NHS Reform: Much Ado About Restructuring
eyeforpharma interviews Dr. James Kingsland, OBE on reforming the NHS to be more patient-centric, and taking the politics out of public services.
“The focus of the white paper from July 2010 was to create patient-centered, clinically-lead NHS, which means we would be aligning clinical decisions with the financial consequences of those decisions. But one of the concerns that some of the people have at the moment is whether we have done a massive amount of restructuring but not a lot of reformation of care,” said Dr. James Kingsland, OBE.
“[The government] talks reform, but what they actually do is restructure organizations. If you asked the general public what are the significant changes they found in the health service since this government has been in power, very few would have any knowledge of this massive restructuring, most would still complain about waiting times, access, some quality of service, and I don't think we've focused well on that over the last three years.”
Keys to reform
We've got lots of data, but we don’t turn that into information.
To reform the NHS would mean taking politics out of the public service, and then, Kingsland argues, making a change in three key areas: culture and behaviors, available information, and leadership. “We rarely change culture. We've changed it for the management-dominated to trying to be clinically-orientated service but we haven’t changed behavior in day-to-day practice.”
Reforming would mean allowing clinicians to make daily decisions with their patients in each consultation about how to best use the NHS resources, e.g. is this the right time for a referral? should medication be prescribed at this point? should a diagnostic test be ordered? Patients need to be offered better information about what’s available, including care, and self-care, as only that way they can make better decisions about how to use the NHS.
Furthermore, a successful reform is dependent on turning data into information. “We're very data-rich in the NHS, but information-poor. We've got lots of data, but we don’t turn that into information,” Kingsland explained, stressing that cost data and activity data can’t, on their own, inform care pathways, and they need to be put in context to be useful.
Moreover, Kingsland argues, shifting budgetary responsibility is a cornerstone of every reform. “The general practitioner with a budget is worth 10 on the general committee, but what we still do is get clinicians to sit down at board tables, talking about how services or new care pathways should be developed. You make them accountable for [the budget] and you get very rapid changes.”
Finally, there’s the need for excellence in leadership, which, Kingsland notices, is very different from management. “Leadership is not just about a person in a position at an organization, it's about a style of practice. We don’t get leadership right, we just say that we need a leader, we create a new organization, we put a physician in charge instead of a manager thinking that it will all be all right, but it isn't.”
NHS becomes patient-centric
In a patient-centric environment, patients need to be given a choice.
“Could you have a more damning headline of what has happened in the past? It’s almost like saying we need to create a health service focused on patient care. What on Earth were you doing beforehand with a service to have to say we have to make it patient-centered? That headline almost describes a huge failure of the previous system if we have to say let's make a service patient-centric,” Kingsland said.
In a patient-centric environment, patients need to be given a choice. People with choice are better informed, they make better decisions, and overall, choice leads to a fairer service. Patients should be offered information about care so that they and their physicians can make better decisions about the patients’ lifestyle, or the quality of care, the care they need and the service they choose.
“In patient-centric NHS, it was always about the self-care agenda and the ability to be more reactive to patient needs when that need required a health service. But sometimes the need cannot be attended to through the clinical service,” Kingsland pointed out. Health promotion and prevention need to be an integral part of the NHS patient-centric agenda, he continued, and patients whose needs cannot be attended to through a medical model should demand more from the service.
Pay as you deliver
Payment on results is an old idea first introduced in the 1990s along with the national tariff, which meant that the cost of a given service was the same across the country, despite potential differences in quality. For example, having your hip replaced in Cornwall might have once been cheaper than having the procedure done in Norwich, but with the creation of the national tariff the differences were eliminated. With a tariff in place, to make a decision about their care, patients need information about the quality of service, i.e. how long it takes to replace the hip, what is the risk of getting a hospital-acquired infection, or getting readmitted with a post-operative complication. Under payment by results model, the cost of the surgery is only covered when those indicators are low.
“Paying on outcome sounds entirely reasonable, but we’re as far from this type of contracting now as we were when the idea first popped up.”
Pharma’s place
According to Kingsland, the NHS reform is a great opportunity for pharma, as long as they know who their customer is, and what that customer expects. “My interaction with the pharma company is talking to their rep who talks about a product, which is a drug, as opposed to the brand in a care pathway down which the product might feature. The true benefits to the practice, or the group of practices, is collecting the evidence, designing pathways, doing audits. The industry has a great strength in all of those areas, but instead of using it, they remain product-focused.”
When pharma introduce a new drug, e.g. for diabetes, Kingsland proposes, instead of talking about the individual product, they should talk about the entire care pathway, i.e. how the drug would change the management of a particular group of patients over a year. They should show how that year of care would account for the total utilization of resources, including the drug cost, what value it would bring to the system. Pharma should also offer to provide audits at the practice level, e.g. by looking at how diabetes management is done at present, and then helping build practice-based service that improves patient outcomes. “If they offered that, I would say: wow, let’s do it!”