Ahead of our NHS Transformation Symposium, guest author and former UK Market Access Director at AbbVie, Allergan and BMS, Richard Marsh, offers his thoughts on transforming the NHS.
Over to Richard…
A bleak background for transformation
The harrowing and horrific case of Lucy Letby was a tragic reminder that the NHS is rarely in the headlines for anything other than the wrong reasons.
To an extent this has always been so, though the years since the pandemic have seen an acceleration of stories of the “NHS is broken” variety, exacerbated by progress (or rather, lack of progress) reports on the endless byzantine and seemingly intractable pay disputes. In March, a British Social Attitudes Survey reported an alarming drop-off in public satisfaction with the NHS.
Against such a bleak background, it is legitimate to ask whether talk of “transforming” the NHS isn’t somewhat fanciful. The idea that the health service in its current form is beyond repair remains a fringe one in British politics – though less outlandish than it was, say, 5 years ago – but we have reached a stage when Britain’s probable next prime minister can state that “the NHS is not sustainable unless we make deep, long-term changes”. Keir Starmer’s prescription for what these changes actually are may remain fuzzy, but there is no doubt that he speaks for a political consensus that things cannot go on as they are.
Three major challenges facing the NHS
A more sober way of summing up the NHS at 75 is that it is wrestling with three major challenges.
1) Recovery from the pandemic and the resulting backlog
One of these is the recovery from the pandemic and the backlog it created – a long and thankless task, not made any easier by spending constraints and workforce shortages. The first-ever long-term NHS workforce plan was at least an acknowledgement of the severity of the staffing challenge, although it inevitably received mixed reviews as to its likely potency.
The financial situation, meanwhile, is ingrained. Both Mr Starmer and his shadow health secretary Wes Streeting pepper every speech with warnings not to expect better from any future Labour government. The wise bet would be on more money for health as part of a Conservative pre-election boost; that, however, is unlikely to change the fundamental calculus of the NHS facing a torrent of demand with only a trickle of extra funds.
2) Integration continues…
The second challenge – which generally receives less public attention than the others – is that the health service is still in the process of “integrating”. It is now a little over a year since the new architecture of the NHS in England was formally set, based around the joined-up lexicon of integrated care organisations, networks and partnerships.
According to those doing the work, implementation so far has gone remarkably well. An upbeat progress report from the NHS Confederation in August reported that integrated care system leaders are confident that the new system is delivering the intended high level of collaboration and coordinated working.
(We will, I am sure, hear more on this point from speakers Penny Dash [Chair of North West London ICS] and Richard Smale [Executive Director of Strategy and Transformation, Bath and North East Somerset, Swindon and Wiltshire ICB] at the Symposium.)
Such news is welcome but needs to be seen in perspective. Collaboration is worthy, but it is not an end by itself. There is not yet systemic evidence that the new integrated structures can deliver the wholescale “transformation” of the NHS that everyone says is required.
Specifically, can they achieve such policy goals as a foundational shift in focus from secondary to primary care, increased intensity in prevention and population health management, and a sustained attack on health inequalities?
It is not even clear that the necessary incentives and biases exist within the new architecture to bring such a metamorphosis about.
One of the points emerging from the NHS Confederation report, for example, is the abiding strength and influence of provider trusts – hospitals in lay-speak – compared with primary care networks (PCNs). ICS leaders have less confidence that the PCNs are sufficiently resourced and led to be game-changers than are hospital-centred organisations.
It is an old story, and arguably the same weakness lay behind the failure of clinical commissioning groups (CCGs) to deliver the goods. Moreover, to the extent that PCNs can be agents of meaningful improvement, it is likely to be only over a longer timescale; this may not satisfy the political imperative to make immediate progress on hospital waiting lists.
These questions of organisation and incentive may be less the stuff of the media gaze, but they occupy – and should occupy – the attention of those actually charged with bringing NHS transformation about.
3) Transformation through technology
A danger, however, is that the fetishisation of bureaucracies – perish the thought that the NHS should be guilty of that – distracts from the third, and most important, challenge, which is transformation through technology.
It is a commonplace belief among health policymakers that the adoption of new technologies – and specifically now the uber-fashionable AI-based innovations– is not only going to transform healthcare as we know it, but that this holds the key to the holy grail of a sustainable NHS.
But if this is what deep and enduring change looks like, how is it to come about?
Those looking to drive this technological revolution, whether from within the NHS or as its partners, need to find answers to many challenges.
The first of these will be very familiar to anyone who has been involved in market access in the pharmaceutical industry in the last 20 years.
In theory, access policies have been built around privileging what is “cost-effective” for the NHS. In practice, however, it is too often cost rather than cost-effectiveness that is the dominant factor. So that even medicines signed off by NICE struggle for uptake.
Institutional attitudes pay lip service to “investment”, but rarely stray from the path of least immediate expense and are heedlessly short-sighted when it comes to capital expenditure in particular. This will need to change if new technology really is to be as transformative as hoped.
In the case of AI-based technologies, the fact that there is, as yet, no established methodology for assessing their true value, is a further complicating factor.
Nor is it yet fixed at what level these new innovations should be procured. Is this (as the Treasury would prefer) a national prerogative, carried out in the name of efficiency and control by an organisation such as the NHS Transformation Directorate?
Or should localism prevail, creating the opportunity for more dynamism and flexibility, though potentially at the expense of uniformity and integration?
NHS Transformation itself operates a policy of what it calls “levelling up” – focusing resources on parts of the NHS that are struggling to break into the digital age, rather than on the pioneers. This approach sits best with the ethos of the NHS, but whether it is the best way to foster innovation is a different matter.
New technologies, we are also told, will empower patients. This is a happy antidote to the “8am scramble” where supplicants hold the line in analogue agony for the privilege of arranging a GP appointment. Yet previous attempts at enhancing patient “choice” have always foundered on the capacity constraints of the health service to accommodate it.
It is hoped that new and imaginative technologies will support smarter choices, in theory boosting effectiveness and releasing capacity. A nice idea, and hopefully not as naïve as the one upon which the NHS was created: that by delivering regimented and proper care to everybody it would ultimately better deal with need and thus reduce demand.
None of these problems are insuperable, but they can only be worked upon with open minds.
Clearly an improved economic outlook with the prospect of a better-funded health service would help. Yet, attitudes and approach are equally important.
It may be a dreadful cliché to say that technology is the solution and not the problem, but just because something has been often said does not make it less true.
And no one can say it more convincingly or winningly than the companies behind these technologies. They are the best experts in understanding and communicating their potential and in realising it as well. They have work to do.