Whole System Transformation of England's National Health Service 18 March 2010 Care Oregon Helen Bevan Paul Corrigan

1. Whole System Transformation of England's National Health Service 18 March 2010 Care Oregon Helen Bevan Paul Corrigan

2. Who we are Helen Bevan Chief of Service Transformation, NHS Institute for Innovation and Improvement, England Paul Corrigan Special Adviser to Secretaries of State for Health and Prime Minister 2001-7 now independent consultant

3. At the end of this session, you will be able to: Gain a perspective on your own system by spending a morning deeply immersed in a real-life transformation case study View and review the scenario from multiple perspectives of large-scale change Take home approaches, tools and insights on transformation that you can apply in your own setting

4. What we will cover • Background to the NHS • NHS as a case study in “discontinuous innovation” • The birth of the NHS and the NHS pre-1997 • Our ten year transformation journey • The levers of change in a national system • The necessary capacity to use those levers • Contemporary issues facing our reformed NHS and the US system • Transforming the way in which we treat Long Term Conditions • Debrief • Take home messages

5. Why might this be useful? • This isn’t “how to do it” “the best way to do it” or “we are perfect” • Understanding some factors and levers that help or hinder transformational change of a large health system • Unintended consequences and failures (and there are plenty) as well as successes • Levers that implement strategy at system level and the necessary capacity shifts of the frontline reality • Case study of “discontinuous innovation”

6. Underpinning principles for systemic change We need both to deliver change at scale

7. English/American translation “Two nations divided by one language”Winston Churchill • Bluestocking • Ha-ha • Spinney • Spotted dick • Chalk and cheese • Chemist • Surgery

8. English/American translation • Bluestocking - an intellectual woman • Ha-ha - a ditch, used to keep animals from getting into the garden. • Spinney - a little copse of trees • Spotted dick- a sweet pudding made from suet, flour, sugar and dried fruit • Chalk and cheese – two people or things that are polar opposites • Chemist - someone who works in a drugstore (pharmacy) • Surgery – the office of a primary care physician

11. A bonus question...... There are only two employers in the world that are bigger than the NHS. One is the Chinese Red Army What or who is the other one?

12. % Gross Domestic Product spent on health

13. How is the NHS performing? • 98% patients can get a routine appointment with their primary care physician/General Practitioner (GP) within 48 hours or with another primary care professional within 24 hours • 97% people with cancer start treatment within 32 days of referral by their GP • 92% patients get surgery in <18 weeks of GP referral • 98% patients get through the emergency room in <4 hours (either treated/discharged or admitted to a bed) • Cancer mortality rates fallen by 19.3% since 95-7 • Biggest reductions in recorded hospital infection rates in the world • (Currently) highest recorded improvements in public satisfaction with NHS since surveys started Everyone (54 million) gets this. No-one pays!

14. The population of Great Britain ENGLAND Source: The Times, August 2009 SCOTLAND WALES SCOTLAND NORTHERN IRELAND NORTHERNIRELAND WALES 8% 5,169,000 people 5% 2,993,000 people 84% 51,446,000 people 3% 1,775,000 people

15. The English NHS today: a complex system • 1.4 million employees • 55 million patients (population) • 1 million patients every 24 hours • funded directly by tax • 10 Strategic Health Authorities (each • covering a population 2.5 - 7 million) • Primary, secondary, tertiary care • Ambulance services • Mental health • Dentists, Opticians, Pharmacies • (drugstores) • Population/public health • School health • Sexual health • etc

16. The lifecycle of a system Source: adapted by John W Kenagy from Brenda J Zimmerman

17. Innovation characteristics • Disruptive innovation • Simplicity; unattractive, overlooked providers • Our capabilities are our disabilities. • Reliability, access, customised care, lower cost • Improve to meet the needs of new, more demanding users Sustaining innovation • Better services, best for our customers • Making better use of existing capabilities • Better functionality and new features • Adapting current ways we do things to meet population and patient needs Source: adapted from John W. Kenagy, MD, MPA

18. The lifecycle of a system Source: adapted by John W Kenagy from Brenda J Zimmerman

19. Why was the NHS established in 1948? • Cataclysmic effects of the war made it possible to have a massive change of system, rather than incremental modification. • The combination of the state and the people had won the war. Together they could do anything • The population had rights healthcare is a right, not something bestowed erratically by charity • Bipartisan agreement that the existing services in a mess and had to be sorted out • Financial difficulties for the voluntary hospitals • Creation of an emergency medical service as part of the war effort • Increasing view among younger members of the medical profession that there was a better way of doing things

20. “It will provide you with all medical, dental and nursing care. Everyone - rich or poor, man, woman or child – can use it. There are no charges… There are no insurance qualifications. But it is not a “charity”. You are all paying for it, mainly as taxpayers, and it will relieve your money worries in time of illness.” Launch of the NHS, July 1948

21. The underpinning philosophy to the formation of the NHS; In 2010, 85% of the English population agree with this principle The collective principle asserts that the resources of medical skill and the apparatus of healing shall be placed at the disposal of the patient, without charge, when he or she needs them; that medical treatment and care should be a communal responsibility that they should be made available to rich and poor alike in accordance with medical need and by no other criteria. It claims that financial anxiety in time of sickness is a serious hindrance to recovery, apart from its unnecessary cruelty. It insists that no society can legitimately call itself civilized if a sick person is denied medical aid because of lack of means. Aneurin Bevan, In Place of Fear, p100

22. Universal coverage is not a panacea to the health of a nation • It helps, but….. • After 61 years, significant health inequalities exist

23. The city of Sheffield

24. London Underground: the Jubilee Line

25. Table question How would people react to this in your country or setting?

26. The lifecycle of a system Source: adapted by John W Kenagy from Brenda J Zimmerman

27. Before the NHS has its 50th birthday… 1984 – Introduction of “General Management” 1987 – big rises in demand, health authorities in debt, waiting lists growing, hospital beds closing 1991 – introduction of “Internal Market”; “purchaser/provider split” and “GP Fundholders”

28. “The hospital bed auction”

29. “Age? You mean now or when we first sat down?”

31. What event happened in 1997 that was seminal to the NHS? How was the NHS viewed by the people at this point?

32. The lifecycle of a system Source: adapted by John W Kenagy from Brenda J Zimmerman

33. The transformational programme has two stages:stage 1: creating a system from an organisationstage 2: using the levers in the system • 1997-2007 creating a system from an organisation. Developing geographically based commissioners to buy the care • Developing separate providers to sell the care • All within a system that has open access for all with no payments for care

34. The architecture of the new NHS from 1997 1. Developing better value in demand Local population based commissioning through PCTs; (GP) Practice Based Commissioning; Patient Choice enshrined in the NHS Constitution 2. Developing better value in supply provision Public hospitals with more independence (Foundation Trusts); new private providers; new forms of primary care provision and polyclinics 3. Pricing: transactional relationship between demand and supply National tariff which ensures providers have to earn money rather than just spend ii covering 70% of hospital work; commissioned contracts for all health services 4. Putting the N back in the HS National contracts for staff; national frameworks for major disease groups; national agreements for which drugs can be used; national independent inspection 5. Linking investment with reform, quality and improvement National improvement programmes to support nationally determined performance goals;

35. NHS Plan (2000) was the biggest change since 1948 • 20,000 more nurses; 2,000 more GPs, 7,500 more hospital specialists; 6,500 more therapists; 100 more staff childcare facilities • challenging national targets for patient waiting times, backed by clear accountability and performance management regimes • Expansion in services for cancer, heart disease and mental health • “earned autonomy” for local hospitals that perform well (“Foundation Trusts”) • National Institute for Clinical Excellence (NICE) to end the “postcode lottery” of drugs and treatments • New contracts for hospital doctors and GPs • 85% of NHS budget given to Primary Care Trusts to determine where it should be spent rather than giving money straight to hospitals • bigger role for the private sector within the NHS • In real terms, 50% extra in funding over five years

36. Structure of the NHS

37. A considerable increase in resources flows through the reform levers • Over 10 years, commissioners learn how to construct a market in care • Providers learn how to provide to that commissioning and be responsible for their own organisations • The national system learns to construct contracts and pricing relationship • We learn to use national contracts for staff to change behaviour.

38. Commissioning Commissioning is the process of determining: the health needs of the population the resources available how to organise service provision for this buying the resources from local providers Commissioning occurs: mainly by Primary Care Trusts for rarer conditions, at PCT group, Strategic Health Authority or national level © NHS Institute for Innovation and Improvement/ DH, 2009

39. Where is “improvement” in all this?

40. A short history of NHS improvement 1998 Pre 1997 • national task and finish teams • “waiting list busters” projects and programmes at local level 1999 2001 2004 • first national Collaborative programme • Cancer Services Collaborative • establishment of NHS Modernisation Agency • national body to support improvement • 151 national improvement programmes • >800 national improvement staff 2010 2005 • delivery agenda for cost and quality • refocus on implementation support; “alliance” of improvement organisations • establishment of NHS Institute for Innovation and Improvement “design” rather than “delivery” organisation; 50 improvement staff; 6 Priority Programmes

41. The “Productive” (Releasing Time) Series

42. The focus is on direct patient care “Everything I need to do my job is conveniently located” ‘The paperwork is easy to understand and quick to complete’ ‘We have the information we need to solve our own problems, and find out if we were successful” I am not interrupted by people requesting information or looking for things ‘It is clear to everyone who is responsible for what” ‘’Handovers are concise, timely and provide all the information I need” Opportunity to increase safety and reliability of care Role Time (e.g. nurse) Total Time Discussion Motion Handovers Admin Roles Information Direct Care Time

43. HIGH Alienated Ascendant Control of the processes Apathetic Anarchic HIGH LOW Commitment of the people Where we are trying to get to… Lean organisation alignment Source: Wickens

44. What we are learning from Releasing Time to Care • How much energy can be unleashed by encouraging front line teams to question how they work and providing simple tools and skills to do this

45. The Productive Ward - the evidence Research study from NHS London • Releasing Time to Care has been a significant catalyst for change • It has resulted in measurable, positive impacts. • 13 percentage points increase in median Direct Care Time • 7 percentage points increase in median Patient Satisfaction Scores • 23 percentage points increase in median Patient Observations Source: NHS London 2009 This equates to having an extra 255 full‑time nurses….while an equivalent level of service improvement without the programme would cost an estimated £7.5 million a year Nursing Management July 2009

46. Practices use nonphysician clinical staff for patient care % reporting practice shares responsibility for managing care, including nurses, medical assistants Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

47. 9 More Senior Staff 8 Consultant Practitioners 7 Advanced Practitioners 6 Senior Practitioners/Specialist Practitioners 5 Practitioners 4 Assistant Practitioners/Associate Practitioners 3 Senior Healthcare Assistants/Technicians 2 Support Workers 1 Initial Entry Level Jobs A Career Framework for the NHS

48. Profile of Current NHS Workforce Senior specialists and managers 9 8 7 6 5 4 3 2 1 Source: Department of Health

49. Major opportunities to improve skill mix Senior specialists and managers 9 8 7 6 5 4 3 2 1 Source: Department of Health

50. Case study: Endoscopy Technician • Benefits: • significant reductions in waiting times for patients • better patient experience • safe, effective care • improvements in staff recruitment and retention • increased flexibility of service provision