BMJ 2015;350:h1172 doi: 10.1136/bmj.h1172 (Published 3 March 2015)
Page 1 of 3
Feature
FEATURE BMJ ROUND TABLE
What hopes for the NHS: the election and beyond? With the UK general election looming, a panel of experts gathered at a The BMJ roundtable discussion held during the Nuffield Trust 2015 health policy summit to discuss the future of the NHS. Gareth Iacobucci reports Gareth Iacobucci news reporter The BMJ, London, UK
If you could change one thing in the NHS, what would it be? That was the question with which The BMJ’s editor in chief, Fiona Godlee, chairing the session, began discussions.
Richard Jones, clinical director at Wessex Cardiovascular Strategic Clinical Network, kicked off by saying he would increase the focus on quality improvement and eliminating waste. The NHS should be “involving everybody in a quality improvement project within their workplace and giving them the support and methods to do that,” he said.
This view was echoed by Suzie Bailey, development director at health sector regulator Monitor.
“We need to be able to teach everybody who works in the health service the basics of quality improvement,” said Bailey, who added that patients should be directly involved in improving care in a more systematic way. Jonathan Michael, chief executive of Oxford University Hospitals NHS Trust, said additional funding was of upmost importance: “The one thing that I would like to see for the NHS after the election is actually more money because many of the things we need to do that we’ve been talking about [at the Summit] are going to need investment. The balance between relentless pursuit of quality but continued increase in demand and money is inescapable.”
Nuffield Trust chief executive, Nigel Edwards, agreed that fiscal pressure was the biggest issue.
“Even with the money that’s signalled in [NHS England’s] Five Year Forward View, the amount of money per person in age adjusted terms is flat. And . . . that’s not very realistic, I think, given the rising expectations and a variety of new drugs and therapies that will be coming on the market. Steve Field, the Care Quality Commission’s chief inspector of general practice, said his priority would be improving the quality of data collection: “The quality of data we collect and use is poor in general medical practice. If we could improve what we
collect and then use it across the whole of England, I think we could have a much better health and social care system.”
A partnership approach between clinicians and patients was the single biggest change cited by Jeremy Taylor, the chief executive of National Voices, a national alliance of health and care charities in England. Massoud Fouladi, the chief medical officer at Circle Health, said his wish would be to promote clinical leadership in the NHS and make leaders “feel good about themselves.”
Rebecca Rosen, senior fellow in health policy at the Nuffield Trust, said she would enable GPs to focus more on continuity of care by equipping practice staff with a broader range of skills. Rounding off, Jennifer Dixon, the chief executive of the Health Foundation, listed several changes she would make, including additional funds and no more structural reorganisation.
Removing politics from the NHS?
Godlee asked the participants whether it was possible to ever truly remove politics from the NHS—and would we even want to?
Edwards said that he felt this election may matter less than previous ones because all parties would face the same challenges if elected. “However the government forms—we’ll face a very similar set of choices, and there’s not very much wriggle room for a new secretary of state. And the fact that the Five Year Forward View has sort of pinned down the politics of this means that actually the NHS has got, probably for the first time, the lead in driving reform,” he said. But Edwards added, “If you’re spending over £100bn, it’s almost impossible to leave the politicians out because they raise the money, they vote the money, they make the arguments to the public to spend it.” Dixon agreed that politics “will always be there,” but she hoped the cautionary tale of Andrew Lansley’s reforms during the last
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BMJ 2015;350:h1172 doi: 10.1136/bmj.h1172 (Published 3 March 2015)
Page 2 of 3
FEATURE
parliament would make politicians more cautious about imposing top down change.
“I’m just hoping that they have accepted the message that I think Andrew Lansley probably taught them—that if you have another big administration defining attempt, that [the instability caused by the Health and Social Care Act] is what happens. And we’ve seen the result, both for Andrew Lansley and for the system.” Taylor said that although health was “inescapably political,” the recent launch of NHS England’s five year plan could be a turning point.
“The Five Year Forward View is a useful vehicle for creating a degree of cross-party consensus or to articulate where that consensus actually exists and to try to help politicians distance themselves from the micromanagement and mechanics of healthcare reform,” he said.
Fouladi concurred that it was impossible to extricate politics from the NHS but said the most important thing was that whichever party wins in May offers stability to the frontline to allow necessary service transformation to take place.
“They need stability, and they need clarity of the goals. Whether you’re a manager or a doctor or a nurse, you need to have that. [It] doesn’t matter who comes to power.”
Culture of blame Jones thought the tone of the political discourse was important because it was crucial doctors were not working in a service that was infused with a “culture of fear and blame.” Rosen expanded on Jones’s point, “I’d like to see the whole nature of the political debate change . . . it feels at the moment as if there is a kind of bias towards politicians and the public bashing the profession. I think that this is partly what is driving so much early retirement in general practice—on top of all the pressure.”
She added, “I don’t think it’s helpful, and if the money is not going to be available to invest to the kinds of levels that people would like to see as they’ve expressed here, then we need honest debate about what one can expect.” Godlee asked Bailey and Field, as representatives of regulatory organisations, to respond to the issues raised about public expectations and pressure on doctors.
Bailey agreed that a debate about the scope of what GPs can offer to patients was “long overdue” among government, staff, and patients. Field said it was right that the CQC’s inspection regime was shining a light on poor care as well as highlighting examples of good practice to patients.
“The work we’re doing now is highlighting that there are generally excellent GP surgeries across the country, but there are a small number which have been there for many years providing appalling care,” he said.
Five Year Forward View Godlee asked participants how they thought the next five years would pan out for the NHS.
Michael returned to Rosen’s point about the need for a more honest discussion about what the health service can afford, “Is it going to come from general taxation, or are we going to look at other options in terms of funding,” he said. “At the moment I think it [the debate] is being ducked.”
Bailey praised the flexibility of the Five Year Forward View but thought it lacked detail about the nation’s level of ambition in terms of public health.
Jones said that clinicians were “brimming with ideas” on how to create the new models of care espoused by the forward view but needed headroom and support to translate ideas into reality. Taylor praised the “hope, direction, and enthusiasm” that the vision had given to the NHS but expressed some concern about how it may be interpreted. “‘New models of care’ to me is a slightly double edged thing because it could become a new reorganisation, whereas what we really want is a relentless focus on improved quality and engagement of patients,” he warned.
Edwards said it would be challenging to accelerate some of the proposed changes, such as integrated working between hospitals and GPs, because of the logistics and pressures of the day jobs. “I think there’s an unanswered question about where the space to do that is,” he said.
Manchester’s integration of health and social care Godlee rounded off the session by asking participants about the plan in Greater Manchester for local government to hold fully integrated health and social care budgets. Specifically, she asked whether this signalled a move away from GP led commissioning. Taylor said the debate about which organisations should commission services was redundant. “The issue is; are they going to lead to better quality care?” he said.
But Field was concerned that the clinical engagement among GPs that had been fostered in CCGs may fall by the wayside if their role is diluted.
“There are lots of GPs who have been more engaged since commissioning came in, and it would be very sad if any changes that came in after the election moved GPs just to be in a sort of advisory role. We’ve had that before, and what you’ll find is that the GPs will go back to provision and won’t be actively engaged in design,” he said. Edwards said Manchester was an interesting experiment that could offer pointers on whether integration on this scale was replicable elsewhere. But he said the acid test would come when difficult decisions about reconfiguring services have to be made in the future. “The real question is when difficult decisions start to be made and they say, ‘OK, we’re going to downgrade Tameside or Oldham or whichever of the various Manchester hospitals need to change,’ how well that holds together.
“I think there’s an open question about whether they [the different local authorities] can hold that all together. If they can it looks very promising. But it will leave some very difficult questions about accountability, and at what point does an elective mayor stand up to secretaries of state and say shall we have different priorities to you?” Listen to Bastiaan Bloem, consultant neurologist at Radboud University Nijmegen Medical Centre, Netherlands, discussing his revolutionary approach to patient centred care and Ashish Jha, professor of health policy and management at Harvard School of Public Health, talking about how the Affordable Care Act has fostered new models of integrated service delivery in the United States at thebmj.com/podcasts. Cite this as: BMJ 2015;350:h1172 © BMJ Publishing Group Ltd 2015
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1172 doi: 10.1136/bmj.h1172 (Published 3 March 2015)
Page 3 of 3
FEATURE
Roundtable participants Nigel Edwards, chief executive of the Nuffield Trust Richard Jones, cardiologist in Portsmouth and clinical director at Wessex Cardiovascular Strateic Clinical Network Jeremy Taylor, chief executive of National Voices, a national alliance of health and care charities in England Steve Field, chief inspector of general practice at Care Quality Commission, GP in Birmingham Suzie Bailey, development director at Monitor Rebecca Rosen, senior fellow in health policy at the Nuffield Trust, GP in south east London Jennifer Dixon, chief executive of the Health Foundation Jonathan Michael, chief executive, Oxford University Hospitals NHS Trust Massoud Fouladi, chief medical officer at Circle Health
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 3
Feature
FEATURE BMJ ROUND TABLE
What hopes for the NHS: the election and beyond? With the UK general election looming, a panel of experts gathered at a The BMJ roundtable discussion held during the Nuffield Trust 2015 health policy summit to discuss the future of the NHS. Gareth Iacobucci reports Gareth Iacobucci news reporter The BMJ, London, UK
If you could change one thing in the NHS, what would it be? That was the question with which The BMJ’s editor in chief, Fiona Godlee, chairing the session, began discussions.
Richard Jones, clinical director at Wessex Cardiovascular Strategic Clinical Network, kicked off by saying he would increase the focus on quality improvement and eliminating waste. The NHS should be “involving everybody in a quality improvement project within their workplace and giving them the support and methods to do that,” he said.
This view was echoed by Suzie Bailey, development director at health sector regulator Monitor.
“We need to be able to teach everybody who works in the health service the basics of quality improvement,” said Bailey, who added that patients should be directly involved in improving care in a more systematic way. Jonathan Michael, chief executive of Oxford University Hospitals NHS Trust, said additional funding was of upmost importance: “The one thing that I would like to see for the NHS after the election is actually more money because many of the things we need to do that we’ve been talking about [at the Summit] are going to need investment. The balance between relentless pursuit of quality but continued increase in demand and money is inescapable.”
Nuffield Trust chief executive, Nigel Edwards, agreed that fiscal pressure was the biggest issue.
“Even with the money that’s signalled in [NHS England’s] Five Year Forward View, the amount of money per person in age adjusted terms is flat. And . . . that’s not very realistic, I think, given the rising expectations and a variety of new drugs and therapies that will be coming on the market. Steve Field, the Care Quality Commission’s chief inspector of general practice, said his priority would be improving the quality of data collection: “The quality of data we collect and use is poor in general medical practice. If we could improve what we
collect and then use it across the whole of England, I think we could have a much better health and social care system.”
A partnership approach between clinicians and patients was the single biggest change cited by Jeremy Taylor, the chief executive of National Voices, a national alliance of health and care charities in England. Massoud Fouladi, the chief medical officer at Circle Health, said his wish would be to promote clinical leadership in the NHS and make leaders “feel good about themselves.”
Rebecca Rosen, senior fellow in health policy at the Nuffield Trust, said she would enable GPs to focus more on continuity of care by equipping practice staff with a broader range of skills. Rounding off, Jennifer Dixon, the chief executive of the Health Foundation, listed several changes she would make, including additional funds and no more structural reorganisation.
Removing politics from the NHS?
Godlee asked the participants whether it was possible to ever truly remove politics from the NHS—and would we even want to?
Edwards said that he felt this election may matter less than previous ones because all parties would face the same challenges if elected. “However the government forms—we’ll face a very similar set of choices, and there’s not very much wriggle room for a new secretary of state. And the fact that the Five Year Forward View has sort of pinned down the politics of this means that actually the NHS has got, probably for the first time, the lead in driving reform,” he said. But Edwards added, “If you’re spending over £100bn, it’s almost impossible to leave the politicians out because they raise the money, they vote the money, they make the arguments to the public to spend it.” Dixon agreed that politics “will always be there,” but she hoped the cautionary tale of Andrew Lansley’s reforms during the last
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1172 doi: 10.1136/bmj.h1172 (Published 3 March 2015)
Page 2 of 3
FEATURE
parliament would make politicians more cautious about imposing top down change.
“I’m just hoping that they have accepted the message that I think Andrew Lansley probably taught them—that if you have another big administration defining attempt, that [the instability caused by the Health and Social Care Act] is what happens. And we’ve seen the result, both for Andrew Lansley and for the system.” Taylor said that although health was “inescapably political,” the recent launch of NHS England’s five year plan could be a turning point.
“The Five Year Forward View is a useful vehicle for creating a degree of cross-party consensus or to articulate where that consensus actually exists and to try to help politicians distance themselves from the micromanagement and mechanics of healthcare reform,” he said.
Fouladi concurred that it was impossible to extricate politics from the NHS but said the most important thing was that whichever party wins in May offers stability to the frontline to allow necessary service transformation to take place.
“They need stability, and they need clarity of the goals. Whether you’re a manager or a doctor or a nurse, you need to have that. [It] doesn’t matter who comes to power.”
Culture of blame Jones thought the tone of the political discourse was important because it was crucial doctors were not working in a service that was infused with a “culture of fear and blame.” Rosen expanded on Jones’s point, “I’d like to see the whole nature of the political debate change . . . it feels at the moment as if there is a kind of bias towards politicians and the public bashing the profession. I think that this is partly what is driving so much early retirement in general practice—on top of all the pressure.”
She added, “I don’t think it’s helpful, and if the money is not going to be available to invest to the kinds of levels that people would like to see as they’ve expressed here, then we need honest debate about what one can expect.” Godlee asked Bailey and Field, as representatives of regulatory organisations, to respond to the issues raised about public expectations and pressure on doctors.
Bailey agreed that a debate about the scope of what GPs can offer to patients was “long overdue” among government, staff, and patients. Field said it was right that the CQC’s inspection regime was shining a light on poor care as well as highlighting examples of good practice to patients.
“The work we’re doing now is highlighting that there are generally excellent GP surgeries across the country, but there are a small number which have been there for many years providing appalling care,” he said.
Five Year Forward View Godlee asked participants how they thought the next five years would pan out for the NHS.
Michael returned to Rosen’s point about the need for a more honest discussion about what the health service can afford, “Is it going to come from general taxation, or are we going to look at other options in terms of funding,” he said. “At the moment I think it [the debate] is being ducked.”
Bailey praised the flexibility of the Five Year Forward View but thought it lacked detail about the nation’s level of ambition in terms of public health.
Jones said that clinicians were “brimming with ideas” on how to create the new models of care espoused by the forward view but needed headroom and support to translate ideas into reality. Taylor praised the “hope, direction, and enthusiasm” that the vision had given to the NHS but expressed some concern about how it may be interpreted. “‘New models of care’ to me is a slightly double edged thing because it could become a new reorganisation, whereas what we really want is a relentless focus on improved quality and engagement of patients,” he warned.
Edwards said it would be challenging to accelerate some of the proposed changes, such as integrated working between hospitals and GPs, because of the logistics and pressures of the day jobs. “I think there’s an unanswered question about where the space to do that is,” he said.
Manchester’s integration of health and social care Godlee rounded off the session by asking participants about the plan in Greater Manchester for local government to hold fully integrated health and social care budgets. Specifically, she asked whether this signalled a move away from GP led commissioning. Taylor said the debate about which organisations should commission services was redundant. “The issue is; are they going to lead to better quality care?” he said.
But Field was concerned that the clinical engagement among GPs that had been fostered in CCGs may fall by the wayside if their role is diluted.
“There are lots of GPs who have been more engaged since commissioning came in, and it would be very sad if any changes that came in after the election moved GPs just to be in a sort of advisory role. We’ve had that before, and what you’ll find is that the GPs will go back to provision and won’t be actively engaged in design,” he said. Edwards said Manchester was an interesting experiment that could offer pointers on whether integration on this scale was replicable elsewhere. But he said the acid test would come when difficult decisions about reconfiguring services have to be made in the future. “The real question is when difficult decisions start to be made and they say, ‘OK, we’re going to downgrade Tameside or Oldham or whichever of the various Manchester hospitals need to change,’ how well that holds together.
“I think there’s an open question about whether they [the different local authorities] can hold that all together. If they can it looks very promising. But it will leave some very difficult questions about accountability, and at what point does an elective mayor stand up to secretaries of state and say shall we have different priorities to you?” Listen to Bastiaan Bloem, consultant neurologist at Radboud University Nijmegen Medical Centre, Netherlands, discussing his revolutionary approach to patient centred care and Ashish Jha, professor of health policy and management at Harvard School of Public Health, talking about how the Affordable Care Act has fostered new models of integrated service delivery in the United States at thebmj.com/podcasts. Cite this as: BMJ 2015;350:h1172 © BMJ Publishing Group Ltd 2015
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2015;350:h1172 doi: 10.1136/bmj.h1172 (Published 3 March 2015)
Page 3 of 3
FEATURE
Roundtable participants Nigel Edwards, chief executive of the Nuffield Trust Richard Jones, cardiologist in Portsmouth and clinical director at Wessex Cardiovascular Strateic Clinical Network Jeremy Taylor, chief executive of National Voices, a national alliance of health and care charities in England Steve Field, chief inspector of general practice at Care Quality Commission, GP in Birmingham Suzie Bailey, development director at Monitor Rebecca Rosen, senior fellow in health policy at the Nuffield Trust, GP in south east London Jennifer Dixon, chief executive of the Health Foundation Jonathan Michael, chief executive, Oxford University Hospitals NHS Trust Massoud Fouladi, chief medical officer at Circle Health
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