Transparent and accountable healthcare: why the culture in the NHS still needs to change
This was published under the 2010 to 2015 Conservative and Liberal Democrat coalition government
Secretary of State for Health Jeremy Hunt talks about his Four Pillar Plan for the NHS and creating a transparent and accountable culture.
More than 60 years ago, Nye Bevan said that “no society can legitimately call itself civilised if a sick person is denied medical aid because of a lack of means”. The National Health Service was built on that founding principle – and in the 21st century we are all Bevanites. However, with an ageing population, Bevan’s means may no longer be the best way to deliver Bevan’s ends.
So NHS England’s excellent Five Year Forward View sets out a vision of how we can change and adapt the NHS. And the government has responded with a ‘Four Pillar Plan’ to deliver that vision.
I want to talk about that plan today – but first I want to thank you. Right now there is unprecedented pressure on the frontline: the triple whammy of improving standards post-Francis, a tight financial settlement and an ageing population has created a perfect storm.
And in the face of that pressure, the NHS is performing exceptionally well. Key operational standards either being met or with good recovery plans in place; winter planning more advanced than ever before; and nearly a million more operations being carried out last year compared to four years ago.
So as we all ask challenging questions about the future of the NHS, it is right to acknowledge the challenges you face every day – and ask you to pass on my thanks to your staff.
It is only natural under that pressure that people want to know about the future. Which is why today I want to spend some time on the four pillars of the government’s plan, and how we will be taking forward the NHS England Forward View.
Our first pillar is to recognise that a strong NHS needs a strong economy.
This is not a political point but economic reality.
Much of the current pressure was caused by an economic crisis. The way to relieve that pressure is both to end that crisis and make sure it is never repeated. As the Forward View makes clear, the only way to grow the £113 billion NHS annual budget is to make sure we have an economy that is generating the tax revenue to finance it.
The second pillar is to respond to an ageing population by making a reality of integrated care closer to home. Within the next two decades the number of over 80s will double to over 5 million. The care they need is different: proactive, out of hospital care focused on prevention of illness – rather than a narrow focus on emergency care when it is too late.
So in the last year we have been taking important steps to deliver this: a proactive care programme which commits GPs to give additional care to nearly a million of their most vulnerable patients; named GPs personally responsible for the care of individual patients; and the integration of health and social care with the £5 bn Better Care Fund launched two weeks ago in which 151 local areas provided detailed plans in order to drive improvement in out-of-hospital care through sharing medical records, 7-day working in health and social care, and reducing hospital emergency admissions.
Then the third pillar of our plan, which I outlined to the King’s Fund last week: to embrace innovation and efficiency in order to realise the £22 billion of savings talked about in the Forward View. Here the challenge is not just to make savings in obvious areas such as procurement, but to develop smart commissioning which tracks the total healthcare costs of every individual so it really does pay to invest in upstream prevention which is usually much cheaper. But the other side to efficiency is straightforward housekeeping: every pound spent on deficits is a pound we cannot spend on improved patient care, so financial discipline is vital even in challenged times.
But today, 1 year on from the government’s formal response to the Francis Report, I want to focus on the fourth and most difficult pillar of all: making sure we get the culture right so that patients are always treated with dignity and respect and experience the highest standards of safety.
Professor Don Berwick said last year: “In the end, culture will trump rules, standards and control strategies every time, and achieving a vastly safer NHS will depend far more on major cultural change than on a new regulatory regime”.
We should remember that.
The NHS was set up with a moral purpose and is - at its heart - a moral being. It is an institution ultimately driven not by treatment or targets or pills - but by the values of the people who work in it. And if we don’t create a culture that nurtures those values, organisational change, policy change, even money will count for little.
Progress one year on
Nearly two years on from Francis, I believe we have made great strides.
A new inspection regime, probably the toughest and most independent in the world, up and running with half of all hospitals inspected and Sir Robert Francis himself on the board of a transformed CQC.
Eighteen hospitals - more than 10% of all NHS acute trusts - put into special measures, with 6 turned round and out again and major progress at nearly all the others.
Ward staffing levels dramatically improved with 5,000 more regular nurses on our wards than just a year ago.
The Sign up to Safety campaign, led by Sir David Dalton, encompassing 110 trusts so far, all committed to halving avoidable harm – and that’s after MRSA and CDiff rates have already been halved in the last four years.
All these things are highly encouraging and would not have been possible without the commitment of frontline staff. But cultures do not change overnight. And there are still two areas where despite these efforts, the culture still needs to change even more.
The first is around accountability.
Professor Sir Mike Richards told me earlier this week he once met a cancer patient who had memorised the names of 112 doctors who had given him care. Individually each were accountable for an element of his care – but collectively no one was. If everyone is accountable, no one is.
I once got a letter from a member of the public that was so bad I asked to meet the lady who wrote it. It concerned the chaotic care received by her late husband.
One part of her story concerned his severe diarrhoea: it started in January one year, but he didn’t get the operation to sort it until November. He was referred for tests, waited, then referred for another opinion, then more tests in a cycle that went on for 10 months. But at no stage did anyone look at the whole picture and say ‘isn’t this crazy that someone’s had diarrhoea since January and we still haven’t sorted it?’ Plenty of people took ownership of doing different things to different parts of his body - but no one took responsibility for the human being that body belonged to.
And eventually that human being died as a result.
A tragic waste of life. And although this should not be the motivation, also a tragic waste of resources for the NHS. Because we know that unsafe care and avoidable harm costs the NHS between £1 and £2.5bn every year, much of which could be saved if we had better lines of accountability for individual patients.
I have previously talked about ‘names above beds’ in hospitals, which two-thirds of NHS Trusts are now implementing. But to have real impact a name above the bed needs to be about more than simply a patient being told the name of their consultant. It is about making sure that people with complex needs have a named clinician responsible for coordinating all their hospital care.
It means challenging a culture of ever-increasing sub-specialties and recognising that for patients with complex needs we need acute generalists or hospitalists who take responsibility for a patient’s whole stay however many departments they need to visit. I am grateful to the Academy of Medical Royal Colleges who have produced best practice guidance on how to achieve this.
And that same principle of accountability matters even more outside hospitals.
This year we restored the 1948 principle of GPs being personally responsible for the care of people on their lists, something that was abandoned in 2004. All over 75s now have named GPs and from next year this will apply to every NHS patient.
The intention, as we expand capacity in primary care, is to make this the heart of a new proactive approach to care in the community where vulnerable people all have named clinicians accountable for making sure they get the care they need. That principle sits at the heart of the Better Care Fund, where named accountable clinicians are a requirement for all social care service users. It also sits at the heart of the NHS England Forward View, which envisaged multi-specialty community providers as one way of making sure patients receive integrated holistic care.
And earlier in the autumn I announced that we will be working with the Royal College of Psychiatrists to ensure people who receive mental health treatment have a named accountable clinician - for exactly the same reasons.
It is of course harder to deliver accountable care when we have a system running ‘hot’ with busy hospitals and GP surgeries. But within two years the number of people with three or more long term conditions will exceed three million for the first time - and unless we have a system that knows clearly where the buck stops for each and every one of them, the tragedy of the patient I described earlier will end up being repeated - at untold human and financial cost.
But it isn’t just accountability for patients – it is accountability to patients as well. Because today’s citizens expect to be put in the driving seat of their own care – and we need to encourage that if they are to take responsibility for staying healthy and managing their long term conditions. Patients not doctors as the boss in a new era when the traditional doctor/patient hierarchy is turned on its head.
So accountability then is the first of the two changes in culture I want to discuss today. The second is about our approach to performance management.
Targets matter - and the key A&E and 18 week targets have driven a huge improvement over the last 15 years. But perhaps because of that success, we have allowed a conventional wisdom to develop that the best way to change anything is through yet another target and a bit more money.
But in 2003 Sir Bruce Keogh and the Society of Cardio-Thoracic Surgeons did things differently. They wanted to improve heart surgery survival rates - but instead of recommending a new target, they did something rather brave. They announced that they wanted to publish data showing the basic results of individual surgeons’ coronary surgery operations.
There was huge scepticism and not a little fear.
People worried that surgeons would not take on risky cases.
They worried surgeons might falsify their data.
They worried about misinterpretation of the data.
So Bruce and his colleagues developed a sophisticated risk adjustment metric. The result? We moved to having heart surgery mortality outcomes significantly better than the European average. Why? Because when surgeons were identified as outliers for mortality rates, the data was checked and - if verified - one of two things generally happened: they either improved their outcomes by reviewing their practice from beginning to end. Or they stopped practising certain types of operation or even occasionally ceased all surgery. A dramatic improvement in personal and national performance for patients - and not a target in sight. Just the gentle pressure of peer review.
We need to learn those lessons today.
Truly world class performance only comes with a learning culture built around the natural desire that sits inside every single doctor and nurse to do a better job for patients.
So this week for the first time Professor Steve Field published outcome data for 8,000 GP practices. Patients can see objective information about the safety and quality of their GP practice, alongside its performance on key metrics for cancer, diabetes, dementia and cardio-vascular.
And today when it comes to hospital care I am pleased to announce we are taking that a stage further. Because for the first time anywhere in the world, on one website we are publishing easy-to-access surgery outcome data for adult cardiac surgery, bariatric surgery, colorectal surgery, interventional cardiology, orthopaedic surgery, thyroid and endocrine surgery, urological surgery, vascular surgery, lung cancer and head and neck surgery. And outcome data will soon be on the way for upper GI surgery, neurosurgery and stress incontinence surgery.
Where the surgeons have led, I hope other non-surgical specialties will follow. So I am also delighted that NHS England has said that next year it will publish the one-year and five-year survival rates for individual hospitals for the four most common cancers – lung, breast, bowel and prostate. These four cancers comprise 50% of all cancers.
And not just cancer performance: through transparency the NHS is transforming the performance of entire hospitals, whether on safety, efficiency or quality; it is improving the outcomes achieved by local authorities in public health and social care; and it is reducing the variation in the care offered by residential care homes.
All of which can make a big contribution to a key objective I want us to share across the whole NHS: to reduce and eventually eliminate the 1,000 avoidable deaths we have every month across the country. This is not a challenge unique to the NHS - France, Germany and the United States all report around one in twenty mortalities as preventable.
But healthcare has been slow to develop a safety culture based on openness and transparency that has become normal in the airline, oil and nuclear industries. I want us to blaze a trail across the world as the first major health economy to adopt an objective of zero avoidable harm - and with over 100 NHS Trusts now enrolled in the Sign Up to Safety movement, I believe there is enthusiasm and commitment to do just that.
As part of that transition to a more transparent learning culture, I am delighted today to formally launch a new part of the NHS Choices website that we have been developing over the last few months.
Called MyNHS, it is a world-first where patients and professionals alike can compare the performance of their local hospital, their local GP surgery, their care services and their local authority in an easy-to-understand table with regularly updated information.
How good is the diabetes care at my local surgery? MyNHS will tell you. What do patients say about the food at my local hospital? It’s there on MyNHS. How good is my local council’s smoking cessation programme? Look on MyNHS. How good is my hip surgeon? MyNHS will be your guide.
MyNHS will be the first time any major health economy has gathered such a wide range of critical performance indicators together in a way that will both inform the public and help professionals to improve care by reducing variation. No targets, no sanctions - just information that helps clinicians and managers do what they want to do anyway: improve the safety and care with which they look after NHS patients.
And because this goes to the heart of the new culture we want to see in the NHS, this needs to be reflected in the NHS Constitution. So today I can announce that I will be consulting on including explicit rights for patients and the public to clear and comparable information about the care available to them.
Role of leaders
But there is a request I want to leave you with, which is to understand the vital role you as leaders play in this cultural transformation.
According to research by the Kings Fund, by far the most important influence on culture is leadership. Without you we can never become the patient-centred learning organisation we all want the NHS to be.
A learning culture is a hungry culture, always curious as to new and better ways of doing things.
A learning culture is an open culture, always supportive of those who speak out about the poor care they have seen or even delivered.
And a learning culture starts from the top – if your team sees you as a listening boss, open to new ideas and constantly restless in the search to do things better, they will copy you. And from board to ward your organisations will replace a culture of compliance with a culture of commitment.
Change that comes from the inside is always more powerful – which is why the most effective organisations always have the highest levels of staff engagement: doctors and nurses giving the best care because they want to, not because they are told to. And when it comes to getting hospital chief executives to do what the government wants, a little less Stalin and a little more Gandhi is culture change that even health secretaries can be part of.