- Posted:Wednesday 22 June 2016
Speaking at our conference, How changes in clinical practice can deliver better value on 22 June 2016, Rt Hon Jeremy Hunt MP, Secretary of State for Health, Department of Health, discusses how improved care can be delivered at better value.
I think this is exactly the right thing for the King’s Fund and for everyone here to be thinking about, because quality and money are probably our two big challenges right now in the NHS that is taking up a huge amount of time and a lot of focus as we cope with really an extraordinary amount of pressure on the frontline. And I’m sure we can have a good discussion, I’m happy to take a few questions, but let me give you a few thoughts to start things off today.
The first is I think there are three myths around this nexus between clinical quality and money. And the first is that there is a binary choice between spending more money or having high quality care, and that you have to a choice between money or quality. And I think the evidence when you look it actually points in exactly the opposite direction. This came to me very graphically actually not in this country but when I went to visit Virginia Mason Hospital is Seattle that many people there, and I know Chris Ham has done a lot of work with Gary Kaplan there. Gary Kaplan was chief executive, or is chief executive at the hospital and he was chief executive in 2003 when they made a terrible clinical error which resulted in the death of a lady called Mary McClinton because they injected the wrong fluid into her brain. It was a clear fluid and the surgeon simply mistook the right fluid for the wrong one and this lady ended up having an agonising death over a period of 2 weeks. And this was really a turning point in that hospital’s history because they were so shocked by what had happened they decided first of all to be completely open and transparent about it, they sent an email to all the staff in the hospital explaining what had happened to try and make sure it didn’t happen again and they knew that would get out to the local press and really damage their reputation.
They then started on a journey where they used as their benchmark the manufacturing system used by Toyota in Japan to eliminate waste and improve quality at the same time. And Gary Kaplan famously said that the journey to safer care is the same as the journey to lower cost. And the interesting thing is that 16 years, or thirteen years on from that Virginia Mason is recognised as possibly the safest hospital in America but Gary also says that his costs are between 30% and 60% less than his competitor hospitals in Seattle and this journey has also meant that as a hospital they moved from deficit into surplus. And we now, thanks to the new CQC inspection regime, can see exactly the same evidence here. If you look at the deficits of the CQC good or outstanding rated trusts they are five times lower than the deficits at the trusts that are inadequate. And when you think about it it’s not very surprising because poor care is one of the most expensive things you can do. If someone in a hospital has a fall that could be avoided they are going to stay in hospital for probably at least three days longer, that will cost the NHS about £1200. If someone has an avoidable bed sore that will cost about £2500 and they’ll probably stay in hospital for an extra twelve days, and you’re going to hear from Tim Briggs later, but some of Tim’s research says that if you pick up an infection in a joint replacement that will cost on average I think £100,000, the figure’s gone up, but it will cost £100,000 to treat.
So we know that poor care is expensive but we also know that simply spending money isn’t the way that you deal with poor care, for a number of reasons. The first, and most obvious of which, is that it’s simply not sustainable to do that and in the end reality dawns because you can't go on having a deficit for ever and every. But secondly because if you just think opening a cheque book is the solution to these problems you actually miss out on the real excitement of improving clinical quality which is understanding the process changes that actually both eliminate waste and improve care at the same time. And what you tend to do if you just think money is the answer is you tend to ossify current clinical practice rather than ask yourself the searching questions about the new clinical practice that could deliver the higher quality.
So that’s the first myth. The second myth is that the journey to improving quality is essentially a managerial rather than a clinical issue and I think we’ve seen in the NHS over decades of experience that when we treat these things as a managerial issue things go badly wrong. On one level it was a huge managerial achievement in the first decade of this century to bring down A&E waiting times and elective care waiting times but we can also see that in the trusts where that was a managerial objective, not aligned with a clinical objective, you ended up with the kind of disasters that we had at Mid Staffs where instructions were coming down from on high to do things to help people hit targets with appalling consequences in terms of clinical care. And it is absolutely essential that the managerial side and the clinical side go together in this, because not only will they not achieve it if the two sides don’t work together but effectively both the managerial side and the clinical side have a veto on progress being made by the other one. So doctors can stop managers achieving their objective and managers can stop doctors achieving their objectives and that’s why it makes no sense to think of them as separate objectives.
And the third thing which is perhaps a lesson for politicians of which there is at least one in the room today, is that this can be achieved as a top down rather than a bottom up process. In the end this is about culture change that comes from within and I will finish just with a few comments about how we get that culture change but if this is seen as a political objective or at least if it’s seen only as a political objective there are huge dangers and this has to be something that comes from inside, something that is inherent and intrinsic and passionate desire of each and every NHS employee.
So how do we get there? Well Christ has hit the nail on the head with the first way which is the ruthless elimination of clinical variation in the system. The latest figure I’ve seen in terms of joint replacement is that the variation in terms of infection rates is between 0.5% and 3%, Tim may have some more up-to-date figures, but this is a truly huge level of variation. Talk to Professor Sir Mike Richards, the chief inspector of hospitals, one of the most senior doctors in the country and he will say that one of his biggest surprises since becoming chief inspector of hospitals, and bear in mind this is someone who knew the NHS like the back of his hand before he took on that job, but even he has been astonished at the level of clinical variation. And if you go into the hospitals that have been put into special measures, and I was at Morecambe Bay last week talking to the team there, and they have succeeded in turning it round as part of the special measures bill, what they say is that the first task was actually to get the message across to clinicians in that trust that their clinical practice was not the norm in the NHS, and that is something where we’re all guilty of this, we all get into our own silos and forget that things are happening differently in other places. So eliminating that variation is important.
Then I think we have to accept that we need to take a long term view if we’re going to do this. A lot of these changes are linked to technology, a lot of the data that you can get about improving clinical practice comes from having good data and good technology to transmit that data, a lot of the process change comes from smart technology, but technology investment will typically have a payback of between three years if you’re lucky and more normally around five to ten years if it’s a big IT system in a hospital. And so we have to take a long term approach and accept that there is high value in small incremental changes that happen consistently over a period of time and it’s not always going to be a big leap forward as the British cycling team are fond of telling us.
And then the third important point to note about the way we go about this is that you will need inevitably a lot of system level changes, not just changes in the level of trusts, and we’ve seen that in the dramatic improvements in stroke care because of the stroke reconfigurations that have, in London, saved I think in their first two years, 22,000 in-patient days as well as saving 170 lives. We see it in the reconfiguration of trauma services into 26 units across the country which have dramatically reduced mortality rates. That is why the new STP process being led by Simon Stevens in NHS England is going to be very important.
So let me finish with how we get there in terms of the culture, because one of the journeys that I’ve been on as Health Secretary when I arrived in this job three and a half years ago, I steered away from anything called culture change because I thought this is just too nebulous and how can I possibly define success in a meaningful way? And I wanted to focus on changes that I was confident I could make in twelve months or 24 months. But I’ve come to understand that actually no change is permanent unless it’s a culture change and no culture change happens unless it comes from inside. And that’s why I have tried to start thinking and thinking publicly about what we do to get culture change. And in the end this is about, for me, re-discovering the link between doctor and patient which I think has, in many ways, been undermined by a concentration of a targets culture and managerial objectives and it’s about rediscovering that clinical accountability between doctor and patient which I think is at the heart of true quality.
And how do we get there? I think the first thing is that we have to be honest when things are going wrong. We have seen a huge transformation in our attitudes towards transparency in the NHS in the last three years, prompted by what happened at Mid Staffs. And that has been very difficult for the NHS because it’s led to huge numbers of negative headlines in the media. But you’re never going to improve quality unless we’re honest about the problems that we face, unless we’re honest about that clinical variation and we see that now happening with the CQC inspection regime, we’re now going to be introducing OFSTED style rating for CCGs to bring that transparency into the commission process and also thanks to the work that Chris and his team at the King’s Fund did we are now looking at the overall quality of care provided to patients by geographical area and we’re going to have OFSTED style ratings for those in mental health, diabetes, dementia, learning disabilities, cancer, maternity. So we’re starting to do that. There’s no country in the world that is doing that, and again that will shine a light on that variation that we know exists and help to spread best practice.
But with transparency also has to come action. And I think we can see that where we’ve been bravest in transparency we’ve also seen the biggest improvements in quality and one example of that that I was talking to the NHS Confed last week is Wexham Park. Three years ago clinicians at Wexham Park knew what the CQC went on to tell us, that the safety of care there was inadequate, they didn’t want to treat their own friends and family in that hospital, there was a culture of what the CQC described as learned helplessness. Then we put them into special measures, one of 27 hospitals, they had new leadership with Sir Andrew Morris and Frimley Park taking them over, they came out of special measures, one of eleven trusts to come out of special measures and what do people say now? Well the CQC said there has been a shift in culture amongst the staff, the number of people willing to treat their own friends and family in that trust has risen from less than half to more than two-thirds and in terms of the eight core areas that they have at that hospital, whereas before six out of the eight were inadequate. Now all eight are good or outstanding. So that is a remarkable turnaround and that has come about because of the total determination of the staff and leadership of that trust to turn things around and do things differently and better, and we’re starting to see that all over the country.
So transparency and action and then the third part of that, absolutely intrinsic which I am sure you’re going to hear a lot about today, is developing a learning culture. I said a year ago at the King’s Fund that I wanted the NHS to become the world’s largest learning organisation and that is a pretty big ambition to have. But I think that history will judge that that was actually the right ambition because the enthusiasm for learning and doing things better is completely unparalleled and the NHS, the commitment of NHS staff to the values of the NHS means that we want to do things better but that also means we have to do things differently, and that’s why I’ve put Monitor and TDA together into a new organisation, NHS Improvement, that is not just meant to be a merger of two regulators, that is meant to be an organisation that is charged with developing and spreading good practice throughout the NHS because we know that everyone wants to improve but some people don’t know how to improve and that’s the role of NHS Improvement.
We’re now modelling ourselves on the airline industry which has learned a lot from the concept of no blame investigations. We’ve now set up the Healthcare Safety Investigation Branch so that when we have the worst breaches of care we will have a rapid no blame investigation with a responsibility to spread the learning from what went wrong across the whole of the NHS and very excitingly Keith Conradi who has run the Air Accident Investigation Branch for over ten years has agreed to come over and be the first chief executive of the Healthcare Safety Investigation Branch. Now we’re the first country in the world to do this, to explicitly model ourselves on those no blame investigations that they’ve had in the airline industry for many years which has seen a dramatic reduction in airline fatalities and it’s a very exciting step.
And then I’ve said that I want to have legislation, and the government is committed to legislation to create a legally safe space for doctors to discuss clinical error without having to think about the professional consequences for them personally, without having to think about the litigation impact so that we can really make sure when things go wrong that we first and foremost do the learning to make sure that we don’t repeat those mistakes, and we shouldn’t forget that this is not just an NHS issue, it is recognised as a problem all over the world. Last month John Hopkins University said that medical error was the third biggest killer in the US after cancer and heart disease responsible for 250,000 deaths a year and the black analysis in this country says that we think it’s about 150 avoidable deaths every week. That does mean we have to be honest about things like the weekend effect uncomfortable though that is. We have to be honest about never events which I’m afraid don’t never happen, in fact we have two incidences of wrong site surgery every week in the NHS.
But we have a chance, if we do this, because of the incredible commitment of NHS staff, to be the organisation that is the pioneering champion for safe high quality care across the world. And right now I would challenge anyone to name a healthcare system anywhere else in the world that is as focused on improving safety and quality across an entire health economy as we are. And I’m absolutely convinced that we’ll get there and that we will call this turbulent period in the NHS’s history, this challenging period, the quality decade just as I hope we will call the first decade of this century the access decade, we’ve brought down waiting times, it was a huge achievement in the first part of this century, now we need to bring the quality and safety in as well and clinical practice, what you’re discussing today, is going to be an absolutely essential way to achieve that.
Thank you very much.