Management has a vital role in saving the NHS, says Bengoa
The NHS is 70 years old. To survive as long again, it needs huge changes.
This seems a sombre statement but it doesn't have to be read that way. Change can happen. Health and social care that is fit to survive another lifetime, and beyond, is possible.
More than that, while reform is necessary, it is no mystery. We know what a new, robust health system has to look like; we know what changes have to be made.
Professor Rafael Bengoa, chief author of a vital report on our local Health and Social Care (HSC), was in Belfast this week to deliver a lecture at Queen's University to mark the seven decades of nationalised health in the UK.
Celebrating 70 years of the NHS: reshaping health care for the next 70 years was not shy about the huge challenges we face as a society. However, it's overall tone and message were about hope.
Northern Ireland is not alone in its need for change. Much of the world faces the same issues as we do.
Ageing populations mean that chronic conditions now dominate clinical workloads, taking up a far higher proportion of resources than ever before. Current structures are not built to deal with this and, even if they were, demand is increasing at a much higher rate than increases in funding could ever match (in NI, demand is increasing by around five or six percent, per year).
Despite this, Prof. Bengoa told his audience that we are one of a select few places to officially recognise that reform is needed.
"There are only six countries that have taken the formal decision to do this. Most of the others are standing still."
Scope has been covering health reform - or the lack of it - in some detail for years. It is easy to look back at Transforming Your Care, published in 2011, and be frustrated at the amount of progress since then.
But the difficulties in taking an organisation as massive as HSC and turning it from one thing into something very different can hardly be overstated - and that is without even considering how to win over the hearts and minds of a public that is protective about national health and, accordingly, instinctively suspicious about a reconfiguration of provision that will see some services increase, but others reduce.
At the highest strategic level, reconfiguration largely boils down to two things: a shift in focus away from specialist settings, where possible, and an integration of systems (which also means an end to the silo mentality that still dominates different parts of HSC).
One common refrain, when criticising the modern-day NHS - reflecting a perception that is probably widely held by the public - is that there are too many managers, paper shufflers on massive salaries, a waste of precious resources that could be spent on more nurses.
Prof. Bengoa, however, feels that senior administration has a crucial role in shaping the future.
"We know we have silo logic - all hospitals in the world have this verticality - and we know we have to break that and I know many people are trying to do so.
"It was OK for acute diseases but it's not OK for chronic. Since 80% of what's coming through the doors today is related to chronic conditions, we know we have to make changes."
Organising lifelong, continuous care on an effective and efficient basis requires tying together various strands from right across the health landscape - such as hospitals, GPs, community nursing, social care and, of course, the patients themselves, along with their families.
Doing that is not medicine, per se. It is management.
He showed the audience a picture of an older woman, with the quote: "I fall frequently. Sometimes I have a fracture. They repair me but I wonder why there's no plan to prevent me falling again."
Prof. Bengoa continued: "What's in this person saying is health and social care need to work together… But the important thing is not how to write another report to do this, it's how to start moving in this direction.
"That's what we need rather than 'We need integrated care, we need this and that'. I think we can assume those as given.
"What's very interesting is we have something we didn't have seven or eight years ago, we have a management arsenal.
"Many of these tools are now being placed in one way or another and in some systems all of them are being placed. They are all useful integrators, to get us away from silo arrangements."
He said further that clinicians and management will themselves need to work together - and, while doctors are able to work without managers, managers are not able to do their job without help from doctors.
Prof. Bengoa mentioned that there are 30 conditions that were responsible for 13% of spending in 2000 and, as of 2014, were now hoovering up 42% of all health and social care funding.
However, he said that the ways to get better value from health structures, in order to adapt to changing circumstances, are not through medical advances – but through administrative changes.
“We should not expect miracles from drugs and technology.
“We know we need new ways of delivering care and now we need to work on quality and productivity. What's frustrating for medical clinicians is that these [changes] aren't clinical, they are managerial.”
So, transformation requires clear thinking, and the breaking of silos, by good management. This needs to be in conjunction with clinicians.
However, moving towards a preventative system, with self-managed care taking place in the community (where possible), also asks a lot of the public.
“Populations in most of the countries I know in Europe have been disconnected from taking care of their own health. That's probably because we have built paternalistic structures.
“Most people think about their life and career, but don't think about their career path in life, in health terms.
“I don't want to victim blame, but to think we will be able to manage the increase in demand without the population starting to take some decisions about their own health - it's going to be very difficult.
“There are many things people are not managing when they could - minor ailments, etc. They end up at the GP, in hospital, when they don't need to. That's very easy to say but we need to make it easy for them to do.
“It's still not affordable for people. It's three times more expensive to get the energy we need from healthy foods than from unhealthy foods. It's harder to buy healthy foods in deprived parts of the UK, where there are also higher density of fast food outlets. 1.2% of food advertising is spent on vegetables, 22% on biscuits and cakes.”
Prof. Bengoa highlighted a number of places around the world where some transformation has taken place, and proved a success.
At the Ryhov Hospital in Sweden, they have got on the front foot in terms of self care, in particular when it comes to kidney dialysis. 60% of patients now carry out their own dialysis (the target is 75%) and, amazingly, clinical outcomes have actually improved.
“The results of this arrangement are something that's a bit annoying for medicine because they [the patients] get better results than when we [medical staff] do it, and it's cheaper.
“That's not going to happen across all parts of medicine… there will always be a need to intervene in a structured way with patients but, in some things, if we start co-producing and co-deciding, with patients I think we will start moving into new territory.”
The Frimley NHS Trust has invested in more community nursing – a key part of transformation – and, while this requires its own spending, it has led to a better value service.
The Netherlands is building on the Buurtzorg model of neighbourhood care that is proving a massive success, and is set to be replicated around the world.
The professor said the important challenge now was action, rather than discussion. There is agreement on what needs to be done, now is the time for implementation.
In that sense, Northern Ireland is already pioneering, being one of the six places in the world to formally face up to the changing demands on our health service and the resultant need for restructuring.
If the key is implementation, the key to implementation itself is incremental victories, according to the global expert.
Transformation “will not be one big bang” but must be step by step. This is not one change, but many. The political and public resistances are real but can be overcome – and this is best done by moving forward steadily, making as many non-controversial adjustments as possible and, at the same time, making the bigger changes on a local level then pointing to improved outcomes as justification for doing similar but sweeping changes everywhere.
Professor Bengoa, who met with MLAs before delivering this lecture, said: “When you get the government back, there's going to be a big political consensus, like there was two years ago [with Delivering Together, the ten-year health plan published before the collapse of the Executive].
“I think if you keep moving one bit at a time you can be one of the first countries that pulls this off.”
Difficult does not mean impossible. Necessary, however, does mean necessary.
The seven years since Transforming Your Care have been frustrating but, even with difficult times ahead for HSC, fundamentally there are reasons to be optimistic.
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