The Evolving NHS Landscape
The dangers of not understanding the system you are in
Written by: Andrew Vincent, Medicology Ltd. Published: 3rd June 2010
As the evolution of our health system takes hold, many services are discovering the hard way that their level of understanding falls short of that necessary to ensure safe passage through increasingly troubled waters. Playing any game when you don’t understand the rules is tough but in healthcare it comes with increasing risk in many forms.
Focused on quality
The traditional focus of frontline clinical staff has been one of quality, both in the momentand from a longer term improvement perspective. Troubles at Mid Staffs remind us of the absolute imperative of maintaining a clinical focus or in not dropping the clinical ball. However, to focus solely on clinical quality, or indeed clinical work in general, brings its own set of risks.
Over recent years, an ever greater agenda of targets and scrutiny has been hoisted onto clinical services and in many respects, this has maintained almost single-minded focus on the clinical arena, as everyone strives to deliver against targets that come with severe penalties for failure to achieve. As working hours have reduced and sickness/ absence rates increased, meeting clinical targets andmaintaining clinical quality has become an uphill battle taking persistent, continuous effort at the expense of longer term service evolution. If the game hadn’t changed, this would be OK but with the evolution of a market, services are finding themselves playing catch up to their more experiencedcommercial competitors and the need for strategic leadership has never been greater. However, that strategic focus must be underpinned by a solid understanding of the environment in which you operate as we’ll illustrate.
Bob’s service
Bob runs a typical local hospital ophthalmology service with a broad caseload that has run stably for many years with good results, although the workload since 18 week targets has been uncomfortably full on. Bob has found it increasingly difficult to bring through improved treatments, with the Trust typically saying that it just can’t afford it. At the same time, they have been pushing Bob to seemore new patients and reduce outpatient consultation time and frequency. Bob seems to have a constant battle on his hands to keep the administrators out of his service and the targets met. The OperationsDirector keeps pushing for every service to have a strategic plan in place but the time to prepare it seems disproportionate to the benefit of what appears to be a paper exercise to satisfy the Trust’s increasing appetite to turn healthcare into a business.
To date, Bob has worked hard, adapted practice where the evidence suggests it should be done and run a reasonably tight ship financially. He’s been sufficiently busy that he’s maintained only a passing interest in the changes proposed and although he is aware of the polyclinic agenda and pushtowards community care, these are of low concern to him because ophthalmology requires equipment and surgery, not really lending itself to a community setting. In his desire to comply with Trust mandates, he has produced a 10 point strategic plan covering the key elements of focus for the next 5years. It includes:
- Key clinical innovations and trendson the horizon
- The move towards more day-casesurgery
- Reforms to clinic structure toimprove throughput
- Immediate and future capitalrequirements
- Manpower required to deliver theservice, including a case for anadditional consultant
- Cost improvement plans aimed atsaving 3.5% per year for the next 2 years
Although Bob’s strategic plan may look like many typical plans, it places his service at severe risk across its lifetime, predominantly because it is detached from what is actually happening on the ground.
The wrong trousers
Bob’s plan may well have been the right plan for the service he is used to running. However, although he has dealt firmly with clinical quality & productivity (the trousers he has been wearing), he really needs to be wearing different trousers, the ones that deal with strategic risk, financial risk, competition and other issues that Bob is less familiar with. Let’s examine what happens over the next few years...
About 12 months later, BUPA opens up a treatment centre on the periphery of the catchment area that Bob’s service usually draws from, under the any willing provider provisions. It is run by an experienced ophthalmologist with a good reputation in brand new facilities. The centre starts to attract cataract day case surgery, partly because of the new semi ‘private’ facilities and also because of the shortened waiting time. Bob’s service does start to lose patients to this service.
About 18 months later, the PCT approaches Bob and says they are looking at setting up a community-based ophthalmology triage service to coincide with the opening of two GP-led health centres, designed to reduce admissions to hospital by resolving minor complaints and medical treatments in the centres themselves and therefore appropriately steering patients according to severity of conditions. Bob is somewhat resistant to the idea, as he doesn’t like the prospect of his consultants running about the country. It all appears to go quiet and Bob hopes the mad idea has been forgotten.
Around 2 months later, Bob gets a call from his service manager who has been reading the Health Service Journal and spotted a tender for a community-based ophthalmic triage service covering their area, with a completion process of around 2 months and an autumn-based start. Responding to this, Bob and his colleagues put together a sensible proposal based on their experience of running an effective ophthalmology service. Unfortunately, the tender gets awarded to BUPA, on the grounds of exact specification match but a substantially lower running cost. It seems that BUPA has built a cost model based on a different approach to staffing, with minor complaints managed in health centres by nurse practitioners, greater use of healthcare assistants and reduced reliance on senior medical staff.Although Bob and colleagues wonder whether quality will be as good, they are especially worried that BUPA can now triage patients and refer/ steer cataracts to themselves.
The Service at risk
Unfortunately, this type of scenario is occurring with ever greater frequency. It’s not that Bob’s done anything wrong and in fact has acted with the utmost integrity. However, his failure to understand the rules of the new game has now placed his service in difficulty. With a greater understanding he could have prepared for these situations, developing alternative business andstaffing models, leading the introduction of community-based services, developing strong relationships and networking with the right people and basing his service plan on what it takes to be successful in the modern, competitive environment.
Risk comes in many forms and it is vital that service leaders understand the evolving structure, key agendas, finance, funding, tendering, service promotion, competition, choice, commissioning and a myriad of other components that go to make up a cruel, unforgiving system for the uninitiated. Everyservice needs a solid strategic plan based on the right principles and correct information. For thatto happen, service leaders need a quick trip to the tailors to purchase the right trousers for aperson about town in the new system!
