Following a weekend of celebratory marches it’s time to get down to the task of writing the next 70 years of NHS history.
Last week I published a series of posts on the kind of outputs that I think should be in this autumn’s contract between the NHS and the people. Today and tomorrow I’ll be thinking about how the NHS is going to make these come about.
Given that there are 1 million consultations every 36 hours taking place in the English NHS we are going to need to change the way these are conducted in order to change the healthcare outputs.
Let’s look at he three changes I posted about last week as examples of what I mean.
If, as a part of improving cancer survival rates, we decide to radically increase the number of diagnostic tests many of these consultations will need very different start and end points. We need those – generally less well-off people – who ‘don’t want to bother the busy doctor’ when they have a pain, to start bothering them.
We need GPs to not mind the risk of looking foolish by sending over 95% of people for tests that come back negative. And we need the consultants to be able to cope with so many more tests, by using artificial intelligence.
This will require many thousands of people to change their present practices.
If we seriously want to improve upon existing inequalities in life expectancy nurses and doctors in poorer areas need to forensically target the numerous individuals who now die in their 50s and 60s and work with them to give them two more decades of life. This calls for a very different type of ‘active’ medicine to identify patients because we know that waiting for them to come to us is not working.
If we want to reverse the prognosis for those recently diagnosed with type 2 diabetes we will need enhanced primary care teams to actively help them work with former patients to transform their diet and exercise regimes. For each patient this represents a year’s hard work to transform their life and active support for the changes.
All of these are excellent policies but not one of them can be implemented unless there is a plan to do so – which actually makes them happen. In giving the NHS extra money from their taxes, the English people are not at all interested in new policies. What they want is new practice. Some of this summer is therefore going to have to be spent on the gritty business of turning policy into practice.
I mentioned in an earlier post that in 2002 when the English people stumped up an extra penny on the pound in National Insurance contributions they were not interested in promises about waiting times policies. They wanted to be able to access their health care faster. They wanted a change in reality, not another policy.
The question, then as now, is how you turn a wish list into changed practices for hundreds of thousands of NHS staff, and how those changed actions can lead to a different service for the public.
So for the next few days let’s look at how the centres of organisations where the contract is agreed – in this case NHSE and NHSI can make real changes to the experience of the public.
First it is important to understand how the supply chain between the room where policy is announced and the room where the change in practice works. What is the relationship between the two?
The initial answer to that question is usually “there is no relationship”. The room where policy is made is in south London – just near the Elephant and Castle in the case of NHS England, or Waterloo if it’s NHS Improvement. The rooms where the changes in practice take place are all over the country. (Some even in south London). There is no direct relationship between the policy and the changed practice.
Front line staff and their patients (even in south London) are not thumbing through the latest policy document to find out what they need to do.
Given there is no direct relationship, we need to create one if we want to implement anything new. In 2001 there was no relationship between the Government pledge to reduce maximum waiting times and the reality of practice. It needed to be made.
The first issue that implementation has to tackle is the construction of that relationship. If we want less well-off patients with worries about cancer to go and see their primary care team we need to change the way that relationship works at the moment. To do that we need to address the anxiety that patients feel about wasting staff time. If we can’t fix that even more people will not go and seek help.
This is the start of a chain which needs building link by link. That chain has to thread its way through the bizarre NHS bureaucracy from policy to practice and back again. If that chain doesn’t exist, if any link is missing, there is no way in which policy can become practice.
In the first decade of this century this became known as ‘deliverology’. Michael Barber who was Head of the Prime Minister’s Delivery Unit and developer of deliverology wrote a very detailed book entitled “Instruction to Deliver” which explains how it works.
If we want any of this summer’s new promises to have any impact on the lives of the public we will need to go back to deliverology and learn how we deliver new things.