Reflections from the other side of the pond

I have just had the pleasure of spending a week in London with a group of US academics who work in the field of Health Management. Time was spent visiting organisations across the capital, listening to health care managers, regulators, policy makers and analysts present on the ‘State of the NHS’.

The following are my ‘take away’ thoughts and reflections and in setting them out I would like to thanks my colleagues from the US for a truly stimulating few days and to colleagues from the NHS and beyond for their energy, enthusiasm and the time given to share their knowledge and experience.

1. No profit please we’re British

When Margaret Thatcher announced back in 1983 that the NHS was ‘safe in our hands’ it revealed more than the positioning of a politician with a consummate sense of the possible. It also signalled the marking out of the boundaries of free market reform.

I heard more mention from US colleagues of the role of profit or surplus in health services provision in the week than I had heard in the previous twenty years here in Europe. I don’t mean talk of the market or commercial sensibilities but what was encapsulated for me in the adage a colleague referred to as ‘no margin, no mission’.

I was left reflecting that in the US the majority of providers may formally be ‘not for profit’ organisations, yet profit or surplus is seen as being a key driver not just for efficiency but also for quality. Compare this to the UK where similar terms are banded about within provider organisations, but their meaning appears to resonate differently – more the box to tick than the tool for change. One NHS Chief Executive we heard from did present a more confident reading of surplus and reinvestment, but overall I was still left with a sense of a half hearted commitment to a business model that not only fails to drive change but which also risks undermining the public service ethic upon which the NHS was originally established. Politicians, think tanks and the public must play their roles in defining the new rules of the game.

2. Regulating the regulator

Health care regulation was an issue of great interest to US colleagues, but seen from their external perspective the relationship between Monitor as the organisational regulator and the Care Quality Commission as the service regulator was not an easy one to decipher. Lay on top of that the additional pressures of political control, professional self management and an approach to patient and public engagement which still owes more to post war paternalism than new century consumerism and one is left looking at a regulatory landscape that still needs to build connections as it avoid pot holes if it is to deliver on its mission to assure and reassure.

3. Would the real NHS please stand up?

John Wyn Owen the eminent professor and ex-health services director who gave colleagues a really insightful first day briefing, talked about the NHS as being made up of a series of distinct regional delivery models and it was apparent as our week went on that whilst the tags of ‘national’ ‘health’ and ‘service’ were still operating as a drivers for improvement, the idea of the NHS increasingly appeared more millstone than enabler. Maybe this is in part down to the fact that while there have been many attempts to structure a renewal of the marriage vows between the public and the NHS, attempts to date had fallen short leaving something of a void at the heart of the project.

4. We just don’t get insurance

One of my big ‘take aways’ is that the British ‘don’t do insurance’. Repeated questions from my American colleagues regarding the current state of private healthcare insurance yielded a series of defensive or noncommittal responses from stakeholder organisations ranging from NHS Foundation Trusts to centre right think tanks. The decline of NHS optometry and dental care services are testament to a political class responding to the danger signals too late, service providers developing and marketing a poor range of products and a public suspicious or disinterested with the financial and public health fall out that has followed. With a health and social care financial tsunami on the horizon what price on history repeating itself?

5. It’s Good to Talk

Our week on the ground suggests that ideas of patient empowerment within the NHS are developing, albeit as a slower pace than in some other sectors of health and social care. It was not lost on US colleagues that the only time during their visit that they heard directly from patients and carers was at an innovative social care project run by a not for profit organisation. Not that tapping into the very significant levels of public support for the NHS was ever going to be a straightforward process. Well entrenched paternalism impinges on both sides of the public provider divide and gains evidently need to be built upon in a systematic manner if the ground swell of public approval for the NHS is to be developed into a broader culture than can meaningfully underpin service improvement.

6. Seconds Away Round Ten!

Colleagues’ responses to questions regarding the most recent structural and organisational changes to the NHS struck me as resembling a boxer being pep talked by their trainer mid fight. The body was tired, the language often rehearsed, but the focus on the win was still there. It was evident that despite or as a result of recent reforms there was still a good deal of energy to drive service improvement and an appetite to use the platform of reform as effectively as possible.

7. In search of the Holly Grail

One of my US based colleagues was on a journey that I would caricature as being a search for the holy grail of universal care. I felt that he left feeling universality was more akin to a pot of gold at the end of the rainbow than a readily accessible model, as he heard tales of variations in access, quality and health outcomes here in the UK. Left me thinking more than ever that the concept of a single payer is a necessary but not a sufficient condition of universality.

8. Seeing the bigger picture

The very existence of AUPHA as an organisation underlines the investment in high quality health management education within the US. Whilst colleagues were presented with some interesting and innovative health management programmes here in the UK, I did not get a sense that they viewed us as a leader in the field, with a good way to go in terms of connecting health management education with broader service training and development. The answer to the question as to whom or what might lead this process in the UK was left somewhat in the air.

9. Big Data – Small Systems?

The consequences of the failure of NHS Net provided an interesting talking point as colleagues struggled to understand how a performance based system which was seeking to build upon the platform of public health and make the much needed connection between health and social care could do this with 20th century IT systems. Colleagues were provided with some interesting small-scale examples of good practice, but I was left with a real sense of the UK being at least a decade behind the best internationally.

10. Lost in Translation

Having started the week feeling that they were looking at two distinct health systems with their own vocabulary and success metrics, the somewhat inevitable clearing of the mists left colleagues with a picture with more recognisable similarities than they might have felt at the start of their week in London. Setting aside for one minute the issue of funding, common themes were aplenty with challenges regarding access, quality, regulation and affordability chief amongst them. How well is the NHS doing right now in terms of meeting those challenges? Well in all truth I worry that the current pace of reform might just not be sufficient to withstand the twin pressures of increasing demand and decreasing revenues. Whether the system then breaks, decays or survives will depend in part of the ability to forge a new National Health that is seen less as a Service and more as a partnership.

So my final ‘take away’ then is that it is always good to talk and that learning often comes at the most surprising moments and can do much to challenge ingrained thinking as well as providing moments to reflect with real pride on services and teams working to improve the health and wellbeing of the community. So the more that those committed to high quality healthcare can share their experiences in an open and honest manner the more likelihood there is that we will successfully meet the many challenges ahead.