The Francis report, mortality rates, the treatment of whistleblowers, relentlessly negative media coverage, and a system crisis over last winter, have combined to create a perfect storm in the NHS. The regulators are under fire, and the reforms have not yet settled in. And in the midst of all this, we suddenly find we were concentrating on the wrong things? In recent years waiting and access times, and healthcare-acquired infection rates, have improved significantly, as indeed has ward cleanliness, mortality and public satisfaction – but overnight the priorities have changed – to compassion and patient experience, clinical safety, care of the frail elderly, and culture
It is pretty clear that openness, listening, safe and compassionate care, and clinical standards are now the order of the day, alongside a pressing need to improve staff morale and engagement. But why has this happened and what needs to change to allow us to make progress?
I believe that solving our emergency care challenge will be the single biggest step we can make to improve in all these areas. By and large, quality and standards are not perceived to be deficient in our elective or highly specialised services. Most safety concerns, and most outcome variability and poor care experiences arise in our hard-pressed acute and ‘front door’ areas. In addition, the relentless pressure, and the sheer difficulty of providing the standard of care our front line staff aspire to deliver under these near-crisis or crisis conditions, is responsible for much of the low morale in the service
Managers put enormous time and effort into trying to address ‘flow’, and worry about both the quality issues and the performance consequences of not achieving the targets. They become demoralised too. Constantly fixing ‘today’ is all-consuming, and it surely detracts from a Board’s ability to innovate by removing any ‘headroom’ that might otherwise be available for fresh thinking about how to sort ‘tomorrow’ and beyond?
My own organisation is highly geared to ‘front door’ activity, and we operate in high demand communities. I no longer believe I can solve these challenges in a sustainable way unless we move, as a system, from an acute model of healthcare to one based on proactively managing the health and well-being of those with long term conditions, including frailty
Most urgently admitted patients have one or more long term conditions, and the proportion is growing. Hospital activity is boosted by a ‘revolving door’ process of frequent readmissions and we know that discharge is delayed, to the detriment of both hospital performance and patient wellbeing, by insufficient capacity in home and community care sectors
The notion of ‘shifting care out of hospitals’ has been received wisdom for years now, yet it hasn’t happened. I have argued before that this is an issue of model of care, not geography
We need to invert the system, so it defaults to home rather than hospital. We need to understand that managing the wellbeing of this growing sector of the population will lead to better health, and lower cost through reduced hospitalisation. To achieve this three things are crucial…
Firstly, we must acknowledge that without significant transformation of the hospital sector the shift will continue to stall. With flat funding, and half of all current monies in the hospital sector, there has to be a transfer of resource if change is to happen. This must mean service rationalisation and, yes, fewer acute hospitals. It is inescapable because we need more capacity outside our hospitals, in both health and social care
Secondly, we need an entirely new leadership approach. Chief Officers like myself are accountable to our own organisational Boards, so we need a means of creating an overarching set of objectives that are equally binding, because only system level collaboration and change will create the necessary transformation. If we do not do this, then narrow organisational interests, and accountabilities, will continue to prevent progress
Thirdly, we need to stop treating every deficit as a performance issue, and understand that driving individual organisations hard using narrow measures will perpetuate the current system, and stifle change
I haven’t met anybody who does not believe we need a ‘chronic disease management model of care’ in the NHS, but we cannot achieve this unless we change the way we operate. If we do not do this, and create a narrative that the public understand and support, then emergency care will remain a struggle, staff will remain demoralised, and patients will continue to be disadvantaged
(This is a precis of a talk I gave to the Australian Disease Management Association annual conference in Sydney in August entitled: ‘Healthcare transformation and chronic disease management; a CEO perspective’)