The NHS needs revolution, but not in the way some might think. The challenges facing the NHS are well documented, with workforce and other resource constraints featuring heavily, alongside the knock-on impacts of the pandemic. So while revolution is needed, it is more in how we think and how we adapt to change that is already in motion, rather than starting afresh with something new.
The revolutionary path to success for Integrated Care Boards (ICBs) tasked with delivering the Triple Aim comes partly from joint Nobel prize-winning economists, Elinor Ostrom and Oliver Williamson. Until recently, the NHS has operated a market approach, resulting in a complex network of individual organisations providing multiple services within localities. Oliver Williamson recognised that healthcare is far too complex to work effectively as a market. He identified that market conditions only work under certain circumstances, typically when there are clear outcomes to be had and lots of providers to choose from.
But managing health conditions is complex. In many cases, people will have multiple healthcare needs and will typically only have access to one local GP practice and one, or perhaps two, local hospitals. This has led to an increasingly siloed approach to health provision, where providers are often rewarded for the volume of activity they complete rather than the outcomes they achieve for their patients. System working provides an opportunity to change this, but only if we are prepared to shed the market mindset which has become ingrained. That’s where stewardship comes in.
Stewardship is essentially about being responsible stewards or navigators of common resources, recognising and incorporating the collaborative working skills needed for success. The traditional analogy used to explain stewardship is of shepherds putting sheep to graze on common ground. As each individual shepherd adds more sheep, the ground becomes overworked and all the shepherds lose out – a concept known as the tragedy of the commons. The same analogy can be applied to any industry with finite resources. But, when those same shepherds were in charge of the common as well as the sheep, they came together naturally and adopted a culture of stewardship.
In her analysis, Elinor Ostrom found that when those who use resources are collectively responsible for them, people more naturally collaborate and cooperate to use resources sustainably for everyone’s benefit. Importantly, is it those directly using or requesting the resources that are best placed to be the stewards. In healthcare, that means involving clinicians and patient groups in deciding how to make best use of resources. This is the approach Arden & GEM has been facilitating in supporting Integrated Care Systems (ICSs) in the Midlands and South East to establish stewardship groups.
Value-based population healthcare
As identified by Professor Sir Muir Gray, the NHS is excellent at providing safe, quality care, but traditionally less good at asking whether we provide the right care. To deliver sustainable health services in line with the Triple Aim, we must be prepared to assess and challenge what we do as well as where and how we do it.
For example, in looking at treatments across a musculoskeletal pathway, we found that approximately half the benefit to patients came from just three or four interventions. In some cases, physiotherapy was showing better outcomes than surgery, with less risk and impact on patients, yet surgery was still recommended – in some areas much more frequently than others. Changing the way we do things might lead to fewer patients moving through hospitals and more resources being directed towards community-based care, with funding following suit.
The market mentality makes it harder to accept these changes and stop activities which are not delivering value but, by adopting a stewardship approach, ICBs are more able to think beyond organisational boundaries and recognise the benefits of directing resources elsewhere. In our experience, clinicians and patients are often particularly good at making tough decisions about what is going to deliver best value, both in health outcomes and in resources, and in championing change when given more control, so involving them in decision-making is crucial.
Fundamentally, this is about culture shift for those of us working within healthcare – and a recognition that we need to improve the public understanding of what good looks like for the future of the NHS. Traditionally, ‘good’ has been about bigger, better and more hospitals and seeing more patients – akin to the market model. But the NHS is an economic outlier in Europe – we spend far more on hospital care than our colleagues in other European countries who traditionally invest more in community settings and preventative care.
ICBs have an opportunity to develop a new culture in which, for example, a hospital trust measures success through improved health outcomes for the system’s population, reduced waiting lists and a reduced budget deficit, and primary care providers spend more on enabling and supporting self-care and prevention than treatment.
This won’t happen overnight – but we are already seeing pockets of change and we know this is something the NHS can achieve. In the same way that quality and safety have become enshrined in the language of the NHS, stewardship, value-based care and sustainability must become part of our daily conversations as we look ahead to the next 75 years of the NHS.