Editor's blog Thursday 11 June 2009: NHS Confederation Conference - Day Two

Using evidence-based information and population health management to deliver high-quality care
Simon Stevens, UnitedHealth
“There are two clichés in the conversation at the moment:
1. The NHS is about to face significant fiscal crunch; and
2. There are 18 months to do something about it.

"The first is true, I’m not sure of the second.

“The NHS has had growth of about 7.4% over five years. Given the financial sector's misdemeanours, UK public spending is about to have a very hard time. If we strip away Chancellor Darling’s rosy assumptions, the Institute for Fiscal Studies suggests an overall real-terms public spending cut by 2.3-2.4% a year.

“It’s pretty hard to see how, given the NHS share of public spending, there won’t be a big impact.

“Have we got 18 months to 2011? If a general election is called in June 2010, it’s hard to see an incoming administration taking away the rest of the financial year’s allocation, but we can’t rule it out. If the election comes before then , it’s likely that year one becomes ‘year zero’, as public speeding rectification begins.

“There is a period of time, but I’m not sure if it’s 24 months. If people want to seek solace from the cuts of the 1970s and 80s, I would suggest that there are several important differences. We now have much more transparency and quality and range of NHS services. Any idea that we could go into a series of downturns and shaft the NHS’s huge achievement on delivering 18 weeks without anyone noticing is strictly for the fairies.

“Good news: the UK is not alone – the financial sector was up to its tricks globally. The US is facing crunches, and President Obama clearly regards getting US finances back on track as intrinsically linked with controlling health spending.

"In Germany, the long-serving health minister Ullerschmidt has termed overspending “part of the government stimulus”. The Netherlands, France and lots of other countries are engaged in the question of how to get more value for the health budget.

“If we look at these countries’ debates, we see many similarities. All that said, it’s quite possible that the size of slowdown required in the UK has been severely underestimated, look at the IMF’s May 20 UK article on “further spending reductions … for long-term sustainability … broad public consensus needed for sizable fiscal adjustment”.

"Most debate on international health comparisons is silly ... ‘we should be more like the French / US / Europeans’ … this ‘balloon’ perspective is not the most interesting conversation on international comparisons.

"There are a lot of micro-level exchanges on best clinical practice every week, by individual clinicians in the pages of The Lancet and the NEJM. What’s missing is the middle level of comparisons, neither macro nor micro – how do you organise and mange parts of health systems?

“The NHS has a  good track record to idea permeability over the past several years. Patient choice (Sweden, Denmark); LTC management models from the US; World-Class Ccommissioning.

"We also now have spending up to the European average. How do we take this forward?

“To take this moment seriously, we now need bigger ideas /game changes, and gthere are real challenges making them happen over next several years. These are the ‘big five’ game changes:
1. The need for greater transparency on clinical variations and addressing them
2. New approaches to managing big buckets of service and cost (maternity, end of life, stroke, dentistry, community heath services). If you look at the figures relating the number of UK midwives to the number of births per year, you’d find that it seems each midwife delivers one baby a week! If midwives got their own power to organise and incentives … end of life issues are well known, most people want . Community care is a black box, depending on your definition spending £10-20 billion a year, doing potentially hugely important work, which in practice is very opaque.
3. Measuring the stock of population health risk – most NHS commissioning is about flow of healthcare transactions and number of episodes of  care delivered, as opposed to health risk burden (in economic terms, the net present value of future consumption requirement). Unless we’re tracing the stock of health risk, decisions will worsen the burden of health risk – it will not show immediately, but have consequences down the track (like obesity). We need population health stock accounts, as well as I&E transactional flow statements from Darzi.
4. Actively managing non-healthcare forms of supply demand – primary care and boards focus on acute demand, but we need to get to the heat sinks of social care, informal care and self-care. Social care’s forthcoming spending options look very poor. In advanced dementia, the ratio of social care spend to health spend is 4:1 if not  5:1. As social care funding drops, this will show up on the NHS side, and in behaviours of informal carers. I’m also interested in the concept of ‘blue zones’ where dementia rates are much lower because populations manage their own lifestyle, diet, physical activity, sense of purpose.
5. Testing and exploring new organisational models – innovation. I put this last because the usual NHS attitude is to go for this first. We do not need PCT reorganisation, but more explicit hybrid commissioning models. Some GPs and PBC groups can do ‘heavy lifting’ commissioning: others cannot or don’t want to. I would allow local authorities to try commissioning for NHS services. We need more mixed models  – the ‘one size fits all’ idea has been tested to destruction. If integrated, care just means putting primary care alongside a voracious FT, primary care won’t win out. I’d also want experiments to see if consultants can be moved into extended multispecialty PCT clinical teams, facilitating clinical solidarity as opposed to local cartels. We should also not throw the baby out with the bathwater in terms of hard-won financial autonomy. The departed Ben Bradshaw’s comments about possible legislation to change accountability of FTs were not great. We need to think beyond 'one-size-fits-all': experimentation and hybrid models are parts of the solution.

“Variations in clinical quality and efficiency continue everywhere: no country does not exhibit large unexplained variations in quality and efficiency. We know in the UK about big differences in needs-adjusted cancer spend between PCT; in acute utilisation; in LTC management. These can be three-fold variations across similar demoraphic areas.

"In the US, work at Dartmouth Medical College by Jack Wennberg and colleagues found a three-fold variation within Medicare with no relation to underlying need. This is all known inside the research literature; known to some extent in mamagement; pretty unknown to patients - and generally not acted on.

“Through commissioning, we need to find out how to get new incentives to make clinicians act on them and make patients respond to them. The CQUIN effort looks a bit underpowered if not disappointing. Getting this right would take inefficiency out of the system, as opposed to ‘slash and burn’ staff reductions or other crude input measures.

“This is the most fundamental challenge”.

Andy Burnham: ‘deep clean’ of unspecified targets and secret freedoms for high-performing  PCTs
Following Simon Stevens and collegaues’ thoughtful presentation, the rest of today has been a bit disappointing.

Andy Burnham’s first speech as Health Secretary, delivered though a heavy cold, was neither fish nor fowl. Burnham seemed slightly nervous, or ill-at-ease: perhaps the long delay (due the the venue’s unwise and very old-school NHS approach to getting delegates into the auditorium  - i.e. form a very long queue) did him no favours.

Once we got in, it was like a dodgy gig - we were left to a bad nineties sound board tape, as the anticipatory auditorium gets packed to the gunwhales. Is the new health secretary getting his guitar in tune? Was there a hidden message in the music – REM’s ‘Everybody Hurts’?

Burnham’s tribute to Alan Johnson, “the postman who delivered for the NHS” drew applause. Praising the service’s achievements (as is mandatory), he promised that he will defend NHS management and stress its value in difficult times: “NHS managers are the backbone of British public service and played pivotal role in the revival of NHS … I will defend and speak for NHS management when it’s under attack”.

To give Burnham credit, he seemed to be the only junior minister who did not man local demonstrations or picket lines during the Hewitt-era reconfigurations.

His jokes were fair: “ you know you’ve made it when you get to be Alastair Campbell’s warm-up man”, as well as pleading with the Confed – his employer as a Parliamentary researcher in 1997 – not to dig out his early appraisals, and certainly not to hand the to the BMA.

However, one of his early phrases was a straight lift from Brewer’s Dictionary Of Management Bullshit Fable And Phrase “can we do more to get through the challenge and to the next level, going from good to world-class?” Let's hope he watches that: it could turn into a nasty habit.

He oputlined the opportunity: “the time an space to reshape health care for the digital age. I sense your weariness at the thought of more reform initiatives; but how about doing things really differently, getting patients public and staff leading reform locally?” Mmm. This sounded better.

A few years ago, he added, “I worried that top-down reform losing hearts and minds, fracturing unity - and without unity, the NHS is nothing I feel hugely encouraged that we came through and we’re genuinely ending the top-down approach”.

He promised to “unlock the 1.4 million people working in the NHS”, which frankly sounds more like the Justice Secretary’s job. Burnham aims to create “a truly people-centred NHS – which genuinely empowers patients and carers as experts potentially backed with control over funds, moving on heath promotion and physical activity, helping people to lead full happy lives, working with public sector partners to wrap care around patients and to place quality at heart of everything”.

Prevention is his ‘fourth key” to add to Nicholson’s “quality, value and innovation", also promising delegates that his mantra will be “the quality agenda is the efficiency agenda”.

He also promised to put reform in a new context, “to move away from the focus on numbers and systems towards patients and experiences”. Burnham said that all trusts should move to include patient quality data with their financial accounts, suggesting a new use of the quality accounts data. Quality accounts will need to include many aspects of patient experience (car parking availability; being met at reception), to promote emphasis and attention to the whole experience of care.

Could he turn into a maker of trite phrases? The risk seems to be there, in the “deep-clean of the target regime”, which turned out to be an intention – he vaguely mentioned something about elements of the 18-week waiting. He is not doing a Lansley: the existing targets that have become service standards are all here to stay.

He also emphasised that the data to inform patient choice should be presented differently by a major teaching hospital and for a cottage hospital, to make it meaningful for patient use. The national quality board will produce advice on this later in the year.

He also emphasised the long-term stability and sustainability for the NHS in deficit times. Burnham emphasised the  need for PCTs to invest in public health and prevention, and to engage more with the DH’s Change4Life programme. Her also trailed the green paper of social care, and made vague mention of schemes to give ol

On the Lansley-inspired issue of future spending, Burnham offered the ‘I’m not writing the next spending review now for Alastair Darling” defence, but also mentioned PM Brown’s assurance to the RCN conference last week that “health will remain our priority”.

Responding to a delegate question on the private patient income cap amendment to the NHS bill, Burnham followed Alan Johnson’s line that “the time has come to look at this again, to see whether it is correct and not overly prescriptive and not holding back NHS service development by not affording providesr necessary flexibility”.

To Kings Fund maestro Niall Dixon’s query about supporting managers during electorally-inspired hysteria, Burnham described himself as “not the kind of person who flinches from change and reform … I don’t want this as political management job doing communications”.

The BBC’s Sarah Montague, the very able conference chair, asked him for his goals given that he may be in the job “just a year”. Not rising to the obvious bait, Burnham said that his priorities would be “getting the NHS Constitution into legislation; embedding Darzi’s quality work in the system; getting changes to the service culture and staff empowered to lead change on public health and prevention”

Mr Burnham has set himself a commendably ambitious agenda.

Alastair Campbell (writer, communicator and strategist) and pornography
He makes the odd nice phrase: on depression – “you drown in with drink and then you drown it with work. it is bad when you get it but you know it’s going to go”; “campaigning isn’t just about getting it in the paper and on telly”; “politics is about government providing services that weren’t there before and are needed, and hopefully won’t be taken away”.

And his candour about his mental health issues is admirable. That much I will give Alastair Campbell (writer, communicator and strategist).

That much and no more. Because other than that, his session exhibited a fundamental paradox, so glaringly obvious that his refusal to acknowledge it is beyond belief. And perhaps there is a benefit to Campbell’s raising the issue of perceived stigma of mental health problems in this forum, to get people double-checking their practice locally. Yet there was very little to learn in the session.

Campbell admitted that he is still “too tribal”, and there is something of the dogmatist and fundamentalist in his blank loathing of the media. It is astounding that he does not get the disconnect between his choice to “put it all out there” over his mental health problems and his whole “tribal” approach to media management.

There is a world of difference between taking an open approach (and he said that the one area where the media had been “fair” to him was over his mental health issues) and the style of communication he practiced with the media, the Cabinet, civil servants and politicians. The overwhelmingly anti-Labour bias of the daily news media through the 1980s and early 90s forged the discipline over messages that an Opposition needs. In office, the needs were different and New Labour did not deviate from the closed, authorised narrative until Campbell had gone. Ministers were briefed against; journalists were fed or excluded; Murdoch was squared.

Basically, Alastair, here is the thing. You single-handedly punched the teeth out of a fair bit of the print media (and they were weak and stupid to let you do it, admittedly), and you then spoon-fed them pureed bullshit for ten years. And now you do not like the thing they have become. You helped make it.

He quoted a media studies exam question: ‘in no more than 700 words, explain the significance of Alastair Campbell’. Here is another quote: a definition of pornography (which he wrote in his early career) – “that which tends to deprave and corrupt”.