Saturday, 16 July 2011

Change in healthcare, and dealing with uncertainty

We’ve been talking about reforming the NHS for a year now. I know that we’ve actually been talking about reforming the NHS for a lot longer than that, but what I mean is that the Lansley agenda has been the topic of conversation now for 12 months. However, for many who work in the health service, it is still the spectre of change that looms, rather than the reality.

We have been kept on our toes, kept in the dark, and kept out of our comfort zones; just as we were beginning to develop a clear sense of what the health service would like after the Lansley Act, we were asked to pause. The pause was a lot like the summer holidays - we entered the vacation with a whole year’s learning under our belts, and managed to forget it all. Since reengaging with the whole topic of health care reform in the last few weeks, I am as confused as I was last July. That does not feel like progress.

The current health bill is a clunky mess. It is not worth building intellectual foundations on what we know so far, as I suspect that we will have to take them down and start again before we have a clear plan to work to. However, this does not mean that we should not have already learned some important themes which we can act on now.

The future of healthcare is tainted by austerity. We have seen how the rate of spending increase cannot continue, and it is widely understood how the pressures of the ageing population, the increasing cost of drugs, technology and patient expectations create a strong driver for efficiency. The concept of efficiency savings creates the impression that we are trying to do less. But we’re not: what we’re actually striving for is technical and allocative efficiency. The latter is something of a hoax- allocative efficiency (the state where is it not possible to increase utility in one place without decreasing it elsewhere - ie everything is as efficient as it could be) is like the 50 year wave or the Yeti: often sighted, but never by anyone you directly know.

Technical efficiency is when a given outcome is achieved at the lowest possible cost. Again, this concept is something of an illusion, but it is a useful goal, and demands that we all ask ourselves the question, ‘How could I have done that better?’ The emerging reality of healthcare is that we cannot do everything we want to do with the money we have. Real and difficult questions will continue to be asked about what healthcare we provide and how. For many people, this will be a new experience, and for a great many it will involve the discomfort of having to work in new ways.

The scope of this new reality has yet to be made real - as I remarked above, the issue of healthcare reform remains largely hypothetical, and not everyone has latched on to the implications yet. Some, however, have, and the contrast is stark.

It is easy to spot the ones who know what healthcare reform means, because these are the people who understand that it doesn’t matter what it is that you actually do, as long as you and the service you provide appear to be indispensible to the people that matter. Services will be judged by outcomes and patient experience, so the service you provide must be the one that delivers something important to patients, in a way that they like. This does not mean that you must drive yourself into the ground every day, but rather it means that your service must adapt to the prevailing circumstances and respond the needs of patients. It has to represent quality, value and patient choice. It has to be the service that patients would choose, and it has to be prepared to change.

I can often see among junior doctors that they have a vision of what their career will look like, and for them, their first consultant job represents their arrival at their destination. They settle in to their new office chair, and look forward to spending the next 30 years making sure that that it moulds perfectly to their backside. They have no intention of moving, and if you need them, you know where to find them. I have also noticed that many of the most influential and inspiring people I have met have travelled in an unusual direction, and their arrival at wherever they end up is not so much a matter of choice and planning, but much more a manifestation of kismet. For them, it is not about the arrival, it is definitely about the journey.

It is this example that we need to learn from over the next ten years. The conclusion that I have drawn is that I have no idea what my career or the health service is going to look like over the next decade, and the challenge is to make sure that my own personal role in the process is challenging and effective. I don’t mind what the NHS looks like in 2020, but I will mind if the patient experience is worse than it is now, and I will mind of the quality of care isn’t better than now.

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