The public sector will soon face its most serious and protracted squeeze on spending. Before we become blasé about this, and assume that the doom and gloom has been over-hyped, consider what it will mean for the NHS in Wales. Projections range from a best-case scenario of annual real increases of 2 per cent for the next three years, followed by 3 per cent for the following three, to a worst case of annual real reductions of 2 per cent for three years followed by 1 per cent reductions for the following three. The best case perhaps does not sound too bad, until you realise it is just a third of what the NHS has had for the last decade. The worst case is a more prolonged and deeper cut than the NHS has ever faced.
How can the NHS in Wales emerge from the next few years, not just still intact, but actually healthier than it is now? Certainly, it will not emerge stronger if it just hunkers down and talks of trimming waste. Survival requires change, not digging in and defending.
Let me highlight two of the key areas where big change is needed. Firstly, the ‘outcomes’ of the NHS in Wales do not always bear comparison with the best in the world. We sometimes fail to prevent unnecessary and premature death and Welsh patients sometimes suffer avoidable adverse consequences of their illness. For example, of the four most common cancers, Wales has the lowest survival rates for two and among the worst for the other two, when compared with the other countries of the UK. Wales also has the highest death rate for coronary heart disease and stroke.
Secondly, there is unjustifiable variation in performance across the Welsh NHS, which must mean that some patients are not getting the best possible care. Making improvements in these areas is self-evidently desirable but requires new thinking and new approaches. Marginal change simply takes too long and is insufficient given the scale of the challenge. Paradoxically, a harsh financial climate may just help. Improved quality of care usually saves money as well as lives.
Looking at the history of innovation in the Welsh NHS reveals lots of change and improvement, often triggered by individual experts and enthusiasts. It also reveals innovation which has not been widely adopted, and innovation which has initially flourished but then withered, leaving little trace a few years down the line. The current 1000 Lives Campaign, to save 1,000 lives in Wales by eradicating health care associated infections, and the work of the National Leadership and Innovation Agency, are excellent but not sufficient. The problem seems to lie mainly with a system which still does not stimulate, support, evaluate and adopt big changes in a sufficiently determined and rigorous way.
What would such a system look like?
Five elements need more attention:
- National policy-making needs to be clear that innovation really is essential, and consistently to make it happen.
- Clinical leaders are often the key catalysts and champions of innovation: NHS Wales needs more of them, and a clear place for them in the managerial hierarchy.
- Collaboration in change is vital, if unacceptable local variations in practice are to end, and we need to resolve the age-old tension between individual clinicians’ freedom to do what they think is best for their patients, with society’s interest in stopping sub-optimal practice.
- Clinicians need to share and learn from each other. The sharing often works quite well, but often people seem unwilling to learn and act differently.
- Finally, all of this needs to be managed in a way which is sensitive to the complexities of service improvement but intolerant of change at the pace of the slowest. We should be clear about what good practice looks like in key areas, and how well local services are performing against that standard.
All of this throws up some interesting paradoxes:
We don’t gather the evidence We advocate basing practice on evidence of effectiveness, but we seldom gather the necessary evidence about what works, and whether best practice is being followed. It has been estimated, for example, that only about 20 per cent of what the NHS routinely does is of proven effectiveness.
We take the horse to water Quite a lot of time and effort is spent disseminating good practice, but there always seem to be good reasons why ‘it couldn’t be adopted here’, and we need to invent another solution. Thus, we see lots of useful innovations springing up all the time in the NHS but rather less copying of other people’s good ideas.
We need to cure ‘Pilotitis’ We’ve got lots of innovative pilot schemes, but when the money runs out the case for continued funding just doesn’t seem to be compelling enough. There are examples of this in every part of Wales – ranging from initiatives to help people manage their long-term conditions to interventions to tackle health inequalities. A case of severe ‘pilotitis’.
We want managers and innovators on the same side Clinical staff with bright ideas – and others in the Third Sector and elsewhere – don’t always seem to be well-connected to the people who make decisions. The world of healthcare is notoriously hierarchical and fragmented into various silos, and the power and territorial tensions that create such division are manifest when the tribe of managers talks of targets and maximum gain for the maximum number, and the tribe of clinicians talks of effectiveness and the best for the individual patient. There is actually a lot of potential common ground between the two – for example, patient safety is a rallying cry that should appeal to all – but there is decades of history yet to overcome.
Doing better sometimes means doing less The biggest gains often come from doing less, not more – stopping unnecessary and ineffective processes. Unfortunately, the practice of defensive medicine (‘do that extra test just in case – we might be sued’) is entrenched; but there are promising examples of people (managers and clinicians together) redesigning ‘patient pathways’ and cutting out tranches of unnecessary activity.
Innovation doesn’t always depend on new ideas It is often just about doing sensible things consistently and universally. The use of very simple checklists in operations, for example, ensures that supplies are available when they are needed and that all the routine checks have been carried out. Ticking the box can save lives.
Many people in the NHS in Wales – from the Welsh Government down – are seriously addressing these issues. Let us hope they succeed. If they do, it will probably be because we get four key things right. Firstly, we need to focus unflinchingly on what matters most – is the NHS preventing premature death and avoidable harm at least as well as the best in the world? Secondly, are we harnessing professional pride to best effect? No-one wants to be second rate, or part of a second rate team Thirdly, do we help the best get better, or waste time trying to coax improvement from the worst?
Finally, the greatest lever of change should be the patient. Who, after all, has the greatest stake in success? But are they being encouraged to demand the best possible? For many Welsh citizens, there is a yawning gulf between the promises of their politicians and public services, and the every-day reality of the service they experience. If wards are dirty, receptionists rude, and medical records lost, the ‘jam tomorrow’ promises of innovation will ring rather hollow. The result: a poverty of expectation. Instead, why do we not routinely collect patients’ views on the outcomes of their treatment – all patients, not just an occasional few – and build that into future performance?
During the 1930s, a campaigner was canvassing against German re-armament on a housing estate in London. One man opened the door and asked him: ‘Did you come up in the lift? Did it smell of pee?’ The visitor replied that it did. ‘Can you stop people peeing in our lift?’ He admitted he couldn’t. ‘Then how are you going to stop Germany re-arming?’
The NHS in Wales does not need any more excellent strategies and fine-sounding intentions. Rather, it needs to concentrate on making some simple improvements to routine practice. Thankfully, the current leadership of the service is on the case.
This article draws on a seminar organised by the Institute of Welsh Affairs and Health Academy Wales and first appeared in the IWA’s journal, Agenda