Making healthcare more human-centred and not system-centred
Health Secretary Jeremy Hunt sets out the direction of reform for the future NHS.
We have just had an election - and whatever the disagreements between the parties, the NHS was most definitely on the ballot paper. Voters told the pollsters time after time that their most important issue was the future of a service that is part of our very essence as a country.
[Political content removed.]
From bureaucratic to patient-centred
Every health secretary has to deal with a crisis of some sort - and my first was not long coming. The Francis Report into the horror of what happened at Mid Staffs shocked me to the core: how could a system which claimed to put patients first allow such lapses in care to continue for 4 years without anyone putting a stop to it? Even more shocking was the rapid realisation that Mid Staffs was not isolated: hospitals up and down the country were making the same, tragic mistakes - a terrible, unintended consequence of a targets culture where system goals mattered more than the care of individual patients.
It was, quite simply, a total betrayal of what the NHS stood for - not least a betrayal of the staff who worked in those hospitals. None of them joined the NHS to be associated with poor care - and yet they found themselves trapped in a huge bureaucracy where too often the price of speaking out was to be bullied, harassed and sometimes hounded from their jobs.
Notwithstanding Mid Staffs, we have much to be proud of in our NHS: the universal access that it pioneered; progress on reducing waiting times; improving cancer survival rates, dementia and mental health care; strong primary care traditions; R&D; medical education and training and our high rating from the Commonwealth Fund.
We also have an excellent 5 year plan for the NHS developed by Simon Stevens which, as we saw from the Budget last week, this government is willing to support financially on the back of a strong economy.
But alongside a plan, we need a vision. That vision encompasses many things: the move from a narrow focus on access targets to a broader vision of what high quality care entails; the change from disjointed episodic care to holistic integrated care; the move to prevention not cure with a much bigger focus on public health and more personal responsibility for our well-being. But running through all these things is a fundamental shift in power from a bureaucratic system where power sits in the hands - ultimately - of politicians to a democratic system where the most powerful person is not the doctor, the manager or even the health secretary but the 1 million patients who use the NHS every 36 hours.
My argument today is simple: if we truly want to change from a bureaucratic to a patient-centric system, the NHS needs a profound transformation in its culture.
‘Patient-centric’ is horrible phrase. How about ‘more human’ - the title of Steve Hilton’s recent book? Because the truth is that decades of building processes around system targets and system objectives, often with the best of intentions, has demoralised staff and patients and dehumanised what should be some of the most human organisations we have.
Just look at some of the metrics we track. ‘Avoidable deaths’ is one of them. And how many are there? Around 800 every single month. That is 800 human beings who have not been treated with dignity, care and respect - with catastrophic consequences.
Another metric is ‘never events,’ the clinical mistakes that are so bad they are simply classified as things that should never, ever happen. One of them is ‘wrong site surgery.’ But how many people know that in our system twice a week on average we operate on the wrong part of someone’s body?
The NHS is by no means unique in this - and arguably it is facing up to these issues better than many other systems. But a more human system would not tolerate them at all. As Steve says, too often “patients have become outputs, their health outcomes, products; our hospitals, factories”.
Honest diagnosis
So how do we change this? As with any illness, the first step is an honest diagnosis.
I call it intelligent transparency - and as we have rolled it out in the last few years there has been fairly predictable opposition. Some worried that openness about failures would lead to an irreversible cycle of decline. Others said it would damage morale and staff retention. When I stood up in the House of Commons two years ago and said care was unsafe not just at Mid Staffs but at 11 other Keogh hospitals, political opponents called it ‘running down the NHS.’
In fact the opposite happened.
Following the Keogh Report and the work of our outstanding Chief Inspector of Hospitals, 21 Trusts - 15% of the total - have been put into special measures. And did staff drain away from them? On the contrary, between them they hired an additional 125 doctors and 871 nurses.
Seven of them have already come out of special measures and nearly all have shown dramatic signs of improvement. This can be seen in the ‘buddying’ arrangements which they adopted with more successful hospitals. George Eliot learned from the IT systems used by QE Birmingham, Buckinghamshire Healthcare is implementing the Salford Royal approach to safety and Medway is learning from the clinical leadership at Guy’s and Thomas’s. Many talk about a dramatic change in culture too - as one nurse at Basildon said to me, ‘if we have a worry about patient care, now they listen to us, before they didn’t.’
But it isn’t just about hospitals. We have pressed on with intelligent transparency for care homes and domiciliary services, where so far nearly 3,000 of 5,000 inspected have been classed as good or outstanding. We have done it for GP surgeries, where the data is less helpful so the Health Foundation is helping us understand how to get better metrics. We have even applied it to the work of individual doctors, where we have become the first country in the world to publish consultant surgery outcomes across 12 specialties, following the pioneering work done in heart surgery by Bruce Keogh and Ben Bridgewater.
And next March we will go further still, becoming the first country in the world to publish avoidable deaths by hospital trust and, with the help of the King’s Fund, publish ratings on the overall quality of care provided to different patient groups in every local health economy. Building on the success of the Friends and Family test, patient experience will be a critical element of how these ratings are constructed.
And has this wave of transparency damaged public confidence in the NHS? Quite the opposite. Last year it went up by 5 percentage points in England to its second highest ever level (compared to Wales, which has resisted transparency, where a survey found public satisfaction fell by 3%). The number of people in England who think they are treated with dignity and respect increased from 63% in 2010 to 76% last year according to Ipsos Mori. Record numbers now say their care is safe and, most encouragingly, the number who think the NHS is one of the best systems in the world has increased by 24 percentage points in the 7 years following Mid Staffs.
Nigel Lawson famously described the NHS as a national religion. The problem with religions is that when you question the prevailing orthodoxy, you can end up facing the Spanish Inquisition. NHS orthodoxy was that criticism should not be made public because it would ‘damage morale.’ We now see that was wrong. Intelligent transparency is becoming a ‘Reformation moment’ for the NHS as the public appreciate that a system with the confidence to be honest about failings is a system that does something to put them right.
And that means honesty with the public about their responsibilities too.
Not just over appropriate use of NHS resources, which is why we are going to put indicative pricing on the outside of more expensive medicines; but also the responsibility each one of us has for our own health and those of our families. Nearly half of the parents of obese children do not even know their child is overweight - even though the subsequent impact in terms of mental and physical health is beyond doubt. Intelligent transparency means an intelligent conversation with the public about the role we all need to play to make ourselves a healthier nation.
Transparency and devolution
One thing though has been a big surprise. Most of the positive changes have come not because people have been instructed, but because they want to make them happen themselves.
Self-directed improvement is the most powerful force unleashed by intelligent transparency: if you help people understand how they are doing against their peers and where they need to improve, in most cases that is exactly what they do. A combination of natural competitiveness and desire to do the best for patients mean rapid change - without a target in sight.
Transparency over outcomes also makes possible true devolution of power.
Every health secretary, of whichever party, arrives in office committed to local decision making, horrified no doubt at the prospect of Nye Bevan’s ‘bedpan from Tredegar’ reverberating around the Palace of Westminster. But then there is a flu epidemic, a care scandal or an A & E nightmare and they discover their inner Stalin as they rush to bang heads together.
But if you have independent, smart measures of performance area by area, hospital by hospital, a health secretary can relax a little. You can start to devolve power - safe on the basis not just of ‘earned autonomy’ for people delivering good quality care, but also because where there are problems, many of them will self-correct. People often say that they need to be given permission to be radical so they can do the right thing for patients. To be empowered to transform services so that they are future proofed, so that they are fit for the 21st century. Well that moment has arrived and we want to support you to make those changes.
With smart metrics we can also be less prescriptive about models of care, allowing more space for local ingenuity and innovation. We need to move further and faster towards Valencia-style population-level commissioning with accountable care organisations or integrated care provision planned in Greater Manchester with DevoManc.
And as we do so, we can be officially neutral about whether one part of the country is trying a local authority-led solution just as another tries an acute-led model and another a GP-led plan. All will be assessed and held accountable through the same sensible, clear metrics, all can learn from each other, and with great relief we can consign to the dustbin the idea of continually ‘rolling out’ new models from Richmond House as local bottom-up solutions take the lead.
The world’s largest learning organisation
To power this we need to foster an inquisitive, curious and hungry learning culture. The world’s fifth largest organisation needs to become the world’s largest learning organisation.
That learning will be as much about efficiency as it is about quality, given the tight financial constraints we face. And as trusts embark on that journey, they will need all the support they can get. So today I can announce that the operating name for the new jointly-led Monitor and TDA will be NHS Improvement. I am also delighted to announce that Ed Smith is to be the new chair, supported by Ara Darzi as a new non-executive director. Ed will launch a recruitment process for the new chief executive immediately, which will be completed by the end of September. I would like to take this opportunity to thank Baroness Hanham, David Bennett, Peter Carr, David Flory and Bob Alexander for their outstanding service to the NHS over many years for which we are incredibly grateful.
Because safety and quality will be at the heart of the new organisation’s remit, Dr Mike Durkin’s safety function will move there with 2 early priorities. Firstly, to work with the Chief Nursing Officer to complete the work started by NICE on safe staffing levels. There can be no compromise on the issue of safe staffing and we need a methodology that properly assesses and publishes what appropriate levels of staffing should be, taking full account of the changes that can be made with new technology and modern multidisciplinary work practices. This will be independently reviewed by NICE, the Chief Inspector of hospitals, and Sir Robert Francis to ensure it meets the high standards of care the NHS aspires to.
And, secondly, Dr Durkin will set up a new Independent Patient Safety Investigation Service modelled on the Air Accident Investigation Branch used by the airline industry. A ‘no blame’ learning culture in that industry has led to dramatic reductions in both fatalities and cost - and we now need to do the same in healthcare.
To further strengthen a culture of continuous improvement, we have to be open to insight and expertise from across the globe. I can therefore announce today the start of an international buddying programme. Five NHS trusts - Surrey and Sussex Healthcare, Leeds Teaching Hospitals, University Hospital Coventry and Warwickshire, Barking Havering and Redbridge, and Shrewsbury and Telford - will from this year be partnered with Virginia Mason in Seattle, perhaps the safest hospital in the world. But we will not stop there: if we want to be the best we must learn from the best - whether Kaiser Permanente in California, the Mayo Clinic, Alzira in Spain, Apollo in India or anyone else - and I look forward to developing further international partnerships over the months ahead.
Game-changing innovation is not sustainable without strong leadership, as we know from the excellent Rose Report published today. In line with its recommendations, the national responsibility for nurturing and developing talented leadership in the NHS - including the NHS Leadership Academy - will be brought together and become the responsibility of Health Education England. However, as the report makes clear, every single NHS organisation will be responsible for nurturing the next generation of leaders. As we said in our manifesto, we are considering how best to recognise and reward high performance.
I am also publishing Professor Sir Bruce Keogh’s progress reviewing the professional codes of doctors and nurses. He says that while there have been some improvements, more work needs to be done on incentives so that, like the airline industry, the default option is openness and not reticence when dealing with errors. At its heart this is about rediscovering true professionalism in a clinical context, so I welcome the fact that the Professional Standards Authority will be holding a summit on this in September with Bruce, who will complete his work in October.
Taken together I want these changes to create a profound change in culture in the NHS. For too long we have assumed that the only way to tackle problems is a combination of money and targets. Both have their roles - but both, too, have unintended consequences. Our focus should be different: not top-down targets but transparency and peer review; learning and self-directed improvement that tap into the basic desire of every doctor, nurse and manager to do a better job for their patients; empowered leaders with the permission and the space to excel. In short turning our size and openness to our advantage with that bold ambition to be the world’s largest learning organisation.
And this is my offer to the NHS today: more transparency in return for fewer targets. Learning and continuous improvement at the heart of a more human system where we eliminate any conflict between organisational priorities and what is right for the patient sitting in front of you.
7-day care
One litmus test of our commitment to this is our approach to 7-day care.
This is not about increasing the total number of hours worked every week by any individual doctor. Doctors already work extremely hard, and their hours should always be within safe limits. But we will reform the consultant contract to remove the opt-out from weekend working for newly qualified hospital doctors. No doctors currently in service will be forced to move onto the new contracts, although we will end extortionate off-contract payments for those who continue to exercise their weekend opt-out. Every weekend swathes of doctors go in to the hospital to see their patients, driven by professionalism and goodwill, but in many cases with no thanks or recognition. The aim is to acknowledge that professionalism by putting their contributions on a formalised footing through a more patient and professionally orientated contract. As a result of these changes by the end of the Parliament, I expect the majority of hospital doctors to be on 7-day contracts.
Around 6,000 people lose their lives every year because we do not have a proper 7-day service in hospitals. You are 15% more likely to die if you are admitted on a Sunday compared to being admitted on a Wednesday. No one could possibly say that this was a system built around the needs of patients - and yet when I pointed this out to the BMA they told me to ‘get real.’ I simply say to the doctors’ union that I can give them 6,000 reasons why they, not I, need to ‘get real.’
They are not remotely in touch with what their members actually believe. I have yet to meet a consultant who would be happy for their own family to be admitted on a weekend or would not prefer to get test results back more quickly for their own patients. Hospitals like Northumbria that have instituted 7-day working have seen staff morale transformed as a result. Timely consultant review when a patient is first admitted, access to key diagnostics, consultant-directed interventions, ongoing consultant review in high dependency areas, and proper assessment of mental health needs: I will not allow the BMA to be a road block to reforms that will save lives.
There will now be 6 weeks to work with BMA union negotiators before a September decision point. But be in no doubt: if we can’t negotiate, we are ready to impose a new contract.
Patient Power 2.0
Taken together, these changes are profoundly important for patients. But they are not complete because they leave untouched the essential power relationship between doctor and patient. However, thanks to technology and science, we now have the possibility to remedy this, with a radical permanent shift in power towards patients.
If intelligent transparency is Patient Power 1.0, this is Patient Power 2.0. We have the chance to make NHS patients the most powerful patients in the world - and we should leap at the opportunity.
Within the next 5 years our electronic health records will be available seamlessly in every care setting. You will be able to access them, share them, mark preferences, and shape the care that you want around them. We will be decoding individual genomes, allowing us to target personalised medicines, improve diagnosis and therapy, and reduce waste. New medical devices will mean an ambulance arrives to pick us up not after a heart attack but before it - as they receive a signal sent from a mobile phone.
With 40,000 health apps now on iTunes, these innovations are coming sooner than most people realise. The future is here, but it needs to be more evenly distributed. Heart rates and blood pressure will no longer be simply a matter for the doctor - patients will know them and monitor them too. Data sharing between doctor and patient means power sharing too. Intelligent transparency creates intelligent patients with healthier outcomes. Get this right and it is no exaggeration to say that the impact will be as profound for humanity in the next decade as the internet has been in the last.
And I want the NHS to get there first.
So last September, we launched myNHS, where patients can see information about the quality of services provided by hospitals, GPs, surgeons, and local authorities all in one place. So far there have been 244,000 visits to the site with raw data being downloaded over 5,000 times.
Last year we also increased the number of GPs offering patients access to their summary medical record online from 3% to 97%, alongside the ability to book appointments and order prescriptions - 2.5 million patients have activated this service so far.
But we need to go much further and today I want to highlight 3 areas in particular.
Firstly, I want to make sure that patients really are in a position to do something about the information they now have for the first time. Real patient power is not just about knowledge - it is being able to act on that knowledge so that those providing care feel financial, as well as operational, consequences.
So from next year as part of the new electronic booking service, which has replaced Choose and Book, all GPs will be asked to tell patients not just which hospitals they can be referred to, but the relevant CQC rating and waiting time as well. Because those ratings now include patient experience, safety and quality of care, patients will for the first time be able to make a truly informed choice about which local service is best for them. Patients also need to be able to make a meaningful choice about which GP surgery is most appropriate for their needs. Right now that is not always possible because practices get full and there is a lack of capacity. We will address this through our New Deal for General Practice which will boost GP provision in under-doctored areas, with NHS England giving particular attention to making sure that there are alternatives available when a practice has been rated ‘inadequate.’
But patient power is not just about being able to choose the right provider - it is also about being able to choose the right service within each provider.
In 3 areas in particular we still too often tell patients what service is available on a take it or leave it basis without allowing them to choose what is most appropriate for their needs. So today I can announce that before the end of this year, NHS England will come up with concrete proposals to make sure that there is meaningful choice and control over services offered in maternity and end of life care and for those with complex long term conditions.
Finally if we are to embrace the potential for technology to shift power to patients, we need patients to be willing and able to harness that technology. Digital inclusion is as vital in healthcare as everywhere else - not least because some of the greatest impacts of new technology in health is with the most vulnerable patients. I have therefore asked Martha Lane-Fox to develop some practical proposals for the NHS National Information Board before the end of the year as to how we can increase take-up of new digital innovations in health by those who will benefit from them the most.
Conclusion
The Forward View sets our course for 5 years. Over those 5 years patients can look forward to a 7-day NHS offering safer and more integrated care than ever before as we start to rise to the big challenges of the 21st century: making healthcare more human-centred and not system-centred.
But the transition to patient power will dominate healthcare for the next 25 years. We cannot resist the democratisation of healthcare any more than we can resist democracy itself. But we can choose whether we want the NHS to be the leader of the pack, turning heads across the globe, or a laggard always struggling to embrace innovation adopted earlier elsewhere.
Mid Staffs, curiously, can help us here. It was indeed a terrible shock as we looked in the mirror and saw just how far we had drifted from a truly patient-centred system. But if we learn the lessons, it could also be a decisive moment of change when we break from the past and resolve to become the first truly democratic, patient-centred healthcare system in the planet.
Starting with intelligent transparency, then using it to foster a learning culture to support and empower staff, then embracing technology to give patients real control of their own health and care - that is the journey that beckons. The world’s largest learning organisation supporting the world’s most powerful patients: time to get real to the opportunity and rush to embrace it.