Hugh Alderwick: The ups and downs on the road to health service improvement

hugh_alderwickParallels between the successful transformation of the Veterans Health Administration (VA) in the United States and the changes needed in the NHS in England have been made for a number of years. But recent troubles at the VA offer some important lessons for the NHS in the future, as explored in a roundtable discussion held at the King’s Fund last week.

The story of the transformation of the VA is familiar to many. Once a fragmented and hospital centred public healthcare system, changes made in the late 1990s helped the VA to become an organisation renowned for providing high quality, affordable care.

The VA achieved this transformation by doing a number of things differently. Leaders articulated a strong vision for change from the top of the organisation, a new organisational structure was developed based on regionally integrated networks (each accountable for delivering care for a defined population within a capitated budget), and clear performance measures were agreed for networks to deliver (the “what”) combined with local flexibility in delivering them (the “how”). Power was also devolved to local leaders to manage the delivery of care. You can read more about the VA’s transformation in this King’s Fund report, Reforming the NHS from within.

These changes resulted in improved outcomes for patients and more care delivered out of hospitals. Among other improvements, the system achieved a 50% reduction in hospital bed days through redesigning and integrating local services.

These were the ups, but more recently there have been downs. As demand for VA services has increased—with increasing numbers of both ageing veterans and those returning from wars in Iraq and Afghanistan—and systemic management problems have emerged, the VA has had difficulties with long waiting times and uneven quality of care. It was also revealed that staff had falsified data to cover up these problems.

So what can we learn from these recent troubles at the VA? Three lessons are particularly important for the NHS today.

First is the need to be tight on the “what” but loose on the “how.” Combining clear national goals with local flexibility in delivering them was a key part of the VA’s transformation in the 1990s. But, over time, the VA has become tighter on the “how,” with much more top-down control in the day to day delivery of care. Making sure the NHS maintains a balance between tight and loose is crucial to create an environment for local innovation, and accountability for system outcomes.

Second is the need for performance management systems that focus on the right things. As the “how” became tighter at the VA, the “what” became more complicated. The number of quality measures used at the VA grew too big, and the performance metrics too complex. The result was a burdensome reporting system that people manipulated, and a lack of clarity about the outcomes that really matter. The NHS needs to make sure that performance management is focused and coherent, rather than costly and confusing—supporting transformation of care rather than being too transactional.

Last is the need for effective leadership at all levels of the system, with leaders who have the right skills to drive improvements in care. While the VA is currently struggling to strike the right balance between top-down and bottom-up approaches to managing change, much of the VA’s success over the past two decades has been based on equipping local leaders and clinicians with the skills and capabilities to drive service improvements within their own organisations. NHS organisations need to develop similar approaches to improvement from within, rather than relying too heavily on top-down approaches and external stimuli for change. This should include a focus on developing leaders, succession planning, and managing talent right across the system— none of which currently receive enough attention in the NHS.

Above all, the experiences of the VA tell us that the road to improvement isn’t smooth. Lessons for the NHS as it navigates this road can be learnt from the recent bumps in the VA’s.

Hugh Alderwick is senior policy assistant to the King’s Fund CEO, Chris Ham, and integrated care programme manager. Before he joined the Fund, Hugh worked as a consultant within PricewaterhouseCooper’s health team. Hugh was also seconded from PwC to work on Sir John Oldham’s Independent Commission on whole person care, which reported to the Labour party at the beginning of 2014. 

Competing interests: The author has no further interests to declare.

This blog first appeared on the King’s Fund website.