Report from the Centre for Health Enterprise annual debate

First published Oct 31st 2011

The Centre’s annual debate sought answers to the question of how key policy areas might contribute to the drive to improve both quality and efficiency of care.  Excellent contributions to start the debate were provided by experts in standards, regulation and competition.

An online survey conducted before the debate had indicated a near perfect bell-shaped distribution in the degree of optimism people shared in the future sustainability of health and care services.  This was offset marginally in favour of the pessimists.  One in 8 registered “not at all confident” with only one in 40 declaring that they were highly confident.

That same survey indicated that Mike Kelly of Nice might have the easiest task in making his case that standards would indeed drive both quality and efficiency, albeit that the survey did indicate only a minor contribution in the short term, with improvement taking several years to pay real dividend.

From this advantageous starting point, Mike kicked off the debate with an excellent exposition reminding us that the whole work of standards began over 40 years ago when Archie Cochrane recognised that the apparently arbitrary degree of variation throughout the system was simply not good enough.

Mike went on to express that the value of establishing standards based on a shared and common interpretation of the best available evidence is shared across all stakeholder groups because it establishes a common language of exchange, which:

• defines the basis on which professionals make their decisions about treatment;
  sets a clear expectation for patients and carers to make their choices;
• defines the benchmark performance against which different providers will be compared;
• enables commissioners to define the criteria they will use to reward quality and performance.

Mike reminded the audience that in driving for continuous improvement, it is important to understand the health gradient linking social and health status.  It is all too easy to deepen health inequity by improving the quality of outcomes disproportionately for those who tend to have the least complex care needs.  The ideal aim in driving new and better standards is to target improvement on those with complex care needs to overcome the current inequity in outcomes.

In contrast, Nick Bishop of CQC entered the debate for regulation with a small opening handicap, having been assessed as the policy area most likely to be neutral in its effect, although it too was perceived to contribute more positively in the longer term.  Nick began by praising the importance of standards as the essential basis against which regulations were defined and compliance assessed.

Nick reminded us of the sheer scale involved in anything to do with healthcare – 1 million GP visits and 2 million prescriptions issued per day, 50 000 visits to A&E and 2000 births just to provide a sample.  To drive home this point, Nick illustrated the sheer scale, by pointing out that a £1 million stack of £50 notes would be roughly the height of the tallest human, whereas the NHS budget would stretch to 220km high – more than 26 Everests.

With so many events in a risky business, there will always be some which don’t turn out as planned, and the quality regulator’s role is to expose where this is happening more than is reasonable.  With over 30 000 organisations to regulate through annual inspection (that is over 120 organisations per day, small and large), the challenge for CQC boils down to the same issue with which Mike began – understanding the unwarranted variations in health.  Somehow, amidst the millions of events and thousands of organisations, CQC must spot an anomalous pattern within the plethora of intelligence to enable them to weed out those providers who are simply not performing within agreed and safe limits – and to do this with a substantially reduced budget compared with historical inspection.

Andrew Taylor was our final speaker in the debate.  Until recently, Andrew was the Chief Executive of the Co-operation and Competition Panel – the body charged with ensuring that none of the provider organisations within the NHS is able to wield its power to the detriment of the service user/ patient or carer. The stance of the Health and Social Care Bill towards competition has probably been the cause of the greatest volume of dispute and objection.  This was no exception in our debate, as again demonstrated in the pre-debate poll, where results showed a strongly polarised opinion.  A strong showing both for and against its contribution to improving quality, and a much smaller neutral vote.  Competition was also felt to offer the strongest contribution to rapid improvement in quality, though with much reducing value over the longer term.

Andrew distinguished between the effect of competition within the NHS, and between the NHS and other providers.  The influence of patient choice to incentivise better performance should not be minimised – currently mainly between providers, but soon to be opened up to choice of individual consultant.  The new area of competition signalled by the Bill is that of increasing market testing by commissioners, with the opening up of the market to any qualified provider (AQP).  Andrew pointed out that in the current wave, the maximum value of community services covered by AQP is unlikely to exceed £50-100m.  Borrowing a leaf from Nick’s scale of measurement less than 0.1% of the NHS budget and a mere BT tower high stack of £50 notes.  In the current round of competitive tendering, commissioners have been instructed to market test 3 services from a list of 12 – every one a service in which the NHS generally fails to offer a service of credible quality – wheel chair services being the archetypal example.

In the debate which followed, there was considerable agreement that these policies are not an either/or choice – each has its place, and each can contribute positively to improving quality and efficiency.  The survey results reinforced the expected views that structural change is seen as the least helpful of any policy approach and integration offers the greatest hope for improvement.  Overwhelmingly though, the plea from the audience was to find voice to the patient, service user or carer, and for a greater sense of local ownership with reduced imposition of centralist control.

A more detailed report, including the survey results will follow.

What of the bill?

First published on Oct 11th 2011

As the Health Bill returns to the House of Lords for its second reading, what are peers expected to make of the increasingly vociferous messages directed at them?

I have written before about how most of the reporting sits at one or other end of a polarised debate, often showing limited understanding of either the NHS or this entire sector of our economy.

Andy Burnham, the new shadow secretary, says scrap the bill and we will work with you.  But this is to deny the fact that the fabric of decision-making structures has already been dismantled beyond the point of no return.  Going back is not an option.  Too much has already changed for that to happen.  Stopping mid change, leaving a vacuum within which confusion and indecision reigns is arguably even worse – possibly the surest way to seal the very demise of the NHS that people are clamouring to avoid.

It is therefore incumbent on the Lords to avoid the temptation for filibustering, scoring points from each other, and other parliamentary devices, so that the debate can be shifted onto a more worthy plane.  Such a debate would pivot around what it takes to secure a sustainable future for health services:

• that are better at adopting innovation,
• in which all elements of the system drive together towards best possible outcomes for available resources,
• that ensure we continue to drive up the health of the nation, whilst also reducing the unacceptable inequity – both in terms of health (mortality /morbidity), but also in access to quality care when needed.

Many improvements have been made to the Bill through its previous readings, the Pause and revision, but uncertainty remains.  The Bill continues to focus too heavily on structural issues, leaving unanswered those more important questions dealing with roles, responsibilities and effective governance.  Such ambiguities include:

• detail of how Clinical Commissioning Groups (CCG) will be held to account;
• how Monitor will promote the integration of services whilst deterring anti-competitive behaviours;
• how the NHS Commissioning Board (NCB) process will work to evaluate and strengthen CCG Boards.

Current indications are that the NCB will continue conflating its important role to determine what needs to be done, with interference in how things should be done.  If CCGs are to drive innovation, improvement and best possible outcomes, then they must feel a real sense of ownership.

Much commentary focuses on these individual issues, but the real risk lies in the unknown cumulative effect of how these interact.  Current debates tend towards passionate defence of both ingrained vested interests and the proliferation of silo working.  These have proven time and again to prevent progress, always keeping internal issues in the spotlight, instead of giving real attention to transforming the way customers (patients, carers, relatives, service users) are meaningfully engaged.  “No decision about me, without me” will never become more than a collection of words until these internal issues are relegated to the back seat.  What we need is an open-minded focus on how to achieve successful transition to a new shape.  The health system is too big and complex, to be susceptible to management by central diktat.  We need more emphasis on applying the best management science to understand how such a complex beast can be steered to achieve the desired outcomes, by using the right incentives.

We welcome the increased attention on integration, but success in tackling quality and efficiency, requires incentives to be aligned with outcomes throughout the whole system.  GPs manage 90% of patient encounters, and need to retain identity as primary care providers, properly integrated with all other aspects of community and hospital care.  There is a real danger that concentrating on developing their role as commissioners will prevent opportunity for better integration of provision.  That GPs will be subject to conflicts is clear in recent stories, and the solution to place commissioning responsibility for primary care in the NCB makes a mockery of localism – surely primary care is the area which most needs and deserves to be given a local commissioning flavour.

Achieving the right balance here demands that Health and Wellbeing Boards are strong enough to direct the NCB and robust enough to hold them to account.  Health and Wellbeing Boards bring the different cultures of NHS and local authorities directly together.  Success of these boards is pivotal to the future.  It is essential that they are rapidly gain maturity to deal with difficult issues robustly, demanding significant organisational development to face up to and overcome these often ingrained cultural differences and tensions.  We see no attempts being made to nurture the new relationships on which success can be assured.

The Lord’s second reading has much to discuss and shape, but its biggest challenge will be to avoid the polarisation and misunderstanding which has shaped debate to date.  There are important matters to be understood, which will make a real and important difference.