The realisation that we can no longer afford to do what we’ve always done is looming large for all suppliers. Whether it’s expressed as the Nicholson Challenge or described eloquently as Hospitals on the edge, our existing systems have grown up with big specialist institutions as the jewel in the NHS crown. But those jewels are now looking distinctly tarnished.
The fiscal pressures mean that we must move en masse –as patients, providers and commissioners – towards a new healthcare model which delivers a health service not an ‘illness service’.
What will this new way of working look like?
There’s an old Irish joke in which a man asking for directions is told “I wouldn’t start from here”, and that is true of our current NHS. Years of striving and delivering efficient process driven healthcare have resulted in lean palaces of specialist intervention. The latest private finance initiative (PFI) funded behemoths were built on the premise that things would never be this way. And now, but a few years later, buildings once trumpeted as the ‘new NHS’ resemble large white elephants designed to bankrupt health communities.
Can this elephant learn to dance with the mouse of primary care?
I’m not certain it can without major changes in corporate culture, beliefs and values.
The initial problem is that our hospitals have evolved to deliver what they deliver. Described by Clayton Christensen as “accidents of history”, we have evolved trusts to achieve financial effectiveness first and clinical effectiveness second. In many cases, it has been right to seek specialist centralisation, but we seldom go far enough, allowing several trusts within a metropolitan area to offer duplicate services – often 24/7 – in the name of choice. We now need to centralise those specialist deliveries while, decentralising the specialist support to primary care.
Contradictory? Possibly. Easy to deliver? No.
Corporate innovation in established high performing organisations is difficult. When there is no cash, it is next to impossible. At economic times like these, new entrants traditionally spot the niche and take the chance. Some fail, some succeed. The established players usually don’t match the start ups and often die. Technology exemplifies this trend; big telecom giants fall and mainframe computer suppliers cease to exist, lost among the personal computer and mobile phone growth.
Is there any hope for the elephant? Traditional elephant keepers – directors of finance everywhere – will correctly point out that we will always need trauma, surgery, diagnostics, and therefore a hospital. They will point out that simply moving care closer to home does not save money.
Unfortunately, beyond the hospital walls the mice of primary care – small agile, fast changing and responsive – are thinking about how they might re-tool for the challenge, now armed with the NHS budget they will innovate like start ups. Some will grow, some will fail.
These mice will not try to manage acute trauma, do surgery in front rooms, or replace the core functions of an acute facility. Instead, they will collaborate with patients to concentrate on long-term diseases and deliver effective management by the people for the people, using whatever technology they can adapt. This better management at home will be how the mouse unintentionally starves the hospital of activity. There is no need for referral management if you do not need to make a referral.
As commissioning groups become real, their attention will shift from self establishment to system management and primary care, and at that point, we will see the new direction.
Trusts must learn how start ups think, how to take chances, how to take business risks for a new way of delivering care, not just closer to home, but in a different way. Clinically-led semi-autonomous business units will need to lead innovative changes in service provision, matching resource, demand and commissioners’ intentions. Trusts will need to demonstrate flexibility and willingness to try a new dance.
If you are sitting atop your elephant now thinking this will never happen, then I have bad news for you; the elephant and mouse music is already playing and the dance has started without you.
Chris Mimnagh is Director of Strategy and Innovation at Aintree University Hospital NHS Foundation Trust