Every year demand for health services – specifically A&E departments – goes up in winter, something that the NHS seems to be unable to plan for. In England, almost 30,000 more people visited A&E than the same week last year, and West Midland Ambulance Service said it was “stretched to the limit” by near-record 999 calls.
The extra health budget provided by chancellor George Osborne in his 2014 Autumn Statement is, in part, a response to this increased pressure. Although demand for services changes, it is difficult for the NHS to have the sort of flexible labour force that private sector companies have developed, such as zero hours contracts. However, this type of labour is increasingly being used for non-NHS employed staff offering healthcare services. But surely, given that we know demand tends to go up in winter, there is something that can be done to mediate this pressure?
Another pressure, and one which is less seasonal, is the changing population demographic, with people living longer and suffering from multiple health problems. Hence patient complexity increases, and with it additional cost – a phenomenon evident globally in all OECD nations, including the US. In the English NHS as many as 65% of admissions to hospitals are from people aged 65 or over, while people aged 85 or over account for 25% of bed days, a number that is rising. Again, this would seem to be something that might be predicted and responded to.
Hospitals asking for help
Indeed, in response to the above, the Nicholson Challenge, set by David Nicholson, the then departing CEO of the NHS in 2009, was a call to transform healthcare delivery to save £20bn. So we might ask how the NHS is instead asking for additional budget?
While it is hospitals asking for additional budget, it is not necessarily hospitals that are the problem. The problem is one that lies at the system level. Nicholson’s challenge was one that required how healthcare is delivered to be transformed, and in rhetorical terms at least, senior managers in healthcare providers and commissioners promised to do do and make significant financial savings.
Yet such transformation relies on care delivered outside hospitals, in primary care settings such as GP surgeries or even extending how people manage their own care. It requires greater emphasis on public health and prevention, self-management of long-term conditions and use of digital technology.
So why hasn’t this happened? Policymakers continually tinker with health and social care structures, with public health in a state of flux. Meanwhile, primary care hasn’t developed sufficient capability and resilience to reduce undesirable A&E attendance (health secretary Jeremy Hunt recently came in for criticism for taking his family straight to A&E rather than waiting for his GP surgery to open).
Having said this, there are pockets of change that have realised the savings required, through reconfiguring services away from hospitals, and encompassing some of the work done by local authorities as happened in Nottinghamshire for example. Perhaps, ultimately what the NHS needs is to learn more widely from such examples, so variation in quality and costs is reduced across local healthcare economies.
“Organisational learning” is much promoted as the best way to spread good practice, but it appears slow to realise, despite a plethora of nationally mandated top-down and locally driven bottom-up initiatives, to drive the changes necessary for the whole system to change.
Cultural change in the different NHS organisations are also promoted by policymakers, but NHS culture is institutionally embedded, as well as incredibly variegated, and so incredibly difficult to shift. More recently, distributed leadership, which extends the influence of leadership to a wider range of professionals, has been another idea put forward. But it similarly encounters institutional barriers such as professional hierarchy or accountability that is focused only towards individuals at the top of organisations.
Business people giving it a go
Yet organisation and management interventions are required. Gerry Robinson, former chair of TV company Granada, successfully made organisational changes, which clinicians, as well as managers, viewed in a positive light, at Rotherham General Hospital in South Yorkshire, for a three-part Open University BBC2 series in 2007 – although businessman John Harvey-Jones admitted defeat when he tried to reconfigure the health system in his Troubleshooter series, first broadcast in 1990.
The analysis of strategic change in healthcare by Andrew Pettigrew, professor of strategy and organisation at Saïd Business School, and colleagues carried out in the 1980s still holds: it’s not the principle of the various organisation and management interventions at fault, but that any intervention needs to be carefully contextualised for the NHS.
Admittedly I work in a business school, so look to the world of business for potential solutions for organisational problems. Notwithstanding what some might regard as my partial perspective, I do believe the NHS needs to be better managed, even more managed, and to make the most of any additional investment needs to look outwards for best practice in organisation and management interventions.