Clinical Diagnostic functions: "Products" or "Services"?

Not needlessly doing things umpteen times is an important thread in improving healthcare peformance and productivity.  And so it is preached that much work can be consolidated across the organisations doing it.  This can be applied to frontline services and to support services - but there are separate issues.

For frontline services, the benefits of consolidation are primarily those of quality and safety.  For example, having fewer centres offering specialised cardiac surgery for children is considered necessary, so that the relatively small numbers of skilled specialists can gain the range and volume of experience that they need.  As an informed society, we are prepared to trade in ease of access to a local facility, so that we secure the best care to which we are entitled.  And it is achievable, because the costs saved by closing some centres can be re-invested to expand, equip and staff the remaining ones.  Some other services are harder to attract public support, even though the arguments are the same - for example, reducing the numbers of maternity units or A&E departments.

For support services, the benefits of consolidation are commonly financially driven. Many of the quality/safety benefits may also apply - less significantly in admin back-office functions, much more so, however, in clinical support services.  Indeed, there are real issues with consolidating diagnostic services.  Access to these capabilities is of front-line-like value to patients, and access by requesting clinicians is also of concern.  However, does every hospital really need the high capital and staffing costs of running its own radiology and pathology services?  After all, their costs continue to escalate owing to scientific advancement, and the highly skilled staff are not always available in sufficient numbers.

One way to exploit the benefit but avoiding the pitfalls is to separate out two facets of these services: the PRODUCT, and the SERVICE.  The product might be a test result, or a PACS image.  The service is the value added to a clinical process, that is created by interpretation and then relevant application to each patient's needs.  Clearly, each hospital needs a pathology service and a radiology service - as, indeed, does every GP.  But do they each need their own capacity to perform the tests or the scans?

The benefits of consolidated production are considerable, potentially.  It can allow local "non-production" clinical leads to focus on service, and not worry about the operational day-to-day issues of running a lab.  It can allow for a far higher degree of choice - for example, GPs able to secure best value radiology services from alternative providers.  However, to realise that potential requires care: to preserve information flows that avoid duplication of work, or to ensure that common technical and medical standards apply to different labs working in a single network.

There is a lot of consolidation being planned and implemented, as the savings to be made are huge (half a billion pounds per year in England alone, from consolidating pathology services - was made for DH by the Carter Committee).  In addition, however, if done right, the gain in service value is also considerable.  Can this be a win-win?

Yes it can BUT only by retaining and extolling the local experts who can then focus upon the SERVICE.  Rather than feeling loss of status through the production being moved elsewhere, the clinicians who stay to offer the service are the ones in whose hands the real benefits will be safe.

Mental Health – a barometer of the NHS?

30 years of campaigning, research and development by professionals, aided by service users and family members who rely on services, have taken the country’s mental health care from hopelessly inadequate to being one of the world’s best. 

30 years ago, the legacy of neglect was evident everywhere.  The era of placing and forgetting about people in remote monolithic institutions was ending, but 30 years ago these institutions still functioned and their legacy services within remained intact. 

Since then, few of these monoliths still remain, most have gone.  But the care given has been totally transformed, everywhere.  Most mental health care is managed in the community, much by GPs and their staff, supported by community-based specialists.  In specialist providers, practitioners in psychotherapy, clinical psychology and psychiatry work closely together in each service user’s interests, in assessing needs, or in offering or monitoring treatment.  And the single biggest change has been the integration of health with social care, without which many (even most) of the last 30 years of transformation would not have been realised. 

But now, in the present situation of radical cost and productivity improvement, the care models that are so highly regarded internationally are under immense stress.  With calls for stringent productivity improvement by national government, mental health services are doubly hit by swingeing cuts in social care by local government.  And the sheer pace of the financial cutbacks is eye-watering.  In consequence, traditional social care systems are likely to be dismantled and integration of work across organisations is subject to reversal.  A lot is at stake.

Productivity has long been an issue in mental health services – after all, the costs were considerable of maintaining the old institutions that delivered little active treatment, and that money is now spent a lot more productively.  A whole new step-change, of at least equal proportions, is now needed – and fast!  Complete redesign will need to address the workforce, its plethora of disciplines and its effectiveness.  More generically qualified staff, supported by fewer highly specialist colleagues, social care input provided directly by the NHS, long-term placements managed more cost effectively – these are thought to be among the ways forward.  But the tools and the means of predicting, achieving and monitoring these changes are rare indeed.

If a whole society, generally, can be judged by how it treats its disadvantaged citizens, then perhaps its health care system specifically can be judged by its mental health services.  If mental health care is a barometer of the NHS, then there has never been a more important time to secure the hard-fought gains of 30 years, as a baseline from which to advance further.

Beware the "Pointy-Head" - a theme for the new year?

Two people have this week, separately and independently of each other, introduced me to the Pointy-Head, the latest in bogeymen. 

The concept is simple, when used to persuade staff to accept major change that will reshape their roles: either you work with us to achieve these much-needed changes, our way, or else the Pointy-Heads will arrive to do it anyway, but in their way.

Is this necessary, or are we at risk of infantilising grown-ups?  The NHS is facing change at an unprecedented rate, and many senior managers struggle to see how such change can be 'sold' to the staff most affected.  In actual fact, the selfsame staff are also: citizens, voters, taxpayers and probably read/listen to news very regularly. Managers need to be courageous and give leadership, by telling people of what they need to know and, actually, already largely know.

The essence of the challenge, what makes it unprecedented, is the speed with which the NHS has gone from being in financial growth (over 8 years) to financial constriction (over 8 years??).  But this is general knowledge.  Change will undoubtedly bring about much-needed improvement in efficiency and productivity, but process improvement will inevitably impact on staffing.

Grown-ups know all of this.  They also know that similar challenges are faced in just about every walk of life.  So involving them in the search for more productive processes, that raise quality AND reduce cost, should be straightforward.  Becoming part of the solution is, after all, a much more comfortable place to be than being part of the problem. They do need honest and frank working relationships with their leaders.

So before invoking the Pointy-Head, might it be useful to revisit the usual levers of change?  One of the two people who introduced 'him' to me thinks so and is actively extolling the alternative: persistent engagement with one's staff, and their participation in design and delivery of change, to grow value to patients - even in tough times.

Happy New Year, and do not fear the Pointy-Head!

The new politics of our market…

Experience suggests that there usually is little real major change of political direction of health, as a consequence of change of government.  A party is in government, does its thing, establishes issues to be tackled next, fights and loses an election, and the next lot casts its brand that owes more to continuity than to discontinuity.  Many examples down the aeons:

·         Administrative reorganisations planned by one government and executed by the next.

·         The Conservatives brought PFI into healthcare, hated by Labour but ‘rescued’ by it when in government and accelerated into use.

·         GP Fundholding to Total Fundholding to Commissioning as practiced by PCTs to Practice Based Commissioning to GP Consortia Commissioning.

·         Remember Regions?? From Regional Health Authorities to Regional outpost Offices of the DH, to (small) Strategic Health Authorities to (large and fewer) SHAs, and now to … Regional outpost Offices of DH.

So how might one view the politics of this recent political upheaval following Coalition politics since May?

Well, one thing stands out, and it emanates from the unprecedented investment during the ‘noughties’ to raise the health spend in England from historic average of about 6.5% of GDP to over 8%.  Abrupt change in economic circumstances, followed by change of government now heralds quite the opposite.  Of course, the NHS has experienced contraction of real-terms funding before, for example during the early 1980s. But everything feels relative to what went before: and what went before this constriction was extraordinary, and therefore this constriction will feel very tight indeed.

But something even more important stands out: general agreement that the previous government’s investment programme was not only massive, it was also inadequately productive.  Many reasons are offered: it takes time for major changes to produce the expected better outcomes; too much of the additional money was spent on better salaries, not on better services; even where new and superior designs of health provision were created, rarely did these displace older service models, running instead in parallel to great total cost.

So, is this another example of more continuity than discontinuity?  Is the Coalition merely rebranding health policy, or even just recycling older models such as GP Total Fundholding?  Or does it herald a genuine new era and, if so, what is new?

Structures are part of the Coalition’s answer, inevitably.  We see a mad rush to disband PCTs and to create GP Commissioning Consortia.  Regions are disappearing again, or are they??  When reading the little that is available and authoritative about GP Commissioning Consortia, those of us with memories of the Primary Care Groups of 2000-2002 might recall quite a lot that is similar: GPs in the driving seat of commissioning decisions, no closures without their approval etc.   We see re-commitment to localism, commitment to reduce ‘micro-management’.

One major point of difference is that PCGs were in charge of setting investment priorities across the system.  But now GP Commissioners will need to set disinvestment priorities instead. 

And so, this all adds up to one clear issue: a dual commitment, in these financially straitened times, BOTH to growing service quality AND to reducing cost.  In previous recessions, politicians, health professionals and the public assumed that less money on healthcare automatically meant lesser or fewer services.  Running out of money? Close some wards, reduce the number of ambulance stations, cut estate maintenance and equipment budgets.  But this isn’t reflected in what is happening now, and few people believe that such cuts are needed. 

The real change is that the pressure is really on to sweat the massive investment made over the last decade, to drive out unprecedented productivity improvements – to do vastly more, with somewhat less. 

PCTs may or may not exist, commissioning may or not be GP-led, these things DO NOT matter an awful lot.  It isn’t structures, it’s this core task that matters.  It matters to every level and each type of organisation in healthcare – NHS or otherwise.  It will fundamentally alter how services are strategically planned, commissioned and provided, and how they are chosen and used.