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This is the presentation that Steve Fairman and Helen Bevan made at the Institute for Healthcare Improvement 25th Annual National Forum on Quality Improvement, 10th December 2013
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@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
A16/B16What can England teach
us about changing healthcare?
Helen Bevan@HelenBevan
Steve Fairman@SteveFairman1
Crystal Ballroom, Salon A-C
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
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
• Strategy at system level versus frontline reality• Case study of “discontinuous innovation”
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
The English NHS: facts and figures• Provides comprehensive healthcare to 51
million people• Funded by direct tax• It’s free at the point of delivery• Virtually EVERYONE uses it
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
The NHS is highly valued by the public – we love it!
Source: Ipsos Mori 2013
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
If there was one thing that the British people took from the [World War II] experience, it was a health service free at the point of use......
And no government of any stripe has dared to try to take it away from us since..... Andrew Marr
History of Modern Britain
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
The British peoplehave the NHSin place of fearAneurin BevanFounder of the NHS
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
The NHS belongs to the people
It is there to improve our health and well-being, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well
as we can to the end of our lives. It works at the limits of science – bringing the highest levels of human knowledge
and skill to save lives and improve health. It touches our lives at times of basic human need, when care and compassion
are what matter most
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
Patients have a legal right to:
• Access to health services• Nationally approved treatments, drugs and
programmes• Respect, consent and confidentiality• Informed choice• Involvement in their healthcare and in the
NHS• Complain and to have that complaint
redressed
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
Populations served by British health systems
(as a % of total population of Great Britain)
84%51,446,000
people
Source: The Times August 2009
5%2,993,000people
SCOTLAND
8%5,169,000people
WALES
3%1,775,000people
NORTHERNIRELAND
ENGLAND
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
What do we know about how our NHS is performing?
16
Some great news!
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
NHS | Presentation to [XXXX Company] | [Type Date]17
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
NHS | Presentation to [XXXX Company] | [Type Date]18
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
NHS | Presentation to [XXXX Company] | [Type Date]19
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
What do we know about how our NHS is performing?
20
Some less great news!
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
NHS | Presentation to [XXXX Company] | [Type Date]21
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
NHS | Presentation to [XXXX Company] | [Type Date]22
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
NHS | Presentation to [XXXX Company] | [Type Date]23
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
NHS | Presentation to [XXXX Company] | [Type Date]24
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS25
Challenges facing the NHS today
Future pressures
• Improving outcomes against the NHS Outcomes Framework
• Significant inequalities in health and life expectancy
• NHS performance on certain diseases lags behind the rest of Europe
• Burden of long term conditions increasing
• Demands on hospitals, emergency admissions and readmissions rising
• Patient experience is too variable
• Unacceptable safety failures
• Ageing population and rising birth rate
• Increasing burden of disease – e.g. by 2035 46% expected to be obese with 550,000 extra cases of diabetes
• Patient and public expectations rising
• ‘Flat real’ financial settlements expected (i.e. only in line with general price inflation)
• Costs expected to keep increasing with new and more technology
• NHS productivity difficult to increase – grew only 0.4% between 1995 and 2010
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
The role of NHS England
• To allocate resources (£63.4bn in 2013/14) to clinical commissioning groups (CCGs)
• To support CCGs to commission services on behalf of their patients (according to evidence-based quality standards)
• To have direct responsibility (and a £24.7bn budget in 2013/14) for commissioning services:• primary care (£11.1bn);• military and prison health services;• high secure psychiatric services; and• specialised services (£12.0bn).
28
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
The role of NHS England (2)
• To create the conditions for value for taxpayers and turn their money into good clinical outcomes through strong and well-directed commissioners
• To ensure that everything that NHS England does:• contributes to continually improving outcomes;• has been clinically-led;• promotes equality and supports a reduction in health
inequalities;• is informed by the needs, views and wishes of
patients and the public; and• promotes innovation and puts research into practice.
29
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
30
“What do you mean, you don’t have real authority, you only have influence?”
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
The history of the NHS in a triangle…
31
QUALITYSTANDARDS
MONEY ENTITLEMENT
TENSION
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
NHS England and transformational change
All our work on the ‘Case for Change’, the ‘Call to Action’ and further work to come, must be:
•Based on clinical arguments about improving outcomes
•Underpinned by a sound evidence base
•An integral part of every local plan
•Something that appeals to both the head and the heart…
32
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
What do we need to do?
1. Understand the scale of the issue
2. Work with patients and be transparent
3. Shift public expectations
4. Shift from the current clinical model (Primary/Community/Secondary….Integrated)
5. Be relentless on efficiency
6. Get the incentives right
7. Find, understand and implement best practice
8. Encourage innovation
34
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
Why do we have a growing financial challenge?
Because the equation…
Demographics + Patient/Public Expectations + Quality
Money
…doesn’t work unless we have transformational change to the current way of delivering health care
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
2. Work with patients and be transparent
39
3. Shift public expectations
AND
Preserving the values that underpin a universal health service, free at the point of use, will mean fundamental changes to how we deliver and use health care services.
This is NOT about:
• Privatising the NHS
• Charging for services
• Restricting access
What the people we serve want….
Person centred coordinated care
“My care is planned with people who work together to understand
me and my carer(s), put me in control, co-ordinate and deliver
services to achieve my best outcomes”
Communication
Information
Decision-makingCare planningTransitions
My goals/outcomes
Emergencies
8 high impact interventions
45
• Early diagnosis
• Primary care referrals and prescribing
• Self-help: patient-carer communities
• Telehealth/telecare
• Case management and coordinated care
• Mental health
• Dementia pathway
• Palliative care
Why working across organisational boundaries is important
The core area for effective integrated
care
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
Improved quality
Co
st
“Cuts”
“ClinicalDevelopment”
“Drift”
Reduced hospitalisationStandardisationTechnology / innovationTime savingReducing clinical errorWaste reduction
With thanks to Jim Easton
The Magic Box
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
7. Find, understand and implement best practice
53
8. Encourage innovation
AND
1. Focus on the needs of patients and local populations
2. Build a culture of partnership and collaboration
3. Speed up adoption of innovation into practice to improve clinical outcomes and patient experience
4. Create wealth through co-development, testing, evaluation and early adoption and spread of new products and services
Aims of NHS EnglandCore objectives for Academic Health Science Networks
@helenbevan@HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents
John Kotter: “Accelerate!”
• We won’t create big change through hierarchy on its own
• We need hierarchy AND network• Many change agents, not just the usual few • Changing our mindset
• From “have to” to “want to”• Head and heart, not just head
and
@helenbevan@HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents
The largest simultaneous improvement initiative in the history of the NHS
@helenbevan
It started with a tweet!
Trainee doctors and improvement leaders started to talk about how they could build a social movement to improve care
Damian RolandStuart Sutton Helen Bevan
Source: @NHSChangeDay
@helenbevan
Probably the only winner of a global
challenge to develop leaders in the corporate
world that names Saul Alinsky and
Marshall Ganz as major influencers
@helenbevan
Change Day 2013 was an extraordinary moment in the history of the NHS. It taught us that large-scale
improvement is possible in the NHS and that the best way to do it is through collective commitment, action
and by keeping it simple.