Siva Anandaciva: know your reviews - from Carter to Berwick

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  • Posted:Wednesday 07 March 2018

Speaking at our Health and Care Explained event on 07 March 2018, Siva Anandaciva, Chief Analyst at The King’s Fund, highlights six major recent reviews of the health and social care system and explains why we should care.


Afternoon everyone.  I wanted us to talk about reviews, particularly in the NHS, whether it’s Lord Carter’s review of efficiency or Don Berwick’s review of patient safety because these reviews are quite interesting beasts.  Whatever they focus on, they’re quite revealing about the policy priorities of the day and the thing about these national reviews is, they’re very different to the national policy documents you’ve heard about already today.  Ruth mentioned the Five Year Forward View.  

The Five Year Forward View is incredibly comprehensive in scope; covers everything from primary care to mental health, everything from finance to quality and even though it was signed off by all seven main ALPs, it was really hot housed and developed within NHS England and then unleashed on the world.  

The national reviews I’m going to talk about are very different.  If you think about the Francis review, into the care failing of Mid Staffordshire Hospital where there was horrific care failings, the review was the response to something, a specific event in this case care failing.  It could have been financial distress, it could have been the collapse of the contract.  It was very narrow in scope, even if the ramifications and recommendations were seismic, it was looking at the quality of care delivered in one hospital.  It operated over a finite period and it was independently led.  It was independently led, these tend to be led by grandees, you know at the bare minimum Knightfor and Deame, your working at a lord or a lady, a baron or baroness if you’re really talking about national review, and that independence means they can take a range of input before having investigated the issue in detail and putting recommendations to government and the government can then either accept and act upon these or dismiss them. 

So what I want to do over the next ten minutes, is a kind of clockwork orange, put matchsticks to open your eyes up and flash six reviews at you incredibly quickly, just to put them on your radar and encourage you to go off and read them.  So this will, and Helen will keep me to time.  

So the first of these reviews is Lord Carter, see I told you a lord, Lord Carter’s review of Operational Productivity in NHS Hospitals.  Now if reviews are a response to something, Lord Carter’s review was a response to the funding and financial pressures in the NHS.  If you’ve got a £20 billion funding gap and need to do more with less then how do you drive that efficiency?  Well Lord Carter wanted to do two things.  

First of all, give hospitals a common language when talking about efficiency, a common understanding and so he developed this metric called the cost per WAU, the cost per weighted activity unit which even from the sounds of it is not the easiest thing to understand.  It’s actually a fairly simply score that allows hospital to compare how efficient they are, regardless of where they in the country, regardless of the different mix of services they provide, it gives the board a score that tells them how efficient we are relative to others.  So that the diagnosis.  

For the treatment, Lord Carter was keen that you could then learn from those trusts that are best in class, those hospitals that are particularly good, so you can improve your efficiency as well.  The idea being, you get a score for your pathology department, how efficient is it?  You rise at opportunities, you go visit the best in class, you learn how they deliver services and improve the efficiency with which you do your services. 

It’s worthwhile keeping the Lord Carter review on your radar because even though it started with hospitals, it’s now looking at community and mental healthcare and in the future will expand into ambulances and specialised services.  It’s spawned a few other programmes like GIRFT, getting it right first time, which also look at operational productivity and is now a major part of NHS Improvement work programme.  So read that review and as you’re doing so, there are few other reasons you should care about it.  

One was the approach the review took was very different.  When I was working in the Department of Health many years ago, what we do is publish a league table, maybe give hospitals a day or a night’s notice that you’re going to get an efficiency league table, that’s going to name and shame the poorest performers.  Lord Carter visited every hospital in England so he could iteratively test, does this measure make sense to you?  Will you use it?  How will you use it?  Will it be useful to you?  Working alongside the front line rather than telling them what to do, can I be a little bit crude in my language, it’s a direct quote.  

The other thing that’s interesting about this review is it reveals the tension between whether these reviews are there to encourage and give information to the frontline to act upon or whether to be a lever that tells the frontline this is what you should do, an instruction and it’s interesting because Lord Carter was very, very clear, he said, you know they want me to put it into the regulatory framework, they want me to put this measure into the contract and I keep telling them to piss off, because the minute I do that, I lose the board.  I lose the board of the hospital because it means it’s not them acting on information it’s them being done to.  I would say the review started in that case, it probably ended up in more of the instruction to deliver.

And the final thing for why it’s interesting, it showed that £5 billion of savings are possible by reducing variation in how hospitals deliver care by 2019, it wouldn’t be quick and it wouldn’t be easy to deliver those savings. 

Moving on to the next review, Don Berwick’s review into patient safety, one of the many reviews that was spawn by the care failings of Mid Staffordshire Hospital and what Don did was look at those care failings and other safety incidents in the NHS and proposed two things.  First of all, that safety concerns and care failings in the NHS are very really due to individual malfeasants by a member of staff.  It’s normally due to a failure of a system of care, and secondly that the NHS needs to improve its capability at continuous quality improvement at a systematic approach to improving quality.  I can’t emphasise the systems bit enough.  I remember a few years ago, somebody telling me a story about paediatric eye surgery.  The child had had their eye surgery completed, and the surgeon was irrigating the eye, just washing it out at the end of surgery and you do that with saline, but the thing about saline is, in high enough concentrations it can blind which is what happened here.  They irrigate the eye and the child’s eye is blinded.

Now I don’t know how you feel when you hear a story like that, but I immediately want to blame somebody.  You think about blaming the surgeon for not checking the right concentration.  You want to blame the operating theatre practitioner for putting the tray together incorrectly, the facilities manager for storing two different concentrations next to each other.  The manufacturer for not labelling the concentrations differently.  As you work down that train, you can see that it’s not down to one individual error, it’s not due to conscious neglect.  It’s a system of issues, a system of processes that we need to address, and that’s been Don’s legacy.  Things like the healthcare safety investigation branch, is modelled on how aircraft investigations are run and no blame culture will tell us everything that happens, unlock the black box so we can see all the process failures and then address them. 

Improving our capability, looking at Virginia Mason, renowned as one of the safest hospitals in the world based in Seattle, a very clear way of approaching safety improvement based on two versions of e-methodology that is now being imported into the NHS.  So care about this review for all these reasons.  If I’m being honest, the main reason I care about this review is it’s beautifully written.  Don Berwick is one of the best writers I have ever read because he brings these stories through with impact, so if you’re looking for a gateway drug into reviews, I would start with Don Berwick’s, Letter to Government, Staff and the People of England that accompanied the review. 

The next review is Bob Watt’s review into information and technology.  Bob is an American physician, a slight tangent note, it’s interesting, when you get a physician coming from another health system to look at the NHS they invariably say similar things of, you’re actually doing a lot better than you think.  You beat yourselves up quite a bit. You seem to be trying to do an awful lot in terms of reform at the same time and what you’re trying to achieve might happen but it’s not going to save as much money as you think and will take more time than you think. That’s kind of irrelevant to what I’m going to say now, but Bob’s review of information technology in the NHS was a response to this desire for the NHS to be paperless originally by 2020, now by 2023 and he said, first of all you need greater clinical engagement in this.  So we’ve seen a professionalisation of the chief clinical information officer, a senior clinician in every trust whose responsibility it is to promote the digital agenda and it’s not just about taking records and turning them into a digital electronic patient record, it’s about looking at app development, really making the most of modern technology to move clinical skills. 

In terms of why you should care; some of the things that came out in Bob’s review that were particularly interesting were the NHS in particular, we tend to abreact to things.  So we have a national programme for IT, that was not a success and so we abreacted and went to a very localised solution.  Every hospital doing something slightly different, running on a slightly different system, different to other hospitals, different to GP practices and Dr Watts has suggested maybe you could have more regional management here, more of a strategy.  Don’t immediately swing between national and local, and the other reason why this is an important review is a lot of what we heard about population health management is predicated on knowing where your costs are, what the needs of your population are and to do that you need to integrate primary, secondary care records.  You need to integrate health and social care records as well, and that can only be done through greater use of technology.  

I know this is quite concussive going after review after review, we’re over half way there now because we’re talking about the Barker commission.  Kate Barker, an eminent economist who a led a commission on the future of health and social care in England as Simon Bottery said this morning, we’ve got two very different systems.  We’ve got a healthcare system, tax payer funded, free at the point of use, a social care system which is means tested.  You’ve got to limbo and pole vault to get access to it, the publicly funded portions. 

What Kate’s review did, and here I probably suggest you don’t look at the detail of the recommendations like what you do at prescription charges, it’s more the ethos of what her commission was saying about integrating how health and social care is planned, organised, potentially funded and its interesting because it shows that health and social care are not static, they’re always in motion and as care needs evolve and now we’re focussing on more coherent holistic care of older patients, you need your systems to evolve as well.  It also raised some of the political toxicity of some of these options because if you want to fund social care you’re looking at going after wealth, if you’re going after wealth, you’re going after assets of people like pensioners and that rubs up against things like the triple lock commitment and then you know, if I saw this sentence, problems of collaborating and harmonising systems short of full structural alignment.  If I saw that in someone else’s presentation I’d say, what a pretentious twit, but it’s in my presentation.  

What I meant by that is, one of the other things this raised is how do you get health and social care working more closely together without full structural integration.  There’s no point in just integrating a workforce, integrating budgets.  You can merge two bankrupt systems, it doesn’t make one financial viable one.  So what opportunities are there for aligning and harmonising how things are done.  I go to places like Norfolk and there’s one OT.  You’ve got one occupational therapist.  It doesn’t matter if you’re working in the NHS or in social care, it feels the same.  You move across the same.  Same adverts, joint terms and conditions so the options here short of full structural alignment.  

The penultimate review is Sir Stewart Rose’s review of leadership.  So Stewart Rose was the former executive chairman of Marks and Spencer’s and about every thirty years we get the chief executive or chair of one of the big retailers to come in and do a review of the NHS, the leadership, this was Sir Stewart Rose and M&S’s time and he did a review that was interesting because the government sat on it for a very, very long time, to the point where when it was published it was very good but almost irrelevant but some of the things he picked up on were the need to reduce regulatory burden on frontline leaders and free them up to do their jobs, the average tenure of a chief executive is two and a half years in post.  

Think about some of these transformation initiatives.  You’ll hear five to eight years.  When they built Cramlington Hospital, this new emergency care hospital in Northumbria, it took eight to ten years to deliver, so you need some stability. 

The other thing was in terms of a different type of leadership.  When I was coming up in the system, what was prioritised was, if you were a trust chief exec you had to maximise your market share, either acquire or obliterate your opposition and it engendered a slightly type A personality.  I look at the system leaders now and it’s a very, very different ethos.  A very much more collaborative type of leadership, different type of leadership.  

And the final review is Sir Robert Naylor’s review of property and estates, which may sound incredibly nerdy, why am I talking to you about estates.  The key reason is it’s about stewardship.  So Samuel Grey talks about stewardship in terms of leaving things in a better shape than when you found them, if you’re talking about the NHS.  I talked to the commercial and finance directors if they have surplus land, if they have surplus assets, they are under incredible pressure to sell it off this financial year to make your books balance. 

If we’re thinking about stewardship, you’re thinking about redeveloping that land, thinking about using it as an asset, a strategic health campus, an academic hub, integrating care homes onto it, integrating primary care.  Sir Robert Naylor’s review challenged us to think more long term about stewards of the NHS rather than just delivery of short term priorities. 

So my final slide is "why?", why have I chosen to focus on reviews and it’s three reasons:

One, because even though we’ve talked about quality estates efficiency, they have some common themes here, this tension between what is the role of the centre and the national bodies, what is the role of the local organisations?  Is there role there to of the central body or the review to provide recommendations and other people to act on them or to force through these recommendations?

The second thing is you can see where the zeitgeist is by what people are reviewing.  That’s through reviews I’ve read about care failings such as in Liverpool community trust but the final reason is, as you probably already picked up, the NHS in particular has loads of shibboleths, all these things that define an in group from an out group and language is one of them.  If you don’t know your three letter acronyms, STF funding is no longer STF funding, it’s now PCF and CSF funding, if you don’t know your three letter acronyms you’re kept out of the group. 

Reviews are part of this let’s call shibboleth.  People talk about Carter trust, people talk about Berwick approach to safety and quality.  The Watts review of technology.  So hopefully if you have time, go off and read the 500 or 600 pages of these reviews and you’ll be even more welcome in the health and care family. 

Thank you very much.