doctors is a bulwark against what might be seen as excessive standardisation. Furthermore, such judgments must be recorded because, 'accountability for these decisions is the best defence of autonomy.'

Recording and compilation of data however is about more than standardising care. Proper collection of data allows you to innovate, anticipate change and improve services. All the doctors we spoke to wanted to see a future NHS system that would require much more information about performance, outcomes and patient experience. As in other professions, where people take responsibility for the collection of data the results are generally much better and can be used more effectively.

Taking responsibility in this way will also require leadership. This is problematic because a very noticeable finding of our work was the extent to which the doctors we spoke to did not feel valued within the hierarchy of the organisation they worked for and by the department of health. They describe a situation in which they and their colleagues feel practically boxed in by a combination of 'helpful advice' from the centre, and a lack of support locally. It results in a considerable degree of disengagement with often very respected clinicians fulfilling a role in which they feel they have no choice but to concentrate on the job with little time for the extras.

Whether they are correct or not is unimportant - it is the perception that counts. This is particularly problematic as we know doctors are some of the most trusted people in our society. They have topped the annual MORI poll on most trusted professions since it was first taken in the1980s (http://news.bbc.co.uk/1/hi/uk/6105616.stm). Such a position of trust also carries with it certain other implicit assumptions on the role of the job. Leadership - organisationally and sometimes even socially - is one of these. The truth is that in many ways doctors have the role of leadership whether they like it or not.

In a system where the focus is on the patient, leadership at the level closest to patients - clinical leadership - will be especially vital. Our design rules for a reformed NHS specify that this must be taken into account so that staff are valued properly - and from our research this can go down to the most basic level of providing designated car parking for staff - and that the leadership potential of clinical staff is properly developed.

It is striking how far many of the levers needed to make a change are in the hands of front-line staff. Our work demonstrates that clinicians have the ability to create well-designed services that provide very high-quality and cost-effective care capable of outperforming any system designed in Whitehall. Nevertheless, there are undoubtedly measures the government could take that would help. For example this might include revisiting payment by results - especially in relation to long-term conditions. The general direction of creating a more autonomous organisation should continue with perhaps a clear statement of the values that underpin the NHS through, for example, a constitution helping to reinforce the idea of the NHS as a system along the lines described above.

There is though one final question from our report. If the ability to change the system is largely in the hands of the people who run it, why have they not taken the opportunity? We need to turn around the current, almost fatalistic, acceptance that change will be imposed from above and that attempts to make local improvements are likely to be unwelcome and unsuccessful. The solution to this problem is not a clinical engagement exercise. Instead it is to strengthen the hands of clinical professionals working closely with the managers of organisations.