Chris Powell: How to change the National Health Service

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The Independent Online

The deal always was that the Government would put the money up, but the National Health Service would have to change. The need for that change was highlighted yesterday in a report by the Office for National Statistics, showing that NHS efficiency has fallen sharply in recent years despite the injection of more money.

But efficiency on its own hardly offers adequate care to patients. The battle is for effectiveness. How is the NHS going to change to spend its new money effectively?

Although most of the new money will be absorbed in paying existing staff nearer to a proper wage, any more money in the short term would probably be useless. The service can't be expanded until new staff have been attracted and trained, and that can take up to 10 years. But in the long term, patient power and money will transform the health service.

The Government has declared that money will follow the patient and that patients will have the right to chose where to go, and that if no NHS hospital can provide an acceptable service, then patients can go private or abroad at NHS expense. This will penalise second-rate providers and boost the good, but such a service is a good decade away. You can't have patient power until you have the flexibility of spare capacity.

The challenge is to get an acceptable level of patient service in current conditions. The NHS is one of Britain's last remaining producer-dominated organisations. Like swathes of industry used to be, it is concerned with doing things its way and not very interested in how the customer might want them done. It's a bit like a visit to a travel agent wanting a holiday, only to be told which company you were to travel with, which resort and hotel and on which dates.

Until this year – when the Government has required hospitals to poll patients – there was little to no consumer research done. No one has known what the patient thinks or wants. Now, "patient focus" has become an NHS slogan, but how is "patient focus" to be achieved? By edict seems to be the answer so far. New instructions and objectives stream from the Department of Health. Managers are targeted to deliver on a myriad of standards. Frustration at the lack of immediate progress fuels ever more demands for detailed outcomes.

The problem is not a lack of ideas – there are many examples of good and innovative practice, of patients able to select the time of their visit, of tests done in one battery rather than sequentially over months, of patients being kept informed, of GPs available at commuter friendly times, of excellent clinical outcomes; but they are small and patchy. The problem is how to get change throughout this enormous and complex organisation.

Ordering is a poor way to get change. It causes resentment. In reality, people listen to and follow those they respect, not just those more senior in the formal hierarchy. Respect is almost always accorded to those at the top of a craft skill. It is particularly difficult for management in the NHS. They don't own the patients, the doctors do (have you ever asked for an appointment with your NHS manager?), and many at the top of their medical craft have formidable intellects. Ordering management to get doctors to work a certain way is not the way to get it done. But if doctors' heroes lead change, then change will happen.

During the past two years I chaired a health authority, where we tried this approach with some success. The best medical talent wants to provide a patient-friendly service. They gather the key players in their group of specialisms – accident and emergency, elective surgery, cancer, coronary disease, general practitioners – across a group of hospitals and surgeries to pioneer change. In monthly meetings after work they agree what steps to take. They are not asked to manage change, just to agree it with their colleagues.

Management comes in behind them with consequential action plans and funds. Change starts to happen as a voluntary act, not a begrudged semblance. It is difficult to hold out when your colleagues in other hospitals and surgeries, in the same discipline and geographic area as you, are moving things forward and you are not, and you have to sit with them and explain your inactivity. It would be good if the 29 new strategic health authorities were able to pick leaders who could lead and inspire their colleagues to provide a better service for their patients.

Longer term, the Government seems to be heading for a system with many of the advantages of social insurance. If the capacity is there, and money follows the patient, a more responsive and flexible service should follow. The only bit that is missing is the restraint on the part of the public that could come from seeing, in bills, the cost of the treatments they are receiving. It is proposed that this will come from education in schools – a slow and weak restraint on frivolous demand.

Pull is better than push. Consumer power will transform a well-funded NHS in the long term. Short term, the professional pride of the medics can be the trigger to a more patient friendly service.

chris.powell@bmpddb.com

The writer is chairman of the Institute of Public Policy Research and recently chaired an NHS health authority

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