This paper reviews the main challenges facing the NHS in England. It assesses the radical reforms proposed by the coalition government and the financial pressures facing the NHS. The paper argues that much more emphasis needs to be given to integrated care in future in the context of an ageing population and the increased prevalence of chronic diseases. The importance of effective leadership in the NHS must be recognised and supported and is likely to be one of the issues highlighted in the Francis Inquiry report into Mid Staffordshire NHS Foundation Trust. There is also a need to look beyond current debates on reform and funding and ask what kind of health and social care system is required in the future. The King's Fund's programme of work on the future system will be raising major questions about the current emphasis on hospital based care and the need to reorient towards supporting people in their own homes and in community settings.
The President: Good evening, ladies and gentlemen. The King's Fund website states that it is a charity that “seeks to understand how the health system in England can be improved”. It then states that “using that insight” it helps to “shape policy, transform services and bring about behaviour change”. Professor Chris Ham was appointed Chief Executive of The King's Fund in April 2010. He has been Professor of Health Policy and Management at the University of Birmingham since 1992. From 2000 to 2004 he was seconded to the Department of Health, where he was Director of the Strategy Unit, working with Ministers on NHS reform. He has advised the WHO and World Bank and he has been awarded a number of honorary fellowships of societies and colleges and in 2004 was awarded the CBE for his services to the National Health Service. I am told his work focuses on the use of research evidence to inform policy and management decisions in areas such as healthcare reform, chronic care, primary care, integrated care, performance improvement and leadership. He is the author of many books and articles about health policy and management. The latest blog post that I found of his on the website was from the 20th February this year and was about how the Prime Minister's summit on implementing the NHS reforms had provided a new focus for debate about what the reforms would mean in practice. One of the points which grabbed my attention was his comment that there is a much greater risk that inertia, rather than privatisation, will block the changes needed to bring about improvement in the quality of care and patient safety, and then he goes on to explore what is required to effect those changes. So it is with great expectation that I await hearing what Professor Ham has to say this evening about Reforming the NHS in England: Opportunities and Challenges. So do join me in welcoming Professor Ham. (Applause).
Professor Ham: Thank you very much, first of all, for the invitation to speak tonight; I am very pleased to be here. The King's Fund is just round the corner, so this is a very convenient location for me; we have splendid premises in Cavendish Square; and I am going to address this very broad topic about NHS reform, something I am sure we have all been following with interest, both because of the personal impact it might have on us and our family members but also because the NHS is such a cherished and valued institution. I will speak for about half an hour because I really welcome questions and the opportunity to debate some of the issues with you. I will set out my stall and I hope there will be both agreements and disagreements as we engage in the debate.
You have heard some of my views on this first slide, that we now have the legislation finally on the statute book at the end of March this year, and that certainly now gives us an opportunity to move on to debate and discuss and work on arguably more important and pressing issues as far as the quality of patient care is concerned. I will start with the Act, and then talk about some of those other more pressing issues.
The reforms really are radical. They build on what previous governments have done, but they go much further and much faster in introducing and extending market principles in the NHS and, because of that, they are going to be quite destabilising. They are turning the organisation on its head. We are getting rid of the old Health Authorities and the Primary Care Trusts and introducing the new GP-led Clinical Commissioning Groups, among many other changes.
We at The King's Fund have always taken issue with those who suggested this is the end of the NHS as we know it. We don't think the Government is intent on privatising the provision of healthcare, although it clearly wants to introduce a bigger role for private and third sector providers. History tells us, if you go back over the last 20 years, starting with Mrs Thatcher's market-based reforms and going on to what Tony Blair did in the last decade, that although there might be radical aspirations for a bigger role for the private sector, the reality is its contribution grows rather more slowly than some people have expected or indeed feared, and our view again at The King's Fund is that rather than embarking on a revolutionary path through this legislation a better approach would have been to build on what had been achieved before, to make changes of course, because the health service always needs to improve, and some of those changes should have involved giving GPs and others a much bigger role in decisions about how the money is spent, but we believe that could have been achieved much more effectively through a step-by-step change rather than such a big bang as the Government is proposing, and – this is where you have anticipated one of the points I wanted to make – rather than fearing privatisation, in fact our view is that inertia is a much bigger risk. Notwithstanding the radicalism, notwithstanding the size of the legislation and the clinical implications, over the years what the health service has demonstrated is an ability to absorb almost everything that is thrown at it and to keep on providing care to patients and improving the quality of that care.
At a time when the money is very tight, which I want to come on to talk about now, we think the need for much bigger and more ambitious change, innovation, if you will, is what is needed. We have also argued that, whatever the legislation says – and I know some of you will be far more expert in this than I am – there is a big difference between what is on the statute book and how that translates into changes within the NHS itself. Implementation in some ways is more important than legislation in shaping what the actual effects of the changes will be in practice. Here are just four things to think about:
How will the new Clinical Commissioning Groups work and how will they relate to the new NHS Commissioning Board at a national level?
Will there be, as Andrew Lansley hopes, a lot of devolution, a lot more power and control in the hands of GPs, or will the Commissioning Board, under David Nicholson, still retain a tight grip on how the NHS runs?
At a national level quite a complicated structure, the Commissioning Board overseeing what the GPs are doing, Monitor, as the new regulator, overseeing how Foundation Trusts and other healthcare providers operate, and the Care Quality Commission still focused on the quality of care and inspecting a range of different providers.
And there is huge potential for confusion between these three big national bodies as to who is doing what and how they will work together – hopefully well, rather than badly. The third issue:
The Government have said all NHS Trusts have to become Foundation Trusts by 2014.
That sounds a long way away, another couple of years. It is going to be a great challenge to deliver that ambition and that objective. There are over a hundred Trusts that have yet to become Foundation Trusts. Many have deep-seated financial problems; they have problems about the quality of care they deliver. It will not be easy for all of them to get to the finishing line within two years. And then the other issue:
Health and Wellbeing Boards, quite widely supported in this contentious legislation, giving local authorities a much bigger role in overseeing the performance of public health, social care in their communities. They don't have many formal powers, but because of the legitimacy that comes with local elections they could become very important players alongside the Clinical Commissioning Groups.
But none of us can tell at this stage because of the gap between legislation, on the one hand, and implementation, on the other hand.
So on to money, which is getting to the core of what I see as the big challenge that is facing the NHS. David Nicholson has said there is a need to find £20 billion of efficiency savings, and more recently we have been told that actually the economy is in worse shape and the public finances are facing tougher challenges than the Government thought two years ago when it came into power, so the figure might well be closer to £40 billion, or indeed might be even more than that, huge sums of money, and, let's be clear, we are not talking about cuts here, because in cash terms more money will be spent on the health service at the end of this Parliament than at the beginning of the Parliament. In broad terms, if the NHS in England was consuming £100 billion of public resources in 2010, by 2014/2015 it will be much more like £115 billion in cash terms. So the £20 billion is about reducing waste, making the health service more efficient, recycling money that could be better spent on new priorities, like the care of people with dementia, for example. But that is a big challenge, because the health service has never delivered efficiency savings on that scale at any point in its history.
Alongside that challenge we are seeing real cuts (and this is where the cuts do come in) in local authority spending and social care, and the obvious knock-on effects into the NHS. If it is difficult to fund social care for people who are eligible for social care, then it will be more difficult to discharge patients from hospital in a timely way, because the resources will not exist to provide the social care in the community, and that will have knock-on consequences, too, for the ability of hospitals to treat patients on waiting lists, because if beds become blocked inappropriately, then we may find ourselves back in the bad old days of operations being cancelled at the last minute simply because of the pressures on the system.
Andrew Dilnot and his team put out some very clear proposals a year ago for the future funding of long-term care, arguing for a partnership model, with the Government to play a bigger part alongside private individuals and family members, and the Government did make a commitment (let's be clear about this) to legislate in the Queen's Speech, which was presented to Parliament yesterday, on its response to Dilnot and legislation to implement its decisions on Dilnot. But actually that didn't happen. This is in the too difficult basket in Whitehall. The Government is saying this is now an issue for the next spending review in a year or so's time, and the reason for that is the one I alluded to earlier on; the state of the public finances being such that there is not that slack or flexibility to find about £2 billion to implement the Dilnot partnership funding solution, and many organisations have made their views on that absolutely clear; great disappointment among organisations representing older people and people with disabilities, for understandable reasons.
The challenge, with all these funding pressures, is will the NHS go back rather than forward? Will we go back to longer waiting times for an operation, for a diagnostic test, for an out-patient appointment? Will the health service have to start rationing healthcare again in the way that we were debating 10 to 15 years ago but largely have moved on from because there has been more money flowing into the system? And there is a political challenge here, because the Prime Minister has been very explicit on more than one occasion in public speeches saying he will give the public his personal commitment to maintain short waiting times in A&E, the four hour maximum wait, short waiting times for operations or for diagnostics tests in hospitals, the 18-week standard and short waits for cancer patients or patients with suspected cancers, and it will be very difficult, in our view, to deliver on those commitments given these funding pressures over not just four years but probably six, seven or eight years. So there is a lot hanging on this politically for the Government as a whole.
We published a paper at The King's Fund shortly after I took up post in July 2010 and the subtitle, I think, tells you what it is all about: the challenge for the NHS in improving productivity, delivering more with the same volume of resource, not more of the same, because there is no more money going in.1 So it is squeezing out those inefficiencies, reducing the waste, delivering more value, if you will, more benefit for patients in the population by using that £100 billion more effectively than it is at the moment, and what we said is that you need to think of it in this way. If we are going to get close to delivering that 20 to 40 billion pounds of efficiency savings we need to do all of these things set out on this inverted pyramid (see Figure 1), and it is inverted for a reason, because we think the most important is engaging frontline clinical staff, doctors, nurses, AHPs and others, supporting them to use resources more effectively in the interests of improving patient care; in the jargon, focusing on the clinical microsystems, by which I mean the GP surgery or the team delivering care in the A&E Department, the basic units, if you like, of clinical staff delivering care to patients, whether it is in the hospital, in the community or indeed in primary care. And the reason we focused on that is because a lot of the evidence suggests the most obvious examples of waste and inefficiency arise out of variations in clinical practice, variations in prescribing in primary care or in referral to hospital by GPs, or indeed within hospitals the decisions that doctors and other clinicians take on how to treat patients, because the people who control the cheque books in the NHS, by and large, are not the managers and the bureaucrats that we hear a lot of critical comments about, the people who hold the cheque books are the people who make those clinical decisions about whether to treat or not and, if to treat, how to treat. So every time a GP writes a prescription, that is signing a cheque on the public purse; every time a GP writes a referral letter, that is signing a cheque; and most of those cheques are entirely appropriate and they are a wise use of public funds. But not all of them are, if you look at the variability between practices and between populations. So engaging clinical teams is fundamentally important. But the other things also will make a difference as to whether the health service can rise to the challenge to find the savings that are needed, and at the moment, if I just draw your attention to the bottom of the pyramid, what can be done at a national level, the Government itself is contributing quite significantly to the still positive financial performance in the health service. It is doing so by constraining pay settlements, a pay freeze, in the NHS, which helps to keep costs down; it is doing so by setting prices that hospitals are paid for treating patients, in fact reducing those prices, deflating the tariff that is paid within the NHS and therefore helping to keep resources within budgets; and at the moment, financially at least, the NHS is in good shape; the NHS had a surplus at the end of the last financial year, which was the first year of real financial constraint, and carries some of that surplus, at least, forward to deal with the financial pressures this year.
What we also said (in a paper we published with our colleagues at the Nuffield Trust, just round the other corner from here) is that the government should give much more attention to how care can be more effectively integrated, co-ordinated around the needs of patients, rather than patients and families having to navigate around a complex and often fragmented system.2 Now, I don't know what your personal experience is or the experience of your family members, but almost everybody I talk to (and I can speak about this from my experience) says that the health service is often very good in delivering episodic care when we need to see our GP or go to the outpatient department or have our tests done. Where it often falls down is those different bits not joining up around the needs of patients. The health service too often is uncoordinated and fragmented, particularly when patients are moving between hospital and the community or between the GP and some other part of the system, and we have argued very strongly at The King's Fund that the healthcare system we need in the future has to be much more integrated, and not just within the NHS, but health and social care need to be much more joined up as well.
The reason, very simply: you only have to look at the demographic pressures and the changes in the disease burden with which the NHS and social care are having to deal; an ageing population, far more people aged not just over 65 but over 75 and over 85, many living independent and generally healthy lives, but increasing numbers of people not doing so, increasing numbers affected not just by a single medical condition but by several, the problem of mul-timorbidity in the ageing population giving rise to the need for treatment by different specialists, as well as by GPs, as well as by nurses and other clinicians working in the community, and if we are going to deliver world class care of the highest possible quality, those different bits of the health and care system need to be much more effectively integrated and co-ordinated around the needs of people who require just that kind of service, and too often at the moment we fall short of what we could and should be doing. We think that will also contribute to finding some of the savings that are needed. There is waste involved in a fragmented system, and there is waste involved when patients are lying in hospital beds when they no longer need to be in an expensive and, sadly sometimes, an unsafe acute hospital because of the lack of resources in the community or the challenge of the hospital working with the community to ensure timely discharge to appropriate care outside of the hospital, and if we could in just that one area achieve better integration, then we could provide better care, arguably at a lower cost; we would deliver some of that £20 billion that is needed.
So integrated care around the needs of patients and populations is a real priority from our point of view. It seems the Government has accepted that argument from both us and from the NHS Future Forum. But there are questions. Although the Prime Minister has said integration is very important; Andrew Lansley has said so; Paul Burstow, the Care Services Minister, a Liberal Democrat, has echoed that; there remain, I think, legitimate questions about how strong, how real is their commitment, because Andrew Lansley's original plan was much more about competition, choice, opening up the health service to new ideas, to innovation from the private sector, or indeed from the third sector, and you could say that more competition, a greater plurality of healthcare providers, would make for a more fragmented health service, not for a more integrated and co-ordinated health service. Policies would have to change if the Government is serious in wanting to see more integrated care. So introducing payment systems to support organisations and professionals to work together, rather than to work separately, and the main payment system we have at the moment, the misnamed Payment by Results, which pays hospitals for the activity they undertake, the number of patients they treat, is not well suited to create the right incentives to integrate between hospitals and the community.
The funding pressures, the service pressures mean that we have to be ambitious in implementing integrated care, in our view. We need to do it at scale, across a city, across a county, a large population, and we need to do it at pace. So the time for small-scale pilots is over and the Government needs to be very clear about its willingness to support integrated care at scale and at pace, and some parts of the country have done this. We have been working at The King's Fund with many organisations and systems across England, and indeed further afield, that have overcome the barriers to integrated care and are demonstrating good results, particularly for frail older people, who are those who most need integrated care. How have they done it? Well, fundamentally because they have had a vision “This is the right thing to do”, they've had the quality of local leadership, in hospitals, in local government and elsewhere, to make it happen. So it can be done, if you like, against the odds where you have strong and effective local leadership to make integrated care happen.
We published another paper about a year ago on The future of leadership and management in the NHS because nobody else seemed to be standing up and making the case for why a big, complex public service needs good leadership and excellent management. It seemed to us that managers, or the bureaucrats as the politicians sometimes say, were an easy target and The King's Fund perhaps could lend some support to the need for effective leadership and management, alongside having doctors and nurses playing a bigger role in managing budgets and managing services, and the subtitle tells you what our theme was.3 Our argument is the health service needs a different style of leadership, not so much based on heroic Chief Executives who come in and do wonderful things; health care is too complex for that; we need much more collective leadership. We need teams leading hospitals and healthcare organisations. We need to play to the strengths of the managers, the financial directors, the medical directors and the others who contribute to improving the performance of the NHS. So making the case for why a big public service spending over £100 billion a year needs management. It seems a strange thing really to have to do. How can we not run the health service with great leadership and great management, but nobody else was making the case, so we decided to do so.
Moving on and perhaps looking to the future, (because I have been describing where we are and some of the challenges that we are faced with), the Francis Inquiry into Mid Staffordshire and the very sad and tragic events and mistakes that happened at Mid Staffs, we are expecting that now to be published in the middle of October. It will be awaited with anticipation in some quarters and indeed trepidation in other quarters, because, you know, bad things happened at Mid Staffordshire Hospital and I think people will be wanting to see what the Francis Inquiry has to say. The good thing about this is it will bring our attention back – if it has wavered, it will bring it back – to the quality of care and patient experience, the core issues that always are at risk of being neglected when we are debating legislation and organisational change. So from that point of view the inquiry report will be very welcome. But, depending on what comes out from the report, the risk of Francis could be that he will interpret the problems of Mid Staffordshire as a problem of regulation, the failure of regulation, particularly the failure of the Care Quality Commission, as the quality regulator, and Monitor, as the Foundation Trust Regulator, to not intervene sooner and more effectively to spot the problems at Mid Staffordshire and then to take the necessary corrective action. Now, I am sure that part of the problem at Mid Staffs was indeed a problem of regulation, but if that is the main conclusion of the Francis Inquiry I will be disappointed, and The King's Fund will make its views known on this issue, too, because the way of avoiding future Mid Staffordshires is not to build up the power of the regulators. The first line of defence around good patient care, high quality patient care should be the skills, the experience and the commitment of the front line clinical teams delivering that care, the teams in the hospital, or indeed elsewhere, and if we have well trained, highly motivated and valued staff in those front line clinical teams there is a very big chance, from all we know of how the health service works, that you will avoid bad things happening, and, if you don't, the likelihood is that bad things will indeed happen. So the issue ought to be focused around professional standards, the care that is delivered by those front line teams, rather than an argument for even more regulation, and, as I say, let's wait and see and let's welcome the prospect of Francis as an opportunity to go back to what really matters in the health service, and that is a relentless focus on improving quality, improving patient experience, a timely reminder of what the NHS is here to do and to do for us.
Again, looking to the future, it is easy and I think safe to anticipate that there will be an even bigger debate about how services are organised at the moment, and particularly how hospital services are organised, not least in London, because London is probably the extreme case of this, if you look across the whole of England. The existing distribution of hospital services is simply not sustainable. We need to grasp the nettle; we need to concentrate, with professional and public support, some of our specialist services in hospitals in fewer centres. The debate recently about paediatric heart surgery across England illustrates the challenges in doing that, because people don't want to travel further, even if that means getting access to a higher quality service that delivers better outcomes. But as Bruce Keogh, the Medical Director for the NHS, has said, if we are serious about improving quality and outcomes, then we cannot continue providing children's heart surgery in as many hospitals as we do today. To use a different example, in London in the last three or four years there has been progress in improving the quality of stroke services. At the beginning of that period there were about 30 hospitals in the capital that were providing specialist stroke care; there are now eight, eight hyper-acute stroke units, and my understanding, from evidence that is yet to be properly published, is that it has been shown that lives are being saved and quality of life of stroke patients is being improved by that concentration of stroke services in those eight specialist units. Stroke and paediatric heart surgery are not the only examples, there are many others where there is a clear relationship between the volume of work that is undertaken and the outcomes delivered for patients and populations; in other words, a strong argument for some specialist services to be concentrated in fewer hospitals.
There is also an argument for some other forms of hospital care to be provided in the community. We have already seen a shift in the lifetime of the NHS: a lot of routine chronic disease management, patients with diabetes or heart failure, has moved from hospital outpatient departments to general practices, and there is scope for more of that to be done. If you think about a typical hospital outpatients department – somebody described it the other day as really a nineteenth century model, not even a twentieth century model – large volumes of patients turning up in large outpatient departments, who arguably could be better treated in other settings, not all of them, but quite a high proportion. And, most contentious of all, there is scope for improving outcomes in A&E and maternity services by reducing the number of local hospitals that provide these services, and here the driver is as much workforce pressure as any other factor. In this country generally we have fewer senior medical staff, consultant staff, in the main hospital specialties than you see in other parts of Europe, in North America and further afield, which means it is very difficult to staff some of these services 24/7 to provide the right level of senior medical input for patients who require that. You know, for some reason, in some of our specialties (A&E is an example), this has begun to change, but historically you see the most junior, least qualified person first and you work your way up to see the consultant, but only after a long period of time and several hand-ons. Now, that cannot be right, and it cannot be right when we simply don't have enough consultants and senior medical staff to provide the best possible care in the existing hospitals that try to do so.
These are very difficult issues to explain to the public, because everybody, understandably, hopes that their local hospital will continue to provide the existing services, but gradually and slowly but surely we are making progress, as in the example I gave earlier of stroke care in London.
The last point I want to make (and then I will summarise and bring these remarks together) is that going beyond the debate about the Health and Social Care Act, we are doing some work at The King's Fund where we recognise the many achievements of the health service and the fact that we are all, I think, fortunate that we value having a universal, comprehensive tax-funded health service, largely free at the point of use, that delivers quick care to a generally high standard. But equally we are clear that that system in many respects has fundamental flaws, and the four I am highlighting here are:
Far too little emphasis on prevention, and far too much emphasis, therefore, on treatment services.
If you look into your crystal ball, the challenges posed by the increasing prevalence of obesity and overweight in the population and the burden of disease that is implied in that around diabetes and heart problems in the future, if we don't reverse those trends, then the burden and the cost on the health service will probably be unsustainable. We have the unenviable record in this country of having the highest rates of obesity and overweight in Europe; in fact, across the world we are second only to the United States. That is not a good position to be in and we need to be much more effective at doing something to prevent obesity and overweight and the health consequences that follow on from that.
We still place too much reliance on hospitals.
I have alluded to this. End of life care would be an example. Many people would prefer to die not in hospital, but at home with the right kind of support, or in a hospice, or in some other alternative setting. Our failure to offer that choice and those alternatives means that far too many people die in hospital, and that is not their first preference. Many hospitals are dealing with patients who don't have acute medical needs. We call them acute hospitals, but actually they are caring for large numbers of older people who no longer need the expensive technological specialist services delivered in our acute hospitals but could be more effectively cared for in other settings, again if we could find a way of releasing resource to provide that care.
The quality of general practice is often high, but it is still too variable.
We produced a major report on this at The King's Fund last March, where we highlighted the known variation in the quality of general practice in this country, and I could talk about that in much more detail. General practice is still fundamentally a cottage industry, delivered by small groups of GPs working with the support of a team, not operating at the scale that is needed to enable more services to be delivered closer to home in a more convenient way to patients and to populations.
Community nursing services, the services provided out of hospital not by GPs but by the wider community health service teams. They are very fragmented.
I have visited a number of parts of the country where people have been trying to explain to me the range of different teams they have in the community, each of which has a logic, but if you add them all together there is no logic, there is no coherence; there is huge duplication and waste in the way we organise the expertise of great skilled nurses and others in the community, but they are not well managed and well organised to deliver the care that is required.
So in all of these different respects, although there are many positive features of how care is delivered in different settings, when you add it all together, in our view, you can describe quite cogently and quite coherently what looks like a broken healthcare delivery system, and we need to address that as a matter of urgency.
So my summary points are these. Times are tough; the challenges are real. We are only a year and a bit into at least four years of deep financial restraint and the challenges have become greater, including in social care as well as the NHS. Integration or collaboration for us is very much the route to survival, how we overcome the fragmentation and deliver much more joined up care around the needs of patients, especially those who are most frail and most vulnerable. Long overdue service reconfiguration, concentrating some services in fewer hospitals and providing other hospital services in the community, where there is a good evidence base to support that, but communicating and explaining to the public why that is a good thing to do. Therefore, innovation is at a premium. We can't carry on doing things in the same old way, and the health service has changed. Let's be clear about this, over its 64-year life the NHS has changed in a way that certainly Nye Bevan, were he to come back today, would not recognise the health service that we have and that we use. But innovation is slow, innovation is piecemeal, and that will not do to deal with these financial and service pressures, and so I reiterate the message: the health service needs the best possible leadership by doctors, nurses and managers to navigate through these very treacherous and challenging waters that lie ahead.
Thank you very much. (Applause).
Discussion
The President: Well, Professor Ham, thank you very much for that terrific gallop through a very large topic. We don't, I am afraid, have a roving microphone today, but if people would like to ask questions, please just raise your hand and I will point a finger to invite you to ask a question, and please say who you are and whether you are a doctor, lawyer, or neither. The gentleman over on the right there.
Professor John Norris: John Norris; I am a neurologist from London. I was interested in your talk because you hinted at the beginning that the reason for the Lansley revolution was really because the NHS is really grinding to a halt; it will soon be almost immobile; so something has to be done. I would suggest that the problem is lack of incentive, like many socialist projects. If there is no incentive, then people don't work. If you look, for instance, at general practice, then GPs don't work in the evenings, they don't work at weekends, they're often off for a fairly grand lunchtime; you can't get your GP at lunchtime. In hospitals you will often find no operations are done on Friday afternoons and in fact, some of the operating rooms are closed even in the morning. Even in outpatients care is pretty scattered throughout the afternoon. So that's the problem; it is a lack of incentive that is the real essential problem. There will always obviously be a need for an NHS for the indigent people, but I think that the majority of people have moved on since 1947 and now a lot more people can afford and would like to have private care. So I think if you give them that combination, which is I suppose what Lansley is doing, sensibly, then maybe we can get there at the end with a combination of NHS plus some degree of privatisation.
Professor Ham: I agree incentives make a difference. I probably disagree that they're the main thing that makes a difference. Wasn't it Ken Clarke, when he was being criticised by the BMA, going back 20 odd years ago, who said something like “If you want to get a message to the medical profession write it on a cheque.” (Laughter.) So he was part of the, you know, incentives matter and make a difference, and they do, yes. Doctors (if I can just talk about doctors) are no different from other human beings; they will respond to the payment systems and the incentives on offer, and we have seen that through successive changes to the GP Contract, haven't we? If you pay doctors to do things in the “quality and outcomes” framework because they get 20% more personal income, then they will do those things, whether there is good clinical evidence to support it or not. Where I depart from you is in saying that is the main thing that is wrong with the health service at the moment. In fact, you were saying much more than that, but let's just focus on that bit of it. I think most people who work in the health service, clinicians especially, managers too, actually have quite a strong vocation and have quite a strong intrinsic professional motivation. If they wanted to make loads of money they would be in the City or in some other occupation where there are much greater financial rewards available. They have chosen to come into healthcare and medicine for other reasons very often, not that money is unimportant, but it's not the main thing that gets them out of bed in the morning, and I think what we can see across the NHS is quite a variable pattern of productivity and performance, even though the incentives that people are faced with are very similar everywhere, and what makes a difference are the people, the leadership, the skill they bring to their hospitals and their primary care organisations, and I know a lot of GPs who will go the extra mile, who don't fit quite the profile that you were describing.
Professor Lesley Regan: Lesley Regan; I am an obstetrician and gynaecologist at Imperial based in St Mary's. I was interested in your comments about innovation and different ways of funding and the lack of integrated care. Claire Perry went into Europe. Before that she had worked with you at The King's Fund, she and I thought about the possibility of setting up new ways of incentivising or, if you like, rewarding hospitals and hospital staff, because at the moment the only way that I earn income or kudos for my institution is to bring a woman into my hospital to do something to her. We talked then about the possibility of funding per capita of the population so that my General Practitioner would have a pot of money on my head that he could use in order to prevent me going into hospital and he having to make a referral, and I just wondered if you felt that The King's Fund maybe ought to spearhead some of those innovative practices.
Professor Ham: I fully agree with you and that is something we have been trying to make the case for. The problem we have at the moment (and this is a legacy of the last Government, not the current Government) is that we have set hospitals up, if I can use this language, as revenue centres or profit centres and the more patients you treat the more income you get and we have held our hospital boards/hospital leaders accountable largely on the basis of their financial performance and whether they are hitting the national targets, and that's all the wrong way round, given the changing age profile, the disease burden. We need to think of hospitals much more as cost centres, cost centres that work as part of much more integrated systems. I am a great fan of what I have seen in the United States, whether it's a Kaiser Permanente or some of the other fully integrated healthcare delivery systems that run the hospitals, their GP services, the community services, and they have a single budget to do that, and if you keep people healthy, you are reducing the expenditure on the system. You know, to use their language, they are health maintenance organisations, that's where the incentives are aligned, and so they don't build up resources of hospitals, because, if they did, they would go bust very quickly. They put the emphasis on keeping people healthy, knowing the population, intervening early and avoiding hospital admissions, except where it is the clinically right and appropriate thing to do, and my view, very strongly aligned with what you and Claire no doubt were discussing, is that that is where we need to migrate. The problem is we are a long way away from that at the moment.
Dr Henderson: I am David Henderson, a GP from Sussex. One thing is that I absolutely don't recognise Dr Norris's description of doctors not being available. My lunchtime now, and most of my colleagues, is spent eating a sandwich with one hand and signing letters, looking at pathology results, doing repeat prescriptions or just sending letters. Also one of the reasons why we are not as available as we were is just what is required of us, the enormous suffocating bureaucracy of working out protocols and how I as a single-handed GP will support a six-doctor practice down the road if they are all smitten by flu next winter. We can't have joint practice managers, we have to have ownership ourselves, so we end up with 30 or 40 different protocol forms to consider and sign. But the point I was going to make was that I am really very inspired by all of this. Ken Clarke, quoted in an interview: “We are going to make it absolutely so good,” he said 20 years ago, “that no-one will want to go privately.” What chance does Mr Ham think there is of achieving even part of the aspirations you mentioned tonight within the next 10 years?
Professor Ham: Do you mean the 20 billion, or do you mean all that stuff?
Dr Henderson: Oh, the 20 billion will probably be directed somewhere else, like the 16,000 million that went on the IT project. I am sorry to be so cynical.
Professor Ham: No, no, no, I'm a glass half full rather than a glass half empty man, so I am optimistic we'll go some way, perhaps a long way, towards doing what is needed. I think the intellectual arguments and practical arguments, for example, in favour of integrated care, are unanswerable; it is a no brainer to me. Why would you want to stand up and make the case for fragmented care?
Dr Henderson: The system works, but it doesn't in practice.
Professor Ham: It doesn't work. So, you know, the logic is, as we have been discussing, we need to find a way, starting not ideally where we would want to start, of moving much more towards GPs, in my view, needing to collaborate through federations and networks with neighbouring GPs, and maybe Clinical Commissioning Groups could facilitate some of that. I think the challenge with CCGs is that most GPs, in my experience, are much more interested in developing their role as service providers than spending a lot of time as commissioners of care, and that is where federations of practices could be helpful, because if we can get them to work through networks you are creating a platform across bigger populations where more things that have traditionally been done in other settings can appropriately be located in a GP setting, and if we can do that and we can build the linkages between specialists in hospitals and primary care teams, we could go much further in the direction I was arguing for. I find it, when I talk to clinical audiences, very easy to make the case for integrated care, as people feel enthusiastic about that. Increasingly managerial audiences get it as well. The doubt I have is the one I was referring to: are the politicians serious when they say they believe in integrated care and will they provide the means? I am not convinced I will remain sceptical until I see the policies change to support all of this. Service reconfiguration I am more sceptical about. I just think we're starting from a long way back in explaining to the public why this is the right thing to do. I mean, take stroke care in London. If it has delivered the benefits which I have been led to understand, why haven't we been out there on the stump making a song and dance and saying “Look, hundreds of lives are now being saved in London because of the clinical reorganisation of stroke care into fewer centres”? And if you can make that case based on evidence from stroke care, it makes it easier to make the case in other areas of care, too. I- think NHS insiders get it; they understand the logic and the rationale; but we've been abysmal in our ability to communicate that to the public out there and to local politicians, who will often be very protective of their local services, so we shouldn't be surprised that that becomes a hard sell. David Nicholson has said on more than one occasion that this is now an opportunity we have to take, because we cannot carry on with the current distribution of hospital services.
Dr Mansell: Martin Mansell. I am a kidney physician and involved with medical negligence. I understand the focus necessarily has to be on the huge changes which you have described to us, but my concern is that there are missed opportunities with the aspects of patient safety, risk management and clinical governance. I don't share your conviction that Monitor and CQC are going to do a better job in the future than they have done so far, and I think they've done a terrible job so far. I think that the repercussions of Francis will be at least as great as Bristol and Shipman, and whatever, and (my final note of cynicism) I thought you'd hit a great idea; you know, let's reconfigure the services, let's slim it down. You spoke about paediatric cardiac surgery, to which I would only reply “the Bristol inquiry”!
Professor Ham: Hmm.
Dr Mansell: I take your point about stroke care; that's a success.
Professor Ham: Yes.
Dr Mansell: It has worked very, very nicely. But, you know, the politically sensitive issues. … The politicians have to get re-elected, I understand that.
Professor Ham: Sure.
Dr Mansell: So a few cynical thoughts.
Professor Ham: Let me just sort of clarify what I was saying about regulation, CQC and Monitor, because I think we're saying largely similar things. I wasn't arguing that Monitor and CQC have done a good job. My argument was if Francis comes out saying they have failed to do a good job and what we need is far more regulation through bodies like Monitor and CQC, that will be a bad outcome, because I don't think regulation is the way of improving patient safety and dealing with the issues that arose at Mid Staffs. I think you have to start at the coal face; you have to start with the clinical teams delivering the care and ask some pretty tough and awkward questions about what were they doing when bad things happened at Mid Staffs and why were they doing those things, and the regulator in London is a long way away from where the patient comes into contact with the service and gets a bad outcome because the clinical team was working in a way that was suboptimal. So the focus of Francis, I agree with you, will have major ramifications, arguably far bigger and more important than the Health and Social Care Act, and I hope it does have that ramification, but it needs to get the diagnosis right to ensure the prescription that follows on from that is one that will help to improve quality and safety, rather than to take us in the wrong direction. Does that make sense?
Dr Mansell: I am not sure what you are proposing as the alternative to Monitor and the CQC, if anything.
Professor Ham: What I am saying is the first line of defence around providing safe, high quality patient care rests with people like you and clinicians across the health service, in daily contact with patients, and fundamentally what is important is we get the right people in with the appropriate training and skills, with revalidation and with all the checks and balances that increasingly are being put into the health service. The next line of defence is the leadership of every hospital, every Clinical Commissioning Group, every mental health trust in the country. The Boards of those organisations have it as a formal part of their responsibility to promote high quality, safe patient care, and so, if that is not being done, they should be held much more directly accountable. Then for a third line of defence to those who are commissioning care from those organisations. So in future, you know, the GPs running the CCGs will be in the firing line if bad things happen within the system, and only then do you get these very distant and remote national bodies, like the CQC and Monitor, who can't possibly oversee a massive national system of very complex providers and give us the assurance that every day every patient in every department is getting the care that patient should expect. So that is what I was trying to argue.
Dr Baker: Larry Baker; I am also a renal physician in London. One way to reduce financial waste in the health service, it seems to me, is to manage patients better.
Professor Ham: Yes.
Dr Baker: I mean, normally the cheapest patient is the well managed patient, and one thing that mitigates against that right now, and will increasingly do so, I think, is the Working Time Directive, which has really reduced continuity of care. If you ask patients, as I often do, “Who was the consultant who looked after you in hospital?” I would think about 80% of them do not know; they say “Oh, a nice young man called Roger”. It has also had a frightening effect on training, particularly of surgeons, who get about half the operating time now that they used to hitherto. So can anything be done about the Working Time Directive, which, whilst it is quite appropriate for lorry drivers and pilots, isn't really appropriate for the medical profession, I don't think.
Professor Ham: Well, I am not a lawyer, (and there are lawyers in the room), but I suspect there is not a lot we can do about the Working Time Directive because it is EU law. For me you are raising a very important point. I think over the next decade, maybe two decades, we are going to see a substantial shift in medical staffing, particularly in hospitals. I think we are going to rely much more on a consultant delivered service. I mean, we are training far more doctors; they are coming from the expansion of medical schools in the last ten to fifteen years. There is a question about will there be enough money around to employ all those doctors coming off the production line and will they choose to go into hospital medicine or into general practice, but assuming those questions can be answered in the affirmative, inevitably it seems to me, with the Working Time Directive, we are going to have to rely, and probably should rely, far more on senior medical staff delivering patient care, rather than doctors in training doing that. I think I alluded in my talk to the fact that, compared with other countries certainly in Europe, traditionally we have relied a lot more on doctors in training and a lot less on senior medical staff, and some of the evidence coming out now from the Colleges and the Academy note the benefits of patients seeing senior medical staff first, rather than seeing doctors in training first. So I think there are a lot of things coming together around that.
Dr Baker: I totally agree about that last bit, but the problem with the outpatients in hospital is that a different junior doctor, maybe a different consultant, looks after the patient on different days and continuity is compromised.
Professor Ham: Yes, but the other bit of that then, and part of the work we are doing at the moment, is that as well as arguing for more senior medical staff and for greater specialism where the evidence supports greater specialism and greater concentration, we would support the view which I think the College of Physicians has also argued recently, about the need for more generalism; the need to rediscover and value the role of what the Americans would call the hospitalist; the acute physician who takes responsibility on the hospital wards when the specialists have done their bit and provides the continuity that perhaps the senior registrars have done in the past when we weren't constrained by 48-hour working weeks.
Mr Gardiner: Bill Gardiner. I am a lawyer, but that is really not the point. I have been a Non-Executive Director of three parts of the health service and I come from a background of the oil business, so I am very, as it were, commercial. I am going to try and make this very simple. You spoke about inertia and certainly management have built-in inertia for protection. You spoke about integration, which I, as a business person, can understand, but on top of all that system in which managers have to integrate there is still the tariff, the Healthcare Resources Group. A hip price is £1,860. Now, that is death to any sort of inventiveness by way of management. I know that progress has to be made and we carry the burden of the tariff, but I just wonder how quickly that will be exposed as the thing which stops the system becoming efficient. I have no doubt about clinical diligence. Clinical diligence should exist without any regulation.
Professor Ham: On the tariff, the way I am seeing it is the Government introduced a tariff based on prices that reflected average costs across the NHS as a whole. It bore no relation to the costs in the hospitals you have been associated with, or indeed, I suspect, anybody else, partly because the information we have in the health service is pretty poor and doesn't provide a good basis for setting more realistic tariffs. The aim has been to move away from prices based on average costs to much more normative price setting looking at best practice and saying “Well, if there is a hospital in the North of England that is delivering good outcomes for hip replacements at half the cost of the tariff, that should be the sum that is paid universally and everybody has to change their practice to move in line”, but there has been very slow progress in doing that, and the tariff, you know, it reinforces the fragmented episodic organisation of care, doesn't it?
Mr Gardiner: Yes.
Professor Ham: People are now talking about moving towards year-of-care tariff payments. If you think about people with chronic diseases, would you put a sort of price on their heads and say for twelve months Mrs Smith, who has primarily, let's say, heart failure or diabetes, would have a sum of money associated with her and the GP practice, if it's appropriate, or the hospital would receive that sum of money? It goes back to the point that was made earlier about capitated budgets and funding. A year-of-care tariff is a person based form of capitation. Actually, I think that is the wrong way to go. It is the wrong way to go because if we move away from paying for widgets and payment by results to paying for year-of-care associated with chronic care, I think we are at risk of replacing one set of silos with another set of silos. If we are going down the route of capitation, as you were indicating, we should do it for populations, because the biggest challenges we are faced with are not for people who have got single conditions, single diagnosis, single chronic diseases, they are that population of older people with multi-morbidities for whom a disease based approach to integration will actually deliver probably no better care, and perhaps worse care, than we have at the moment, and if you look at the examples of high-performing integrated healthcare delivery systems in other countries they don't go down the tariff route and they don't go down person based capitation, they say “Here is a sum of money to deliver the full range of care for the population of people you serve in this county or this city or this membership group. Live within the budget and if you save money in the expensive bit of the system you can redeploy it under your own control in another bit of the system”. Wouldn't it be great if we had integrated hospitals and community services very closely aligned with social care and with GPs being not employed by but associated with those much more integrated organisations? So we give Imperial Academic Health Sciences' system a budget covering the whole of the population in North-West London that you serve and if you find innovative ways of developing your community services to reduce demands on the hospital, you can do that within a single organisation because your incentives are aligned around the integrated model of care closer to home that many people have talked about but very few people have delivered. So I am contradicting what I said in response to you earlier on, because incentives do matter, but I think it is less about personal incentives for individual GPs or hospital docs; I think it is much more the organisational incentives that motivate those people who are leading hospitals and other organisations to do the right thing.
Mr Adler: David Adler, a retired NHS Manager. I joined the NHS in the early '90s and I retired four years ago. In the course of the time I was in the NHS I was very privileged to see some of the wonderful clinical physicians, who are very, very dedicated. I suspect also that that is one of the reasons why the NHS, as you put it, has always taken everything thrown at it. What I would like to come to is the point you made several times about integration. I would say that from the day I joined the NHS in those early '90s there were people striving for exactly that goal. There were politicians saying “Yes, it's the right thing”. Just referring to that, the one significant block that has apparently been consistent throughout all that time to integration happening (and I appreciate your view) I would suggest is the different funding streams to different aspects of care, whether it's GPs, hospitals, social care, all these things that need to be integrated, and until there is a co-ordinated single funding stream I can't see anything changing. Can you see how that funding stream might come about, given that the politicians have been saying “Well, yes, I think it is the right thing to do”?
Professor Ham: Again, I partly agree with you but not wholly. I think having different funding streams doesn't help, but I don't think it is the only reason or the main reason why integration is a difficult goal to achieve in practice. We have organisational complexity. I was working in a county in the East of England about a month ago and I think there were nine or ten separate organisations in the room serving a population of about three-quarters of a million. That was probably about seven or eight too many, in my view. Successive governments have created organisational complexity. We have professional divisions and tribes, don't we? How long ago was it we had the division in British medicine that said GPs work in the community and specialists work in hospitals? When you visit other countries and look at their healthcare systems – and I have had the privilege of going to Mayo Clinic and Intermountain Healthcare and many in the States, where you see a very different model of multispecialty medical practice, the GPs working closely alongside specialists of different kinds and that ease of clinical communication and contact that can only be envied, and yet we had that settlement 200 years ago between GPs and specialists, which we are still struggling to overcome. I think that is a fundamental obstacle to doing integration. On your point, look at Wales, look at Scotland, look at Northern Ireland, they're much closer to the model you are describing. Northern Ireland, in particular, has a health and social care system, one organisation running the service as a single budget. Does it deliver the results we would like from integrated care? Not always. And so the implication is that budgetary integration/ organisational integration will not always take us where we would like to be. There are so many different things that need to be done together to realise what you see in living examples of high performing integrated systems – I mentioned Kaiser Permanente as one of those – because one of the other factors that is important (and I hesitate to get into this at this point in the evening) is the fragmentation of information and information systems. So when you look at a Kaiser Permanente or a Veterans Health Administration or a Mayo Clinic, they have had for many years a fully functioning health IT system with an electronic patient record system, so wherever a patient fetches up within those systems the clinical staff or the receptionist can access the details of that patient there and then, and I think that is a fundamental facilitator of more joined up working. So even if you have got separate organisations, if we were to at some point have the solutions that the National Programme for IT was working towards, I think that in itself could go some way towards overcoming fragmentation.
The President: Let us take one last question. Alec Samuels.
Mr Samuels: Alec Samuels, a lawyer, but had close experience of providing social services. The principal theme, sir, that you seemed to be speaking of this evening is the relationship between health and social services. Your point was that it was either integration or fragmentation, which of course is right. At the moment we have this terrible rivalry between the two systems. The hospitals want to push the patients out into the community and Social Services want to push the clients into the hospitals, because both sides are saying that there is inappropriate placement at the moment. Now, I was going to suggest some kind of institutional integration, but I hear you now, sir, saying that there is really not much in that. I think the fundamental question I would put to you is: is not social care health?
Professor Ham: Well, it is, and the distinction between the NHS and social care was born in that post-war settlement when the demographic profile was very different, when few people were living to healthy old ages in the way that we celebrate and applaud today, and yet we have not been able to revisit that post-war settlement and ask some of these fundamental questions. I think part of the solution is to say let's break down what Frank Dobson used to describe as “the Berlin Wall” between health and social care. Let's probably put it under the control of a single organisation; let's bring the budgets together; let's find a way of connecting these separate information systems and getting (and this is a key point for me) those front line health and social care teams together, co-locate them, put them in the same building, have a single leader of those teams, a single point of access, a single way of assessing the needs of the people they are responsible for; because Mrs Smith, who is 85, who has a combination of diabetes, heart failure; she lives on her own, she gets isolated, she gets depressed; she needs practical help in her home from time to time; she may need Meals-on-Wheels to come along; she doesn't make a distinction between social care and health care. She needs care; she needs support to help her live independently in the best possible quality of life, and to negotiate and navigate around a system that is not designed to deliver that joined up care around her needs is really a tragedy and a travesty, and I have seen examples closer to home. I won't use an American example again. Down in the South West of England, in Torbay, Torbay has the most integrated health and social care system that I am aware of, because the local people in Torquay and Brixham and Paignton said 10 years ago “We have a population where 23% of people are 65 and over”. The average for England was 16% in those days. These people are retiring to the English Riviera, for reasons we all understand. And so they took a local decision. Whatever the national arrangements might be, for their population it made sense to break down that “Berlin Wall”, and you see the results. They have been much more successful at keeping patients out of hospital who don't need to be admitted. They intervene early; the GPs work with the fully integrated teams of nurses and physios and social care staff. They pooled their budgets; they decided to do that locally; and they have invested pooled resources more in social care than in health care, because their experience, knowing their population, is that that is a more effective way of getting the results you are searching for than just pumping more into GP services or community nursing services. So there is real evidence (that is what I am saying in a long-winded answer to your question) from places that are doing this that it is the right thing to do. It is not just about a single organisation, it is not just about flexible use of budgets, it is much more, but it can be done.
The President: Thank you very much. Well, we have had a very interesting evening and I would like to call upon Bertie Leigh to express that.
Mr Bertie Leigh: Professor Ham, thank you very much for a fascinating lecture. You covered an enormous canvas with great authority. We all love the NHS passionately and that tends sometimes to mean that discussions are conducted with rather more passion than information and rather more enthusiasm than insight, and to hear somebody like you talking as a sympathetic critic of policy and a sympathetic critic of what we are doing, it has been a fascinating evening and we are very grateful to you. Thank you very much indeed. (Applause).
Professor Ham: Thank you.
The President: And just by way of a small token of thanks.
Professor Ham: Thank you very much.
The President: I hope that will amuse you for some time to come.
