Will the NHS really be different in five years’ time?

16 March 2015

Simon’ Steven’s Five Year Forward View published last October sets an agenda for the NHS which is a “shared view of the NHS’ national leadership, and reflects an emerging consensus amongst patient groups, clinicians, local communities and frontline NHS leaders”.  For many the view is not only welcome, but provides a very sensible culmination of 25 years of debates about how best to reform health and social care. I find it hard to identify people I work with who are not fully committed to wellness promotion, disease and ill-health prevention, and stronger connectivity in treatment and care management across health and social care. The implementation question then is not whether to change, or even how to change, but instead, how ready is the system to change and is five years a realistic timeframe?

If we look at some of the readiness assessment tools which have been developed to support the healthcare reforms in the USA, particularly around Accountable Care Organisations (ACO), it sheds some insight on the scale of the endeavour[1]. These tools include important pre-requisites for effective operation as an ACO such as:

  • An ability to deliver genuine patient centeredness in care design, care pathway implementation and, most important of all, day-to-day self-management of health and wellbeing;
  • Investment in enabling technology which allows patient information to be shared between patients and health and social care professionals to inform real-time decisions about treatment and care management;
  • Payment and re-imbursement systems that align payments and rewards to the outputs, outcomes and impact the systems is seeking to achieve; and
  • Cultural coherence and a shared purpose and understanding across health and care professionals at a strategic and an operational level, and across organisational boundaries.

Whilst we can all cite examples of health and social care systems which exhibit some of these characteristics, at least in part, there are few that could truly claim to have everything in place, even those who have benefited from participating in the Integrated Care Pioneer programme.

In my experience, there is a more complex and fundamental reason as to why we have not yet achieved readiness for new models of care, namely ‘NHS systemic inertia’. This systemic inertia arises from the dissonance which results from a hierarchical management model being applied to a service that really requires local agility and freedoms to innovate if it is to truly meet the needs of service users and local communities. Time and again, local leaders necessarily prioritise adherence to short-term centrally driven process and financial targets which are based on old ways of working even, where these may mitigate a move to new and improved ways of working. This hierarchical structure is deeply embedded in the culture, is re-enforced by management training, and is reflected in all of the performance ‘norms’ used for monitoring organisational success.

Ultimately, we need a new way of collectively holding the NHS to account, one which is driven by information and evidence but which is more permissive, empowering and can harness the benefits of innovation. In a world where every other aspect of their lives is responsive and innovative, service users and health and social care professionals are bound to have expectations of a more agile NHS. In a politically accountable system, it takes a very strong national leadership to move away from the traditional hierarchical model. There are encouraging signals that this is starting to happen. The use of the term ‘View’ rather than ‘Plan’ or ‘Strategy’ indicates an implicit appetite for change across the NHS leadership team. The appetite for change at a local level is illustrated by the scale of response to the national call to participate in the New Models of Care programme.  A strong local leadership team, with a strong shared vision and collective trust, should be well positioned to take responsibility for making change happen within this framework.

Jacque Mallender is a Partner at Optimity Matrix

[1] See for example: American Institute for Research – Bundled Payment for Care Improvement: Readiness self-assessment; American Medical Group Association – ACO readiness assessment; University of California Berkeley – Safety Net ACO readiness assessment tool ;Health Dimensions Group – Health care reform readiness assessment; Research Triangle Institute – ACO accelerated development session – pre-meeting registration and planning tool; National Committee for Quality Assurance – ACO accreditation programme (incorporating the standards review of structures and processes and the relevant performance measures from HEDIS – the widely recognised Health Effectiveness and Data Information Set).



David Welbourn

17 March, 2015

A sound reflection, and as you rightly state it will need strong leadership to fight off the tendency to measure everything by compliance with process, irrespective of whether that process is still fit for purpose. Strong leadership knows when to back off, when to defend front line staff against the bullying culture reinforced by fearful politicians and lazy journalism, and when to cede its own position for the greater good. There are still too few leaders with the chutzpah to stand firm against the power-crazed!