Scotland’s independent think tank
Scotland’s independent think tank

Less debate, more action – how to accelerate NHS reform – Paul Gray

A couple of days ago I posted a tweet thanking a doctor for showing kindness to my mother-in-law, who is very ill in hospital. Within less than 48 hours, it had been liked over 3,000 times.

Whatever else the future holds for health and care services, it is very clear that people value the core of kindness that runs through these services like lettering in a stick of rock. Whatever blemishes and imperfections we seek to address through future reforms, we must never be so focused on process and numbers that we squeeze out the essence of care.

Care does not happen in a vacuum and kindness is not shown by machines. So as we think about the bold changes which need to be made in order to have health and care services that deal with today’s pressures while transforming to meet the needs of tomorrow, we must not forget that care is provided by people. In speaking about workforce, let us remember that the workforce is not an amorphous mass of interchangeable ciphers. It is composed of real people with real lives, real skills, real aspirations, real hopes and fears, and real pressures. It is multifaceted, complex, and not all visible, and by no means all paid or recognised for the care it provides. 

One of the answers to some of the workforce pressures is to say that we need more – more of something, or more of everything. There is of course scope to rebalance between or among professions, but there are no doctors on shelves, carers in cupboards, social workers in holding areas, or nurses in warehouses, all waiting to be called. A wife caring for her husband does not have a spare to call on when she is exhausted. The third sector is not a bottomless pit of resources that can be picked up and laid down at will. The answer may lie in increased numbers in some areas; but it may equally lie in different and more flexible configurations of what we already have; and it certainly lies in cutting out duplication and rework, and passing people from one service to another without making joins.

Would it really need to take very long to describe the kind of multidisciplinary teams that would respond variously to the recommendations of The Promise, the Review of Adult Health and Social Care, the compelling need to deal with the backlog of waiting times, and the demography and health status of Scotland in the longer term? Would it make sense to start where we are, and do what we can, rather than having a competition where the loudest voice will probably win?

Two potentially contentious points. One, we need to abandon all hope of a better past; we should learn from the past but we cannot change it. And two, particularly in positions of leadership, the future is determined by the choices you make and the actions you take, not by what you ask for, or what you say you will do.

Two points also occur about the interaction between workforce pressures, and technology. First, how much time would it save if information about a person was available wherever they went, for access by professionals with a legitimate reason to see it? Might that be achieved by giving individuals access to their own health and care records, with appropriate safeguards? And second, the vastly accelerated roll-out of NHS Near Me, giving access to video consultations in response to the restrictions imposed by Covid, has shown that technology can benefit both staff and citizens – what other similar innovations are waiting in the wings, that could make a real difference? For any sake, let’s not go back to the attenuated processes of the past for that sort of thing. Time is too short, and resources too precious, and patient care too important to be sacrificed on the altar of multi-layered decision making.

I wrote a few months ago for Reform Scotland (link) about things that I learned and things that I got wrong while I was chief executive of NHS Scotland. One of the things I learned was that in health and care services there is too much interorganisational and interprofessional protectionism – too many silos. Some of it is learned behaviour, some of it results from accidents of history; it is rarely wilful, and often subconscious. I took some steps to correct this but in retrospect I did not do nearly enough. The language of person-centred services already exists (although it remains possible to spend half an hour debating whether a person, a citizen, a client and a patient are the same thing).

The fundamental shift that would make a real difference would be to move from the language of putting people at the centre, to implementing processes which actually achieve that. This will not involve waiting for new discoveries, or the invention of a hitherto unknown process – it requires a determined commitment to finding the people and organisations that already do this well, and a willingness to learn from them, and to spread that knowledge widely and fast. In many instances, this will involve accepting that the third sector has something to teach the public sector; in other instances it will involve accepting that you can learn from what works in another area. I also counsel against assuming that the public sector cannot learn from the best in the private sector when it comes to customer service; this is by no means a suggestion that services need expensive consultancy to tell them what to do – I am certain that there are plenty of organisations who would be delighted to share their learning as part of their contribution to corporate social responsibility.

Then comes the hard bit – if your organisational design, systems or processes, or your professional boundaries, are favouring the provider rather than the person or community we are here to serve, will you make the changes that are necessary to remove the barriers? The alternative is for everyone to insist that they are unique, and that their unique geography, demography, social context, funding situation and history mean that they can find no way to adopt something that works elsewhere. That leads only to an ever-increasing range of unique ways to remain provider-centric.

None of this says that every service needs to be designed in the same way. Inner cities are not best served by approaches that work well in remote and rural areas. Children are not small adults – they need different approaches to care and treatment. Complex, specialist procedures offer better outcomes when they are delivered from centres of expertise rather than distributed across a wide range of locations where they are performed infrequently.

But if the basic principle that services are organised and delivered in ways which are responsive to the needs of people and communities drives decision making, the form will follow the function. Structural change is not the starting point: if it is required it should be implemented in response to evidence of population needs, in pursuit of better outcomes, and with genuinely transparent public involvement. Because whatever the NHS may feel like from the inside, from the outside it can look and feel immense, pervasive, and monolithic. At times, trying to get it to listen can feel like shouting at the Sphinx, and trying to get it to move feels about as productive as trying to tow Greenland.

Yet inside that colossus, skill, wisdom, care, insight, and compassion are in abundance. Daily, individuals go above and beyond the call of duty. They perform procedures of incredibly delicacy; they care unstintingly for the dying; they comfort the bereaved; they balance risk; they make judgements that are truly life and death. We speak about the doctors and the nurses, but what of the porters, the receptionists, the healthcare support workers, the cooks, the volunteers, the ward clerks, the scientists, the administrators, the pharmacists, the chaplains – and many more – who make the NHS the well-loved institution that it is? They have shown beyond all doubt over the last year or so that they are ready and able to be part of what it could be. They have shown flexibility, willingness to adapt, and a strong commitment to professional care. Their voices matter as we think about what should come next.

There are some difficult things we could consider. At the moment many people are waiting for investigations and procedures which have been delayed because of a focus on coronavirus. These waiting lists will need to be tackled over an extended period. What might we do differently in order to achieve this? Should we think about whether some of the targets that currently exist should remain?

In that context, would there be scope to review the 12-week treatment time guarantee (TTG)? The NHS already stratifies some treatments by clinically assessed need. There are 31- and 62-day targets for cancer diagnosis and treatment, for example. I suggest that these should remain, but that the opportunity be taken to review whether other conditions should be similarly stratified. As we emerge from the pandemic, it will be important that the waiting lists are tackled in a clinically justifiable order, based on a clearly expressed recovery plan which is neither defined nor hindered by territorial boundaries, and I suggest in that context that it would be prudent to take the opportunity to review the TTG.

In making changes, let us not forget what we know. We know that if people are cared for at home, or in a homely setting, they generally have better outcomes. We know that if the Emergency Department of a hospital is over-crowded and the target of seeing and treating 95% of people within 4 hours is regularly breached, that suggests pressure in other parts of the system too, and outcomes are likely to be worse. So, let us not treat every target as something to be endlessly reviewed.

In conclusion then, I suggest a simple framework for testing recovery plans and decisions about change. Such plans are essential and I detect little or no resistance to the proposition that change is needed; there is no time to lose. But testing proposed changes against these questions could help to take the discussion forward to solutions that can be implemented, rather than generating debate among particular interest groups for its own sake.

  • Does the public understand what you are doing and why?
  • Do the people providing this service understand what is proposed and why?
  • What evidence are you using to justify the change you want to make?
  • How does your proposal improve access to services, the quality of the service provided or the sustainability of the service overall?
  • Does your proposal have an impact on the access, quality or sustainability of another service? (In other words, are you making improvements at someone else’s expense?)
  • How will you measure the success of the changes you propose?

Professor Paul Gray was chief executive of NHS Scotland, 2013-19