Changing the NHS – The need for a new Skills Mix – 6

A quick recap.

My current series of posts are discussing some of the important changes in NHS and linked public services practice that we will need to bring about over the next few years. For each change I am demonstrating how the six different methods I outlined in the introduction to this exercise will help to bring them about.

We need to know the HOW of change as much as the what.

For the last two weeks we have examined the first four issues of change,

    • Persuading people to change the work practice that they are used to (and have often been taught)
    • Developing and using an overarching narrative for the change.
    • Thinking about spread from the beginning.
    • Developing alternative financial incentives.

This week we will discuss the final two.

    • If you plan to save money from change, making sure you have the skill sets in place to do so.

    • Working through the unintended consequences that will inevitably happen in a complex system.

First of all, it’s important to emphasise that not all innovations in the NHS are brought in to save money. Indeed, some important innovations are very expensive. But if you read through the pitches made for many innovations, they claim that if adopted they will realise an ROI (return on investment) of 3, 4 or 5 times the outlay (and sometimes completely eye-watering amounts). These claims are frequently supported by academic papers reporting on interesting cases.

As someone who has spent much of the last 20 years reading these pitches, the first thing to say is that nearly everybody promoting these money saying claims, really believes them. Most of them love the NHS and not only want to implement their innovations at scale, but want to help it prosper and use its resources more wisely.

They are not making up their claims. OK, there are still snake oil salesmen, but they are few and far between.

However, despite the honesty of those making their pitch, those at the receiving end within the NHS rarely believe them.

Honest people, arguing for an innovation which they firmly believe will save money, are listened to by people who don’t believe them.

There is something important going on here which, if we want to introduce and spread innovation to improve the efficacy of the NHS, we had best understand.

We can’t afford to let so many of these innovations pass us by.

Some of the answer to this conundrum is to be found in my final post last week – the fragmented way in which the NHS is financed.

Most people outside of the NHS (public and most politicians included) believe that because the NHS is a single payor model, there is in fact a single pot of money which pays for everything. This is “British Constitution 101” (or as I like to think of it  the “A” level I took in 1966) and, in those terms, of course true. The public pay their taxes to the Treasury which pays the DHSC which in turn pays NHSE.

BUT, and it’s a very large £160 billion ‘but’, the finances within the NHS are then fragmented in such a way as to build enormous walls between these divisions. And it is this fragmentation that causes investment in one part of the NHS (point ‘a’), and savings in another part (point ‘b’), to remain entirely divorced from one another. There is no hope of getting your savings from b to pay for a.

And this is the reality that the NHS listener to the innovation pitch lives with.

For the innovator reality is one where it’s all “NHS money” and obviously you can reach into b to pay for a.

I’ve sat through hundreds of these conversations. What looks to be an intelligent conversation is in fact taking place in two very different languages describing two very different realities.

The innovator makes a strong case but the moment they leave the room, the NHS person shakes their head, knowing they can’t make the savings work.

New financial flows within the NHS – and even between it and social care – will certainly happen. The NHS Plan 2025 will suggest implementing new models of financial flow (as the NHS Plan of 2000 did).

In a few years’ time, with good judgment from the NHS, these innovatory financial flows will become the norm. But before that they will themselves be NHS innovations.

And I am afraid that, until then, this will add an additional burden to those trying to develop innovation in the NHS. Not only do they need to develop their own innovation, but at the same time demonstrate how it – say a new skill – will develop its own new financial flow.

So, alongside developing the innovation, the innovator needs to suggest to the NHS how it can change its fragmented financial system to save some real money.

And it is only if both happen that the NHS will save any money.

But while the innovator has this additional task, the NHS also needs to undertake some harder work if it is going to successfully gather the ‘saved money’.

And let’s be frank. There are few people working in the NHS with the skills needed to save the money that the innovation is meant to deliver. Most of the effort will be spent developing the new service that the innovation suggests.

The saving of money in another part of the NHS is usually forgotten.

Unless the NHS can develop this mindset and these skills in the next decade, I really fear for its future.

Nearly everyone agrees that the NHS needs to develop a new model of care which both moves care out of hospital and plays a bigger role in preventing ill health.

Both of these aims involve investing in ‘a’ to save money in ‘b’.

If money is not in reality saved in ‘b’ to spend in ‘a’ then NHS will have funding problems that make those it has presently, look very straightforward.

So the real skills (and not the just good intentions) of making sure that savings are real  – and then having the skills to move them from one part of the NHS to re-invest in another – will be crucial.

And to make a wider point this not just about the technical skills but about a crucial part of the morality of the NHS.

If there are more efficient ways of spending other people’s money, then as a part of its stewardship of the relationship between those people, their money and the service, it must ensure the money is saved.