10 Apr, 12 | by BMJ
Over the last few weeks my reading and listening has made me consider whether we are at a crossroads in understanding and agreeing the purpose and nature of healthcare. Let me start with this quote from the evaluation of the 16 integrated care pilots that were supported by the Department of Health:
“Over the past 50 years healthcare systems have been focusing on strengthening acute care sectors to respond to the needs of patients suffering from life-threatening conditions such as heart attacks. Thus, healthcare systems may not be well equipped to respond to the needs of increasingly older patients suffering from multiple chronic conditions and who require a combination of regular primary care support with both predictable and unpredictable specialist care. The goals of care for those with chronic and/or disabling conditions are not to cure (as is the case for acute conditions), but to enhance functional status, minimise distressing symptoms, and prolong and enhance quality of life through secondary prevention. It is clear that these goals are less likely to be achieved through traditional approaches to care that focus on individual diseases and are based on a relationship between an individual health/social care service-user and a single health/social care professional.”
It appears to me that we continue to labour to try and make a system work, for which the context has so fundamentally changed that it is destined to fail. It feels as if a truly radical approach is required. This feeling was reinforced as I read a paper calling for a revolution in social and professional attitudes and beliefs about health and social care. Perhaps what is needed is to stop trying to make the old system fit the new paradigm. Instead we should articulate the need for a change in social attitudes, change the training and ways of working of health professionals and create a policy framework that supports transformation and accelerates innovation across the system.
The difficulty of such an approach cannot be underestimated. It came as a shock when I first read (some time ago), in Crossing the Quality Chasm, that “Scientific knowledge about best care is not applied systematically or expeditiously to clinical practice. It now takes an average of 17 years for new knowledge generated by randomised controlled trials to be incorporated into practice, and even then application is highly uneven.” The publication of a report setting out how the NHS could set about accelerating the adoption of innovation and best practice is welcome but may get shoved aside and ignored in the tumult of reform. That would be more than unfortunate, as focussing on the how is something to which we must surely give greater emphasis.
Given the importance of “how,” the evaluation of the 16 integrated care pilots is a fascinating and well written report which carries a number of significant messages, the most important of which is, “it was too early to identify impact within the timescales of the pilots.” Having been involved in a number of large scale change management initiatives over the last twenty years I recognise that two years is just about enough time to “warm up.” Large scale change takes time, continuity of care, and resilience. Most of all it needs flexibility and adaptability. This last point was highlighted in one of the eclectic range of podcasts I get to listen to as I travel across Lincolnshire and beyond, to meetings. This one discussed the problems associated with the National Programme for IT (NPfIT). A large scale, top down, highly prescribed programme of change in a complex context is fraught with risk. The lessons from what happened to the NPfIT need to be used to avoid more of the same.
Sitting in what used to be the Professional Executive Meeting—but is now a meeting of seven organisations—the four Clinical Commissioning Groups, Local Authority Public Health, Commissioning Support Services, and the remnants of the PCT Cluster—I ruminated on what lay ahead. I hope that the principles, being driven by the reforms, of creating accountability for use of resources across Primary Care and a drastic culling of management costs will help deliver what is needed. It is a big ask and large scale change needs not only time, continuity of care and resilience but, right now, it needs a large dollop of optimism!
Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.