What can England teach us about changing healthcare?

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

A16/B16What can England teach

us about changing healthcare?

Helen Bevan@HelenBevan

Steve Fairman@SteveFairman1

Crystal Ballroom, Salon A-C


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

• Strategy at system level versus frontline reality• Case study of “discontinuous innovation”


The English NHS: facts and figures• Provides comprehensive healthcare to 54

million people• Funded by direct tax• It’s free• Virtually EVERYONE uses it• There is lots of patient choice


What Britain loves



The NHS is highly valued by the public – we love it!

Source: Ipsos Mori 2013


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


The British peoplehave the NHSin place of fearAneurin BevanFounder of the NHS



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


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

SCOTLAND8%5,169,000people

WALES

3%1,775,000people

NORTHERNIRELAND

ENGLAND


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





What do we know about how our NHS is performing?

16

Some great news!

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHSNHS | Presentation to [XXXX Company] | [Type Date]17




What do we know about how our NHS is performing?

20

Some less great news!





@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


We could adopt this view…

26

“Be ambitious – you can’t take two steps over a gap”

David Lloyd George


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


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


“What do you mean, you don’t have real authority, you only have influence?”


The history of the NHS in a triangle…

31

QUALITYSTANDARDS

MONEY ENTITLEMENT

TENSION


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


www.nhschangemodel.nhs.uk

The NHS Change Model


What do we need to do?1. Understand the scale of the issue2. Work with patients and be transparent3. Shift public expectations4. Shift from the current clinical model

(Primary/Community/Secondary….Integrated)5. Be relentless on efficiency6. Get the incentives right7. Find, understand and implement best practice8. Encourage innovation

34


1. Understand the scale of the issue

35


The Gap…

36


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


The Dependency Ratio is rising alarmingly

38


2. Work with patients and be transparent

39

3. Shift public expectations

AND


A Call to Action

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 are the engagement themes?

We know there is more to do and recommendations for improvement already exist

Current challenges

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


4. Shift from the current clinical model

46

Why working across organisational boundaries is important

The core area for effective integrated

care


5. Be relentless on efficiency

49


Improved quality

Cos

t

“Cuts”

“ClinicalDevelopment”

“Drift”

Reduced hospitalisationStandardisationTechnology / innovationTime savingReducing clinical errorWaste reduction

With thanks to Jim Easton

The Magic Box


6. Get the incentives right

51

CommissioningCommissioning


7. Find, understand and implement best practice

53

8. Encourage innovation

AND


The Academic Health Science Networks

54

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

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

A 189,000 pledge mountain!

59 Source: @NHSChangeDay

@helenbevan

People took action all over the country

@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.

@helenbevan

3rd March 2014www.changeday.nhs.uk

@helenbevan

@HelenBevan

....the last era of management was about how much performance we could extract from people .....the next is all about how much humanity we can inspireDov Speidman

Health & Medicine

What can England teach us about changing healthcare?