“Making care closer to home a reality.” A Talk at the King’s Fund 22/02/24

A breakfast discussion of their pamphlet

(Watch live from 08:30)

A very different post today. This morning I’ve been asked to talk at the King’s Fund as part of a breakfast discussion of their new pamphlet on “Making care closer to home a reality”. Regular readers will know that this is a topic I have posted about – frequently.

The report recognises that this issue has been the direction of policy for some time.

And that’s the most important fact about both this report and the overall policy direction. The main lesson to learn about why it hasn’t happened is that as a way of bringing about change policy is feeble.

But time and time again those trying to bring about change return to the belief that what we need to make it happen is a policy. I’ve spent years of my life doing this, teaching social policy, working in policy departments, lobbying to try to get policy changed.

But let’s be clear – policy alone is just not enough.

In 2024 virtually everyone looking at the long-term future of the NHS would argue that a lot of its care needs to move from hospitals into the community and, if possible, to homes. So, lesson number 1 is that just because everyone agrees that this is what should happen, don’t assume that such universal agreement will make it happen.

In December 2022, The King’s Fund asked me to talk at another breakfast event.    Then they were publishing another report “Strategies to reduce waiting times for elective care.”

That breakfast was a very unusual experience for me. The report suggested that when I was special adviser to New Labour Secretaries of State and Prime Ministers that what we set out to do, worked! Working with the NHS to reduce long waits did actually work.  50+ years of giving talks and this was the first time I had been asked to talk to a report that suggested something I had been involved in had worked!

In my December 2022 talk I worked through the report detailing the activities in which we had been involved to reduce long waits, extending the King’s Fund analysis a bit in ways that will come as no surprise to blog readers.

Given that the December 2022 report was an analysis of how change was brought about, and the February 2024 one is an analysis of how the King’s Fund think change should happen, I thought I’d use their December 2022 analysis of a successful change as a frame to understand how in reality the current change they want will actually be brought about.

So that’s how I’m approaching my talk today.

I will talk through the frame of their own analysis of bringing about successful change rather than look in the crystal ball for the future.

And before anyone says it. I do know that implementing a policy of moving care out of hospitals is a different and more complex activity than reducing long waits.

But there are strong lessons to learn from the success of reducing waits in the early noughties for the policy of moving care into the community in the 20s.

First – Focus

In their current pamphlet, the word the King’s Fund uses most often is focus. If we are to move more NHS care into the home, it will be necessary to focus on this change.

They are right. But two additional aspects of that focus are necessary.

First the focus needs to be there for a long while. Of course, on a week-by-week basis the NHS are doing a wide range of activities, but when the NHS reduced long waits the focus was there pretty strongly for a decade. And the NHS Plan 2000, supplemented by Labour’s successful manifesto of 2001, outlined that this focus would be there for a while longer.

In recent years, if a focus has lasted for a few months, it’s been doing well.

So, readers of my blog will know that for me we need a new NHS Plan 2025 and that will outline a few foci. Moving to more prevention and yes, moving care into the community have to be at the core of that focus. It will take a decade of continual hard work.

Secondly, that focus will have to be led from the very top. As the King’s Fund noticed in its work on reducing long waits,

What was exceptional about Blair was he took this seriously and was happy to take four monthly meetings – I don’t know, each probably would have taken a few hours – so every month he’s spending hours doing this, but that signals to everybody this is the government’s top priority because the Prime Minister is interested in it” P51.

(Quote from leader involved in implementation of shorter waits programme)

 (All quotes from Strategies to Reduce Waiting Times)

I was involved in these meetings. From 2001-5 on the DH side of the table outlining what the Secretary of State for Health was doing; what we might do differently; and how that might happen. Then coming back to the next meeting and running through I what had happened. It wasn’t just Tony Blair in the meeting but the Cabinet Secretary – making sure that both political and civil servant lines of accountability worked.

And then from 2005-7 I was involved on the PM’s side of the table.

For focus to work for a decade, it needs hard consistent work at the very top.

Second – Financial Incentives

Regular blog readers will know that one of my 6 “how to” arguments for change involve creating financial incentives which incentivise the outcomes that you want. In 2002 it was suggested to the NHS that trusts that did more work would get more money for doing it. As I’ve said on many occasions there was resistance to this. But we persisted and it worked.

“An evaluation showed that the introduction of PbR in England appeared to have led to more rapid reductions in lengths of stay and in the proportion of day cases than in Scotland, resulting in cost savings of between 1 per cent and 3 per cent.” P 40

Paying organisations that do more work more money for that more work is a good idea (and again regular blog readers will know that the present system that claims to do this – just doesn’t do it.)

And before you think that in 2002 payment by results (PBR) was bringing more care into hospitals and this policy is to reduce the amount of care in hospitals means that PBR would move care in the wrong direction…

Well no – the crucial word in payment for results, is that you pay for the results you want (and not for the ones you don’t). So if you want to pay for more care in the community and less in hospitals, you construct a financial flow that succeeds in incentivising that.

One example I keep coming back to is paying domiciliary care workers to carry out health monitoring in people’s homes. This is an example of moving NHS care into peoples’ homes. And I would suggest that if we want that to happen, we need to pay the domiciliary care workers to do it. Second if we want some of that health monitoring to reduce the number of emergency bed days spent in hospital (also moving care into the community) that when a domiciliary care worker succeeds in doing it their organisation should be paid by the NHS for the achievement.

We don’t have to pay for any old results, we pay for the results that we want.

Third – Performance Management.

I hope regular blog readers are now familiar with the phrase “The trouble with performance management is that it doesn’t manage performance”. Therefore, simply saying that if we want the switch to care outside of hospital to take place NHSE must performance management that change, is not going to achieve much. What we need for such an important change is to have NHSE working to shift performance in such a way that actually works.

The King’s Fund work on successful strategies to reduce waiting times gives us some pointers about performance management that actually worked.

“For me, the big and really important step is, so how do you respond when this performance oversight framework reveals that someone’s really struggling, or off the pace? And I firmly believe that simply calling people in for a meeting, and pointing a finger…… so what sort of help do you need?’ And ‘this isn’t about you, this is about people who aren’t getting the access they need” pp53/54

The King’s Fund analysis on performance management 2001-10 demonstrates what an improvement focus is needed to help move performance forward. But they found (2001) that this worked because the Modernisation Agency were involved in improving performance. This meant that people were offered help to improve and from the King’s Fund analysis it seemed to work.

Fifth – Reform

Lastly one of the main changes that happened to bring down long waits was the implementation of a range of reforms of how care was carried out. The King’s Fund found,

“So rather than simply having the existing process and getting everyone to do more and more of it and faster and faster, [the team] along with NHS colleagues then ran a series of programmes to support staff re-examining the process of delivering elective care to work out, well, how can we achieve more, better output from the available resources? And as you’ll expect, often there were wonderful where staff, when patients, when they were consulted, could say, well, look, we could do this in a different way, do things in parallel rather than in [single visits to] clinics… [This was] often a very helpful device to improve waiting times as well as the experience of patients and staff.” pp 55/56

If we are to successfully shift care into the community and into people’s homes, then the nature of the care and how it is delivered will be very different from care at the moment. Again, to return to my example of the role of social care – by 2035 social care staff will be playing a much bigger role in healthcare. The same will be true with the use of technologies that involve patients and their carers.

So, thanks to the King’s Fund report of December 2022 for giving me a way into the King’s Fund report of February 2024.

Lessons for successful implementation of change can be reapplied to new circumstances.