Fixing the NHS: Hurdling today’s barriers for a fitter future. #Health

The 3 Es: employment, ‘ealth and education

Photo by Carlos Magno on Unsplash

With a new government, can we avoid catastrophic NHS collapse and hollowed-out privatisation? Let’s try:

• 1 national project on patient waiting to tame demand and liberate funding.

• 2 necessary developments for any major national project to succeed.

• 3 areas for reform once demand has been tamed and funding liberated.

To unlock this problem, we analyse health as quintessentially a knowledge industry.

The knowledge-distance paradox

Since health is about knowledge – who knows what, where information comes from – networks shape provision. People first shared knowledge through training or working together, so hospitals mushroomed with new diagnostics, and treatments. Knowledge was in heads and on paper, so GPs and hospital doctors exchanged letters while patients travelled. Despite the advent of computers, this paradigm has shaped today’s care.

Small clinics thinly-spread across the country wouldn’t work, while a hospital every few miles would cost too much, so healthcare has always flowed between the top left and lower right quadrants, offering continuity of care (local access) with high quality interventions (remote skills) when needed (read more here). One way or another, 7½ million people are now caught in the crosshairs of our chart.

1 national project

A sustainable NHS is at least a decade away, so we must beat today’s emergencies, free up budget, and learn to work smarter, all at the same time. Since everything is connected in complex systems, you can start anywhere. How about those 7½ million people? That would meet the political imperative, boost performance and raise morale.

7½ million people are caught in the crosshairs

The high impact options are all hybrid, crossing primary and secondary care: one-stop shops, tried many times; some form of Darzi polyclinics; accelerated pathways; virtual wards; etc.

Let’s imagine 100 centres nationwide, each closing 4,000 patient pathways a month. They wouldn’t clear the backlog on their own, but by trading across existing demand, hospitals could focus on complex pathways and surgery, halving the backlog in a year.

2 necessary conditions

This project will fail if it is run entirely from the centre or entirely by local teams: the NHS fails routinely in both directions. However, you need to unify a national programme, so here are two mechanisms:

The numbers. Through NICE, the UK leads the world in cost-effectiveness, while the Green Book is great but rarely exploited in full. Let’s centralise – through templates and specifications – value-propositions, dataset definitions, and how numbers will drive the new services.

However, we will need better numbers, better deployed. Realtime open data on usage and outcomes can provide operational feedback, but the NHS cannot afford its usual layers of audit and control.

The digital arts. Digital technology shapes all: what we see; where we go; how we learn. Digital design, information infrastructure and AI must move centre stage, which means a clearer grasp of ‘digital’ across the NHS.

Formal design matters: digital prototyping, detailed attention to staff and patient movements, and equipment usage. Digital prototypes – computer models – are the only way for all stakeholders to share in the design: staff, patients, carers and suppliers. A central set of digital prototypes would provide launch metrics, cap the cost of variation, mitigate the risk of failure, and kill the confusion of 100 locally championed concepts.

Three cultural changes

This should buy time and free resources, first, for standardisation. Clinical and local choice simply cost too much financially and in variable outcomes. Second, the NHS needs a safer culture, not through commitments to zero but by striving for less: fewer poor outcomes next year than this year. Third, management: the NHS borrows from other sectors and extemporises for itself but often gets the worst of both worlds.

Is this too simple? Those with NHS experience describe horrendous complexity and complain that their lives are routinely devoured by clashing circumstances.

Let’s start simply and see if the final picture makes sense.

1,2,3… How long and what will it cost?

Clearly, if one in nine of us is waiting in the NHS, the problem won’t disappear for free or just by trying harder. As I’ve advocated for 20 years, let’s take an industrial approach to this frantically difficult problem, give ourselves 2 years to slash the waiting while learning enough to keep improving care year-on-year, and set a budget of up to £10 billion (the 2022/23 health and social care budget was £182 billion).

Once running, these centres would continue to devour waiting much faster, with better outcomes (as we’ll see), and at lower cost per patient than is possible today, triggering a domino-effect of savings for further rounds of improvement. If one were brave, one would make this a one-off funding bolus, and freeze the NHS budget for the next 7 years.

Can everyone waiting be brought to an ideal outcome for <£1,000? My guess is that well-designed and well-run centres will drive the cost to around or below £500, but that’s not the survival question.  If you can trade waiting trade between centres and the rest of the NHS, the survival question becomes:

Which 7½ million people in the system could be brought to an ideal outcome for £1,000 or less?

It’s a mild cheat, because you would select patients for accelerated treatment and swap them for patients unsuitable for fast-tracking. However, the whole system would be unclogging as the dominoes tumbled.

The next five posts

First, we must explore the 2 necessary developments bulleted at the front: numbers and the digital arts:

• Fixing the NHS: the digital arts and a simple knowledge model

• Fixing the NHS: the digital arts and service design

• Fixing the NHS: the digital arts and getting the right numbers

After that, we will combine our models of knowing and doing:

• Fixing the NHS: making the process-knowledge vortex work in healthcare

Finally, the full recipe:

• How to design a centre that closes 4,000 patient journeys a month for £1,000/patient or less, all in.

What are the odds?

My first limbs came from the US, but I got my first NHS legs in 1967, after our family was airlifted out of Beirut and the 6 Day War (different story), when I ended up at Roehampton.

Since then, I’ve studied (school, degree, PhD, the usual), run photonics R&D (technical and business models, patents, conferences, management, the usual), and led health research as a professor (grants, papers, students, the usual). I’ve even won a couple of prizes for papers on modelling.

I’ve also been an NHS patient.  I’ve been told things that weren’t true, mostly because people wanted them to be true or thought they knew enough to guess. Optimism isn’t a substitute for measurement or having done the sort of modelling that would make sense of what I was being shown. Once in a while, someone else did the measurement or I’d seen enough modelling to cast doubt on what I was being told…

This is a quirky view of a system in crisis.  The odds are against it working, but good odds have never been my long suit.

Professor Young: researching for 40+ years; in healthcare for 25; and using NHS limbs for 50+.