the transformation that are missing from current iterations of thinking

There is consistent evidence from a macro perspective that the key drivers of cost growth are:

• disease incidence (prevention),
• high cost technology (manufacturer pressure & patient expectation) and
• over diagnosis (clinical culture and system pressure)

And NOT demographic pressure or the “ageing population”

Similarly, the Glasgow work found that the current problems in NHS in Scotland are as a result of 

1) falling % of NHS £ to “community” led to hike in non elective (and a range of other issues)

2) problems not due to too little funding overall

3) worried well – especially in most affluent population

4) systemic and cultural incentives leading to over diagnosis

5) degradation of primary and community care over 10 years, including social care.

One might characterise the problems as the NHS being structuraly underfunded, not managing demand at all well, maybe having too much supply, or too much of some forms of supply, the wrong set of incentives and maybe all of the above.

 

 
The following are suggestions of some solutions some of which aren’t featuring strongly in the current narrative. This isn’t intended to be critical of the immense work that has gone into STPs and similar, it is merely a reflection of some of the issues I perceive as missing.

These things are difficult to write in to a plan as they rely on changing cultures and attitudes at the frontline.

These are NHS focused – hopefully someone will add the social care parallel.

Thanks to Kev Smith & Steve Laitner for bright ideas.

1 Challenging the narrative around population and demographic factors

• challenging the narrative everywhere that “the ageing population will NOT spell certain doom and system meltdown”.
• The “ageing population, demographic time bomb” narrative is harmful as it takes us away from the core and critical issues. We need to get the narrative right here. Population projections are mostly wrong, don’t take into account changing epi and social / tec (smartphone) and broader social trends.
• We ignore the issue of “healthy ageing” (in the broadest possible – not just a medical paradigm – construct at our peril. Most problems caused by lost fitness, preventable disease & attitude

2  Demand side issues

• Prevention and long term demand management – ignored at our peril. Wanless told us this 15 years ago.
• Disease incidence matters. It’s the number of casesrather than the average cost per case that is really driving costs.
• Cheapest setting of care. Changing defaults of care to reduce demand. NB – but be mindful of the economics!
• Reduce expensive treatments where cheap ones will do. Really sorting the obvious QIPP targets – resp inhalers, DM meds, aVEGFs etc (list could go on forever)
• We ignore the industry of over diagnosis (and consequent over treatment) at our peril. Over-diagnosis/medicalization/and role of the pharma in this – systemic and cultural cues for over-diagnosis are significant driver of cost growth. Addressing patient / citizen expectation is a critical part of this.

3 Philosophical issues we may want to reconsider

• Relook at what is the social purpose of NHS – is the NHS about “keeping yer gran alive” vs a productive economy, vibrant society and extending  HEALTHY lives and improving quality of life. What is the social purpose of the NHS…..why does it exist.
• Reconsider healthy people as investment in infrastructure for economy. For eg – work and health inter relationships – we massively under use this. It is a TWO way relationship. This has issues re how we manage waiting lists – getting to those off work early to prevent chronicity, but this leads to overt prioritisation on working age population. There are ethical and political questions inherent there.
• reconsider the question of why do we invest in the NHS – Does the NHS “meet the health need of a population” or is it an investment in healthy people. Put simply – do we use resources to buy parks and bike lanes or cath labs and cancer drugs
• NHS resourcing as a determinant of health. This is underplayed. There are 3 immediately relevant components – The Hospital / GP split, the allocation of resources for GP and deprivation weighting. In Sheffield the NHS spend is c£1.1bn, employer of c20,000 people (more if you include supply chain). How engaged is the NHS as an social and economic force, not just a treatment factory.
• Moving from medical and interventionist to social and behavioural model of service. 
• The way in which the service handles “prevention” and the shift from a purely medical model to a medical / behavioural / social model is critical.
• Systems versus organisations. In the current construct organisations will inherently act in own interest rather than system interests and patient / pop interests. This is obviously understandable, but redressing this will be challenging.
• Difficult conversations with the public about revising the compact (especially around rescue, often for limited gain and high marginal cost, and the opportunity cost of these in terms of other people denied care.)

4 Cultural factors in health and care system.

• We ignore the coalface at our peril. Getting into the issues of clinical and managerial culture. Stewardship of resources and connecting resource committers to the money.
• Care for multi-morbidity (recent NICE guidance and BMJ article) is largely undeveloped. Needs significant attention. We need to move towards system to enable and interventions that manage population level risk (rather than refined pathways for xxxxxx), risk that is agnostic of the specific conditions. The default should be generalist, anticipatory care but supported by rest of system. There are 4 times as many complex patients in the community as there are in hospital beds. These are largely invisible in data and planning terms. But GP is looking after these.
• Population medicine. What would a population healthcare approach look like for big targets – Heart, lungs, neuro, cancer. For example renal has been successful in the face of an inability to meet an ever increasing demand for dialysis capacity. The response was a sustained focus in on transplant, aggressive population management BP, CKD, CKD 3 to 4 transition, ditto 4 to 5 with a view to prevent and delay.
• What does a population approach in mental health look like. Mix of medical and social approach.
• Outcomes v money. We always focus on the money, this drives us to act in specific ways. Maybe we should have a default of “tell us what you are planning to do is about population health outcomes, till you have answered this q we can’t move onto the money”. Models of care need to (obviously) be based on triple aim outcomes (CMS in the USA this well defined – cost per patient month is THE critical metric cost wise, stratified by segment of registered pop; outcome metrics easy to define (the usual set) and ditto quality.

5 Supply side issues – it MATTERS and isn’t being discussed much

• The basic financial ask of the STP is the shrink the NHS by 10%, unless parliament put more £ in this is the net effect of demand growth and funding availability.
• BUT………Supply side considerations may be considerably more than demand side in the short run. Not many of the demand side interventions are showing much promise in short term time horizon.
• be ambitious re primary care + social care – investment – getting to 20% of NHS spend (there may be slipperiness about definition of primary care – if you count GP, optometry, pharmacy, community dental together might be close….so I mean General Practice (why don’t we call them family health services – like we used to) – not necessarily GPs however).
• Social care – ditto, investment (though obvious difficulty of recent shrinking of local govt, cross org boundaries etc.)
• Model of care on provider side – where and how do we have this conversation. Needs to be in the plan? Scope and scale – how big / what pop (mindful of economies of scale, administration costs in smaller etc.) and IS or ISNT hospital “in” (my view is it can’t not be). ACO is NOT about org form. About so much more than that……
• Model of commissioning – larger CCG covering bigger boundary?? Merge functions of CCG and LA commissioning to have true joint commissioning. Smaller “commissioner” and transfer many planning functions to provider…
• Who commissions what. Should LA commission some or all aspects of NHS? Split hospital and out of hospital
• Regulatory system- system not organization. Where and how to engineer the conversation with NHSI on this. What is the regulatory ask?
• Incentives around money flow – moving away from PBR etc. Capitation is no panacea – and needs to be used carefully, maybe blended in with some FFS to stimulate market in high value services.
• Any system that has transformed has person level data transformation – both for clinical care and a range of secondary uses – at its heart. We are miles off this.

 
Of note, the Canadians are also thinking some interesting thoughts

Better now, six ideas to transform health in Canada

https://books.google.co.uk/books/about/Better_Now.html?id=Qw46DQEACAAJ&redir_esc=y

Sound familiar?

refs

OBR http://budgetresponsibility.org.uk/docs/dlm_uploads/Health-FSAP.pdf

Nuffield Trust – financial sustainability of the NHS – http://www.nuffieldtrust.org.uk/blog/nhs-financially-sustainable

http://www.gla.ac.uk/media/media_443695_en.pdf & http://www.gla.ac.uk/media/media_443697_en.pdf

Gray, Population healthcare: a new clinical responsibility – JRSM Dec 06, 2016. http://journals.sagepub.com/doi/full/10.1177/0141076816679770

Gray. Designing healthcare for a different future – JRSM Dec 06, 2016. http://journals.sagepub.com/doi/full/10.1177/0141076816679781