What is wrong with the NHS? #4 Fashions and Fads...or a Cunning Plan?

The NHS has been struggling to cope with rising demand, tepid fiscal growth and relentless restructuring.? Leaders in the service could be excused if they put on their hard hats and hunkered down.

Far from it.

We have had a veritable series of white knights galloping over the horizon pulling all sorts of bandwagons and an awful lot of people have been keen to jump on them.

In my living memory we have had Outcome-based Commissioning, Accountable Care, Population Health Management, Community Matrons, Health Coaching, Predictive Modelling, Case Management, Virtual Wards, Long-Term Condition Management, Case Management, Tele-Care, Lean, TQM, Continuous Improvement Systems from Toyota, Six Sigma and many more besides.?

We have now gone AI-mad.

In most cases, it would start with a sound idea.? The Croydon Virtual Ward that was launched in 2005 was inspirational and grounded on a lot of academic research and practice from across the globe.? It was a multi-disciplinary response to people who have complex care needs and who are at risk of crisis episodes in secondary care.? I am not convinced Croydon got a huge amount of support from the Centre back in 2005, but Croydon invested management resources and effective leadership and they should be rightly proud of what was achieved.? Other localities took on the concept such as Devon and Wandsworth.? (I think all of them suffered collateral damage from the abolition of Health Authorities.)

Eventually, the ‘good idea’ is recognised by the Centre as being the saviour of the NHS and money is attached to its implementation across the country.? ￡450m over two years was set aside in the 2022-23 Planning Guidance – some 17 years after the Croydon work – to increase the number of ‘virtual beds’.? ?Virtual Wards are seen to be the answer to long term frailty and rising costs of emergency admissions, all Integrated Systems should have them.

Are these grounded on the excellent reviews of Croydon, Devon and Wandsworth?? Are they properly managed, are they sized appropriately, do they have sponsorship from the senior clinicians, are the information systems in place, what about the admission and discharge protocols?? I am not always convinced.? Croydon did it properly and the evaluation showed it saved money and improved patient outcomes and experiences.?

If you don’t do it properly then it is more likely to be under-managed and wasteful.

My point is that initiatives like Virtual Wards do work but, they need a huge amount of effort, clinical and managerial leadership and local commitment.? They are not quick fixes.? They need time. When they are implemented as quick fixes to get the money but avoid the much bigger and wider and deeper problems surrounding urgent care pressures then they inevitably fail.? When they fail, leaders jump onto the next bandwagon.

Using outcome measures to inform commissioner/provider relationships is obvious.? Expecting outcome-based commissioning to deliver cost savings and improved quality, just by paying providers differently is more than fanciful and bordering on fraudulent.

The sad thing is that all these techniques have a role to play, but they are not the answer or even a major part of the answer facing health systems across the NHS.

My worry is that the fashion and fads, while attracting a disproportionate amount of air time, are at the same time distracting leadership teams from the basic call for operational excellence.?

If you want a great Virtual Ward, read the Croydon evaluations and look at the Johns Hopkins Guided Care model.? See what it takes to do it well and then work out if and how you can devote sufficient clinical and executive leadership to make it work as originally designed.

If you put in only 50% of the work required, your Virtual Ward will probably cost more and introduce duplication, confusion and inefficiency. The idea will then be shown to have failed and you will be getting your binoculars to spot the next white knight.

One more example.? Case Management.? This is a similar concept to Virtual Wards.? It works as a highly effective foundation for integrated care across primary and secondary care boundaries.? Look at any population health pyramid across the world and you will see Case Management as a key building block for solutions to the top 5% of people that consume approximate 55% of costs.

Good case management saves money and improves patient outcomes.

My mother-in-law had a really good case manager.? It made a massive difference and then it didn’t.? When we had the toughest challenges integrating the care she was receiving, she was contacting or attending primary care roughly twice a week and she had two difficult and protracted emergency admissions.? I called the practice and suggested that the case manager didn’t seem to be as responsive, the answer was:

“We don’t have case management here anymore”

Virtual Wards, Case Management, Artificial Intelligence (perhaps) and all the other fashions and fads can have a role but my message to leaders is to please do them properly, but put more energy and effort into the ‘cunning plan’…

…which is effective and inspirational leadership, strategic clarity, good operational management, financial discipline, performance management, motivated and committed workforce and good alignment of clinical and executive priorities.?

If you believe Artificial Intelligence is a tool to put those in place, then go for it.