Letter: Health bill is still fit for the challenges ahead

All political parties at the last election reiterated their commitment to the principles of the NHS but also acknowledged the need for the NHS to adapt in order to meet the challenges ahead. But our remarkable National Health Service sometimes struggles to be an organisation with a memory.

In the Queen's Speech of 25 May 2010, just over a year ago,the Government's priorities for the coming Parliamentary year were outlined. The Coalition's White Paper for the NHS was heralded which was to make clear that reform was needed to provide a sustainable National Framework for the NHS in England. The speech highlighted support for producing a patient led NHS, focussed on outcomes with a commitment to deliver a significant reduction in bureaucracy. At the heart of these reforms is a commitment to ensure that the voice of patients and the role of doctors will be strengthened in the National Health Service".

The main objectives of the Bill were and still are:

To create an NHS led by clinical decision makers that is more responsive to patients and fosters continuous quality improvements.
Shape an NHS which drives up standards of care, eliminates waste and achieves outcomes that are among the best in the world.
Ensure patients genuinely share in making decisions about their care and have more choice and control.

There cannot be a single citizen in England that does not share these aspirations for the NHS. Indeed of all those concerned with current NHS reform surely none could argue against these principles.

These broad principles have underpinned most of the previous legislation for the NHS over the last 20 years. However the current Bill is distinct in providing a fundamental and practical approach, setting out a series of measures to achieve these objectives based on the best evidence available.

Establish an independent NHS board to allocate resources, provide commissioning guidance and allow General Practices to commission services on behalf of their patients.
Improve efficiency and outcomes with a strengthening role of the Care Quality Commission, with a new Outcomes Framework to ensure quality becomes systemic within the NHS; and by developing Monitor into an economic regulator to oversee aspects of access and competition in the NHS.
Significantly cut out the number of health quangos and help cut the cost of NHS administration by a third.
Develop a culture within the NHS which regards the patient as the source of all control rather than persisting with 'top down' control;succinctly described as ‘no decision about me without me'
Deliver care that is customised to the individual. A personalised service knows the names of patients, where they are and follows their journeys through care systems. List based General Practice remains the closest system to deliver that ambition.
Redefine productivity to focus on healing whilst continuously reducing waste where sometimes the waste of enthusiasm, spirit and ideas can be more damaging than the waste of time, supplies or space.

Following the adoption of many of the findings of the NHS Future Forum announced recently, these principles still apply, and will be translated into the current Health and Social Care Bill. These common-sense measures are designed to help the NHS adapt, just as other services and industries have, to the challenges they face in the 21^st century. The quality and productivity challenge for the NHS, which aims to maintain the current service on an allocation that is reduced by at least 15% during the next 3 year spending review, will require a new paradigm with a significant change on mind set. Productivity and quality requires the expert management of the demand on the NHS. This can be achieved in three ways;

Through a substantial change to the tariff which can shift millions of pounds around the service to improve utilisation of NHS resources.
Workforce re-engineering to deliver new ways of working as well as reducing costs through downsizing and pay restraints.
But of greatest significance, through clinical processes that change and improve care pathways which concentrate efforts on the systematic removal of work out of hospital and reducing waste, inefficiency and duplication in care delivery. New care pathways must be developed that do not overuse resources or supply care that is poorly evidence based; in effect doing only what is required.

There also needs to be a significant refocus for some local public health activity so both commissioning and provision of healthcare are delivered to a registered population rather than a geographic locality covered by a local authority. Although both approaches support a population based approach, this brings significant challenges for the integration of care particularly with other primary care contractors who do not work with registered lists of patients. Many services, for example screening and vaccinations, are provided on a specific population basis and require systematic and rigorous approaches to delivery. There is also the expectation that prevention is everybody's business and people need to be enabled to have more control over the factors that affect their own health.

These measures will set free frontline clinicians, who have a unique role and understanding of patient needs and experience, to guide the NHS into the 21^st century. There is no change in the certainty that clinicians really are best placed to do this and this commitment has only been strengthened following the Futures Forum report.

In its current form, habits and environment, the NHS won't be able to continue to deliver the healthcare that patients want or deserve. NHS management cannot independently do the job of transforming services and just trying harder at previous attempts will not work. Clinicians working together to change systems of care on behalf of their patients will. The current NHS reforms and the national financial challenges to public services ask for big changes – and it is not yet happening. To pause too long may be unthinkably damaging.

Roles and responsibilities within our NHS have previously not been clearly defined and the skills and leadership required to deliver significant change are under developed. However the reforms give more clarity to who should do what and how care should be provided.

The tools for reform are well described. The need for accurate, comprehensive, trusted and fully devolved budgets along with consistent and usable data, backed up by evidence and good metrics which can really establish improvement are exhaustively debated, but not universally delivered.

Our NHS remains hugely bureaucratic; often too focused on system re-organisation and in the past sometimes regarding patients and clinicians as obstacles. Transactions rather than outcomes are measured and clinicians are often peripheral to commissioning. Innovation too often is stifled.

Innovation, that is new ways of doing things that bring new benefits, are best identified and lead by those best placed to recognise and develop them.The NHS must not continue to try and deliver different services largely through the same established processes run by the same remote NHS management.

The two parties that make up the Coalition Government strongly agree with the founding principles of the NHS – healthcare paid for out national taxation, equal access for all, and free at the point of need. The proposals for modernising the NHS are a testament to the Governments commitment to these principles. All the evidence suggests that the country and the NHS face some tough challenges ahead. If the NHS is to play its part then it must modernise and adapt to these challenges if it is to be sustainable and strong for the future.

A closer look at what the new legislation could mean

Both the original white paper and eventual legislation are designed to produce better outcomes for patients and offer new accountability arrangements. For commissioners this means the alignment of clinical and financial accountability where the referrer becomes personally responsible for the deployment of NHS resources. It aims to facilitate the delivery of a world class service with outcomes that rival any internationally. The NHS Outcomes Framework and its five domains detail how this is to be achieved. In the past ‘World Class Commissioning' lacked insight and traction because it was deficient in clinical engagement. This will now be addressed.

Much debate and misunderstanding abounds about both the form and function of GP Commissioning Consortia and the process to achieve clinically lead commissioning. Too much emphasis is currently being given to the structural development of these organisations whilst focus is lost from the required function and delivery. The ambition is to reduce bureaucracy in the NHS and truly lead a modernisation of care for the sustained benefit of patients, not merely to restructure the bodies which administer NHS functions.

Of course, we must enable the newly named Clinical commissioning Groups (formerly GP commissioning consortia) to be ready to take on these challenges and we must put appropriate measures in place to check they are fit for purpose before they take on the challenge for real. The authorisation process for CCGs must reflect five key questions to assure the appropriate development of CCGs and to check they are truly fit for purpose;

How are patients empowered through the development of the consortium? Can the CC G demonstrate that there will be an improvement in the integration of patients' voices, opinions, experience and need in commissioning and care planning? How does the consortium ensure, for its registered population, that there is truly no decision made about the patient without that patient and they are supported to have optimal wellbeing?

How has the CCG ensured that there is a multidisciplinary team approach to both the structure and functioning of the consortium? How are the full range of health care professional working and providing care in the patients' community engaged in managing the local commissioning agenda? This must be more than just the appointments to the CCG governing body in the prescribed governance arrangements. How will this team then interact with the Clinical Senates created by the NHS Commissioning Board?

How will the CCG achieve an appropriate joint working arrangement with the Local Authority, when it is necessary to do so to improve health and healthcare for patients? What alignment is being developed between CCG and Health and Wellbeing Boards for the wider local public health agenda and for achieving a consensus about health needs and priorities through the Joint Strategic Needs Assessment (JSNA)? What focus is being given to preventative care and improved self care by working in partnership with public health clinicians? How can we ensure that CCGs work closely with social care to integrate health and social care pathways where it makes sense to do so, but also to ensure that investment in social interventions release cash from inefficient or inappropriate health interventions?

How will cross sector working between Primary and Secondary care be encouraged to co-produce a seamless service, deliver better integration of care with a reduction in transactional costs and a better experience for patients being referred for hospital services? How is the clinical community within local hospitals being engaged in designing new care pathways? How can urgent care, long term condition management and health inequalities be improved through cross sector working? Again the appointment of a secondary care clinician to the CCG governing body and working with Clinical Senates will not be enough.

How is the capability and capacity of the constituent General Practices being assessed and improved through re-skilling and up-skilling the PHCT? Ultimately the commissioning cycle which starts with a needs assessment begins in the consulting room. Writing a prescription and making a referral results in new NHS spend. These are commissioning acts and must be recognised as such. How can constituent practices within a GPCC be encouraged and empowered to ‘make more and buy less' for their registered patients ensuring quality and safety in doing so? How is leadership both as the development of individuals and a style of practice being supported? How is unwarranted variation in care between practices being addressed?

A chain effect in improving healthcare quality needs to be recognised through these reforms. There are four levels or hierarchical segments in any productive healthcare system and if a bottom up approach is truly desirable then;

At the top level must be the level of purpose, the reason for the system and the aims it serves. This is where quality is defined and must be about the experience of the patient and community receiving healthcare. This is the patient-led NHS.
The next most important level is at the interface where care is delivered, the ‘micro' level of care. This is where quality is delivered, or fails, and is the direct responsibility of the individuals and teams who provide care. This is often a micro system of multiple agencies and agents, and for the NHS teams that do the work. This may be General Practice or other community services, or may be the specialist teams within a hospital setting. The proposed reforms recognise that improvements in the quality of services require the active commitment of those who do the day to work. By empowering clinicians and patients we can move beyond shortcomings of earlier approaches to supporting the NHS.
A further level down in the hierarchy is the ‘meso' level where the processes which helps the micro systems knit together operate. This gives organisational context and in future this will be the CCGs.
All these levels exist within an important environmental context level where there are facilitators to support the organisational forms which ultimately encourages the support of the micro systems, -the facilitators of the facilitators – The ‘macro' level. This is the NHS Commissioning Board.

This is the proper hierarchy for care delivery in our NHS with patients needs leading the direction of travel and not bureaucratic transactions. NHS reform must pursue perfection for each and every patient and it is the micro systems that will deliver this.

The overall quality of the service must be the degree to which the entire system achieves the prevention of ill health and premature death, the relief of suffering, reduction in disability and support the functioning of patients and their communities. Each part must work effectively towards the overall goal and contribute to results that will be measured through the NHS Outcomes Framework.

Rules are needed to deliver NHS change and the following enables this.

The culture of our NHS should be to regard the patient as the source of all control rather than persisting with the organisational control that is currently inherent within the system. A service that is funded by the public purse must be directed, designed by and focused on the needs, expectations and experience of the public.
Delivery of care needs to be customised to the individual, avoiding unhelpful variation, particularly in relation to prescribing, referral, rates of procedures and other types of treatment. A personalised service knows the names of patients; it knows where they are and follows their journey through care systems. List-based General Practice is the micro system that remains the closest to delivering this ambition. These reforms are an affirmation of general practice.
Productivity needs to be redefined to focus on increasing value for patients and healing whilst continually reducing waste; and the waste of enthusiasm, spirit, ideas and innovation can be more damaging than the waste of time, supplies and space. The commitment, information, insights, experience and organisational memory that people bring to the service must never be wasted – particularly as we know that it is precisely these ‘human' elements that people give to public service that patients value the most.
Care must be based on healing relationships, whilst recognising that there are lots of different sources of care with an expanding pluralist market and that organisations must work together to provide these networks of care relationships and ensure continuity in a system that works for patient benefit.
The NHS is a part of the knowledge economy: information, data and knowledge will be key to modernising the NHS, as it has been to improving and modernising industries and services delivered in all other walks of life. We must improve knowledge sharing and information flows so that data can be freely and conveniently accessed by frontline professionals across health and social care, and patients should have access to their records and to the latest and best available clinical knowledge. Variation in clinical care must be addressed by harnessing effective technologies that have been designed to meet the requirements of healthcare professionals.
Decisions in healthcare must be based on evidence and science and be put into practice. Evidence based care pathways will help clinicians achieve this. NICE will continue to play a pivotal role in defining optimum care and its quality standards will support clinicians and patients and alike. On this basis and consistently provided, the NHS can begin to provide warranty within the work that it does. At present health providers guarantee nothing.
Safety needs to be improved as a system rather than exhorting individuals to change, with safety built into transformed services and general care design. General practice must be able to support the safety agenda. Certain responsibilities such as safeguarding children become even more important during times of change. CCGs will have a duty to safeguard and promote the welfare of children through the Local Safeguarding Children Board.
Secrecy must end as this is in the interests of organisations rather than patients. Embracing transparency has been a very difficult pill for NHS organisations to swallow and openness has been selective.
Planned care must anticipate needs rather than react to illness. General Practice is ideally placed to identify patients who are at risk of a health crisis and to ensure an optimal approach to avert this. Community profiling can identify areas for improved efforts on health improvement, for example to improve screening programme uptake or tackle high rates of smoking or obesity.
Co-operation across organisations should be the highest professional value. The values of co-production and system alignment should be paramount, because we know that patient care improves as a result.

New ways of working need a lot of help and support, strong leadership and knowledge management within the system as well as 21^st century technologies. New care' also requires new systems and with changing roles and responsibilities we will need to see a rapid evolution of CCGs with a different focus and remit.

The next stage of the evolution of our NHS is the most challenging in the 63 years of its existence. We need to collectively embrace the principles above and strive for and believe in perfection. The challenge identified through QIPP is not going to be easy, but isn't everything impossible until it is solved?

From Dr James Kingsland,
Special adviser on commissioning, Department of Health