Professor of Healthcare Systems Terry Young looks at the next set of challenges the service faces
The National Health Service was founded six years before the first kidney transplant, when X-rays were captured on film and moving images and contrast media were still radiological novelties. Meanwhile, a nascent pharmaceutical sector was learning to produce penicillin while seeking to plan drug discovery rather than waiting for happy accidents.
However, the seminal event of the 1940s was the birth of the NHS with the idea, not of heroic medicine performing miracles for the lucky few, but of mundane medicine that worked for millions. Indeed, the heroic and mundane characterised the next 70 years in a struggle to manage the migration of the heroically expensive to the affordably mundane in delivering mass-medicine.
This quest is a very British story about evidence, social conscience, policy and funding. The British Doctors Study ran for half a century from 1951 but within 4 years had demonstrated the link between smoking and cancer. It confounded popular belief – that smoking was good for you – and established clinical investigation as the way to make medical choices, following on from Sir Austin Bradford Hill’s breakthrough randomised control trial (RCT) of streptomycin in 1948. Clinical trials typically divide a group of people (e.g. with pulmonary TB) into two groups at random (so that they are as similar as possible). One is given the intervention under test (administrating streptomycin) and other is not, and the outcomes (recovery from TB) are counted.
With the establishment of NICE (now the National Institute for Health and Care Excellence) in 1999, the struggle between the heroic and the mundane took a new turn as the NHS set the production of guidance upon a combination of trials results and economic principles to assess when society (through the NHS) should pay for a treatment. Though initially radical, the open addition of affordability – alongside safety, efficacy or performance – to the criteria guiding clinical choices, the role of NICE is now embedded in law through the Health and Social Care Act (2012).
So, what lies ahead in the battle between the heroic and the mundane? So far, against a backdrop of incredible advances in what can be imaged, diagnosed, and treated, the NHS has applied a combination of clinical evidence and economics to interpret its original mandate in the rough and tumble of care for everyone, free at the point of delivery.
With cost and capacity pressures likely to intensify under the heightened expectations of a population that lives longer and with longer periods of illness, we must ask how the NHS can address quality and affordability in new ways.
An obvious challenge lies in converting the best evidence to best practice, itself a twofold problem. First, doctors do not always implement what is known to be best, especially if doing so presents practical problems. Thus, prescribing practice tends to comply better with NICE guidelines than surgical procedures or the use of medical devices. Second, guidance is unlikely to be implemented where the doctor is unconvinced by it. Turning what we know into what we do is therefore a second major challenge.
However, we must look beyond individual clinical decisions, since, even if technology and drugs were free, healthcare costs would still spiral because most of what the NHS spends is on salaries. The efficiency and effectiveness with which the NHS uses the time of its staff is probably the biggest challenge facing it in the 21st Century. We do not know how much NHS staff time is lost because we do not measure service failure. The next patient may appear because something has gone wrong or simply through the illness: most of the time, it is hard to know without analysis. Nonetheless, the past few decades have seen waves of initiatives to improve the way care is delivered. However, blockages and overflows persist. Another major challenge then, is to design better structures and operational processes and systematically to implement them.
This pair of critical challenges throws a fresh light on the need for evidence. In our data-rich world – social media, clinical records, pharmacy transactions, transport links, and even the weather – there is information to be mined and turned into evidence to drive better patient experiences and outcomes. A fresh look at the information and data sources available is therefore needed, along with research that enables it to be forged into evidence that can drive service delivery as well as clinical decisions.
The final piece of the puzzle is business models that reward outcomes and better experiences. Through the Quality and Outcomes Framework and Payment by Results, the NHS has experimented with getting value for money. The experience has been mixed and often incentives simply drive more activity. Another challenge, then, is to develop a consistent approach that covers all aspects of provision.
In setting up the NHS, the UK government committed to do something dramatic and to attend to the practicalities afterwards. Seventy years down the line, we are still in awe of this resolve and must not underestimate the many, often hidden, problems that the NHS has solved with innovation and panache. Its back-to-front approach of starting with the dream and then working out how to keep the dream alive has proved remarkably robust.
The question now is whether the NHS continues to retro-engineer fixes or whether it needs something more fundamental. The dream is viable, but there is a strong case to recast the dream in formal design. We now know enough about quality, evidence and funding models to specify what we really want, and during the same 70 years, industry has taken service design into unimagined realms of performance and efficiency. In doing so has cracked many of the logistics, information management, and process control problems that beset the NHS. We can have a very different NHS.
After 70 years of the NHS, we still face a question of resolve rather than viability: do we really want it?
This was originally published in full by the Clinical Commissioning Groups Association; Main image: CC by Flickr/BirminghamEastsideNHSJuniorDoctors Protest)