The NHS must change or die

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Ministers and managers keep telling us the NHS is serious about innovation. Take this from David Nicholson, chief executive of the NHS in England, in his 2011 report Innovation, Health and Wealth. “Simply doing more of what we have always done is no longer an option. We need to do things differently. We need to radically transform the way we deliver services. Innovation is the way—the only way—we can meet these challenges. Innovation must become core business for the NHS.”⇑

Amen to that. The only change I would make would be to unsplit the infinitive, but that’s mere pedantry. But despite the torrent of words expended on the issue, in Nicholson’s report and elsewhere, I still wonder whether the NHS really gets it. The solutions advanced are many and various, but few mention the unpalatable fact that in life outside the NHS innovation is often driven by failure. Organisations that do not win market share or make the best use of their capital go to the wall. Their assets are taken over by others who either make better use of them, or fail in their turn.

When he called for evidence and ideas about how to adopt and diffuse innovation across the NHS, Nicholson got 301 responses. Just one mentioned the need for an explicit failure process that allows the NHS to fail fast and become better at decommissioning and disinvestment. The commonest response, mentioned by more than half of respondents, was for better horizontal knowledge exchange, so that successful innovations can spread. But this has already been tried, and tried, and tried again. What else are the NHS National Innovation Centre, the NHS Institute for Innovation and Improvement, the NHS Innovation Hubs, the NHS Technology Adoption Centre, and the Innovative Technology Adoption Procurement Programme supposed to be doing? Honestly, they all exist.

They lie on top of one another like geological layers rich in the fossils of extinct initiatives to tackle this long-standing problem. Nicholson has promised a “sunset review” of all these bodies—to declutter the landscape, as his report puts it—but in truth the sun set on most of them long ago. No disrespect to those who have done their best to make them work, but they might have been better employed elsewhere.

Not lined up for the chop, of course, is QIPP, the Quality, Innovation, Productivity and Prevention programme that is charged with meeting the Nicholson challenge of saving £20bn (€24.8bn; $31.2bn) in the NHS in England over four years. Most of the savings made so far by QIPP have nothing to do with any of the four words that make up its acronym, unless you count the freeze on public sector pay as a contribution to increasing productivity. So far, the savings have exemplified the normal NHS response to tightened budgets: do less, delay or deny treatments, freeze pay. As a short term strategy, it has worked well. But it doesn’t begin to meet the long term challenge.

One reason for this is the natural instinct to circle the wagons when threats appear. Far from using the pressure on budgets as a reason for welcoming cost cutting ideas from outside, as a commercial enterprise might, NHS managers do the opposite. Companies that supply products to the NHS—even products whose adoption would cut costs—have seen their markets shrink. Discretionary spending is the first to go. New technology does not drive out old, as Paul Corrigan, a health adviser to Tony Blair, told a recent Reform conference on innovation in the NHS.

There are, of course, some examples of innovation in individual NHS organisations, and the same conference heard from Aintree University Hospitals NHS Foundation Trust, which has replaced paper patient records with an electronic version. Aintree’s chief executive, Catherine Beardshaw, said that a £1.4m a year saving was being achieved. What she did not emphasise quite so strongly is that the saving came from making redundant 70 staff who previously managed the paper records.

But in an organisation where salaries account for such a large proportion of costs (between 60% and 70% in hospitals), gains in efficiency will come only from a smaller workforce. Tough as it is on those made redundant, a QIPP programme that was really working would be evidenced by falling hospital staff numbers and rising bed closures. Only in that way can the money be made available to commission the out of hospital care that is seen as the major hope of controlling costs in the long term.

Far from boasting about job losses, however, the government does its best to pretend there aren’t any. In fact, there are a few. In 2010-11, overall staff numbers in the NHS in England fell by 14 900 (1.3%), the largest fall in a decade. And the King’s Fund’s most recent quarterly monitoring report found that more than half the finance directors surveyed were planning further reductions. But these lost jobs are mostly those of managers released by the government’s plans to cut management costs by 45%. Cuts in hospital clinical and nursing staff will be needed, too, if QIPP is to succeed. But there is little sign of that.

And even successes such as Aintree’s tend to be isolated, as unrepresentative as the Potemkin villages prettied up by the Soviet regime to impress foreign visitors. Jim Easton, the NHS national director of improvement and efficiency, told the 20-22 June NHS Confederation conference of his conversations with managers who have led successful and well publicised local change programmes and were surprised that none of their peers had been in touch to learn from their experiences. The lack of curiosity was “pathetic,” he said.

Nicholson asserts, correctly, that business as usual cannot deliver the results. It’s a pity, then, that the approach being taken to improve innovation in the NHS in England smacks so strongly of business as usual.