In my introductory piece to this series of posts “The Mechanics and Morality of Change in the NHS” I identified six themes that I believe any innovator needs to consider before, during and after the process of introducing change to the NHS. (New readers may want to read that first).
Ensure the skills needed to deliver promised cost savings are present.
It seems to me that almost everyone agrees that the model of NHS care needs to change over the coming decade. Moving care out of hospitals by focusing, as this set of posts recommends, much more work on prevention seems to be a goal shared by many.
Change on this scale will take at least 10 years. The whole point of these changes will be to shift some resources from one part of the NHS (for example the amount of care taking place in emergency beds in hospital) to another (for example the amount of care taking place at home). Everyone admits this will take time as the shifting of resources from one part of the system to another will be complex.
This is what we mean by creating a new model. Some thousands of clinicians that presently work in hospitals will be spending their working hours in the community.
(Incidentally this took over 30 years to achieve in mental health where most clinicians now work in the community. 10 years will be speedy but it will need to be achieved).
If this doesn’t happen, if the spread of resources stay in the same proportion in the same institutions, then whatever we call it, it really won’t be a new model.
I am stressing this point because one of the ways in which we sometimes bring about change is reassure people that the change we are bringing in is nothing to worry about as it’s only a little one. “You won’t really notice it. Your work will be much the same so there is nothing really to worry about.”
My point here is that if we are genuinely creating a new model of care, then saying that it’s not a big change would not be true. More problematically, by underselling its magnitude we undermine the change itself. If we try to sell this change by telling people that it’s not significant, the only way we can make that promise of insignificance work would be to make the change we want and need less and less significant. By saying, “you really don’t have to worry, you won’t notice anything very much”, we would succeed only in constructing a change which no-one notices because it’s not very significant.
The change-makers fear of saying “I’m afraid this is probably quite a big change”, undermines how much change can be achieved.
An example here are ‘virtual’ wards. (And if someone had followed my injunction to insist that you need a public facing narrative, that name alone demonstrates that it is not a good idea to call something that 80-year-olds have to feel is safe, the name ‘virtual’. Virtual safety doesn’t sound very safe. If you have to sell new experiences to the public thinking about how you frame it, what you call it, is vital)
Virtual wards (or hospitals at home) need to develop over time into a very big change in the way in the which health care is delivered. Delivering health care through virtual technology will, within our decade, become the mainstream. More health care interactions will happen via technology than through people – and if you think that odd consider the proportion of health care interactions that happen through medicines when there are no health care professionals around today.
Within half that time – 5 years my prediction – every ICB will have a single institution, a hospital at home, which will have developed the expertise to provide both the anticipatory medicine that will keep people out of hospital and the safe monitoring of patients who have been discharged.
This is an example of what we are talking about as a new model of care. But at the moment, it is being developed as an adjunct to the existing model. (“Don’t worry not much change nothing to see here”), and by saying that we are undermining the possibility of change.
If we are to be successful in creating a new model of NHS care, we need to recognise that some of these changes are big time.
Whilst I think I have been able to point out that that many of the skills required to bring about change within the NHS and social care are present in the existing structure, we need to be clear when they aren’t.
And one of those change sits at the core of this big change towards secondary prevention. Many people (me included) make the case that prevention – if the financial flows are right- can save money in x and reinvest hat money in prevention. But very often when this has been tried, the money hasn’t been saved in x and so the extra investment in prevention has to be found from new resources.
As many senior civil servants have said to me in despair “This invest to save idea is very clear about spending the investment and very opaque in getting hold of the savings”
Historically the NHS has not been good at this. Now it needs to be.
Up until now when we constructed a new service, even if one of the rationales for it was saving money in another part of the NHS, we spent all of our time and effort creating the new service and NOT in saving the money we claimed it would.
In other services new ways of working (like hospitals at home) would, as an integral part of its introduction, contain the necessary set of skills to develop the pathway in such a way as to ensure that there were real savings. The changes would be seen as failures (and stopped) if those savings did not accrue.
So, if we are really going to create a different model of care, and we are to create new preventative services that will shift resources from one part of the NHS to another, we need to have the skills within the NHS to do it.
Many of those skills are in the private sector. But many are also in civil society. Nearly every organisation that has shifted its direction from one service to another, has had to develop the skill of saving money in one area in order to spend it in another.
Most organisations don’t have the Treasury to fall back on to pay for their failure to save money through transformation. They have had to do the hard work of finding the money through transformation themselves.
Some of our biggest charities now work very differently from how they did before. (And yes, some private sector organisations). Not all charities and private sector organisations are good at this, but there are those from whom the NHS needs to learn.
To successfully change itself, the NHS is going to need help. Making sure that the NHS has the skills to deliver significant savings from new programmes will be essential.