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Whole System Transformation of England's National Health Service 18 March 2010 Care Oregon Helen Bevan Paul Corrigan. Who we are. Helen Bevan Chief of Service Transformation, NHS Institute for Innovation and Improvement, England

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Whole System

Transformation of


National Health Service

18 March 2010

Care Oregon

Helen Bevan

Paul Corrigan

who we are
Who we are

Helen Bevan

Chief of Service Transformation, NHS Institute for Innovation and Improvement, England

Paul Corrigan Special Adviser to Secretaries of State for Health and Prime Minister 2001-7 now independent consultant

at the end of this session you will be able to
At the end of this session, you will be able to:

Gain a perspective on your own system by spending a morning deeply immersed in a real-life transformation case study

View and review the scenario from multiple perspectives of large-scale change

Take home approaches, tools and insights on transformation that you can apply in your own setting

what we will cover
What we will cover
  • Background to the NHS
  • NHS as a case study in “discontinuous innovation”
  • The birth of the NHS and the NHS pre-1997
  • Our ten year transformation journey
  • The levers of change in a national system
  • The necessary capacity to use those levers
  • Contemporary issues facing our reformed NHS and the US system
  • Transforming the way in which we treat Long Term Conditions
  • Debrief
  • Take home messages
why might this be useful
Why might this be useful?
  • This isn’t “how to do it” “the best way to do it” or “we are perfect”
  • Understanding some factors and levers that help or hinder transformational change of a large health system
  • Unintended consequences and failures (and there are plenty) as well as successes
  • Levers that implement strategy at system level and the necessary capacity shifts of the frontline reality
  • Case study of “discontinuous innovation”
underpinning principles for systemic change
Underpinning principles for systemic change

We need both to deliver change at scale

english american translation two nations divided by one language winston churchill
English/American translation “Two nations divided by one language”Winston Churchill
  • Bluestocking
  • Ha-ha
  • Spinney
  • Spotted dick
  • Chalk and cheese
  • Chemist
  • Surgery
english american translation
English/American translation
  • Bluestocking - an intellectual woman
  • Ha-ha - a ditch, used to keep animals from getting into the garden.
  • Spinney - a little copse of trees
  • Spotted dick- a sweet pudding made from suet, flour, sugar and dried fruit
  • Chalk and cheese – two people or things that are polar opposites
  • Chemist - someone who works in a drugstore (pharmacy)
  • Surgery – the office of a primary care physician
a bonus question
A bonus question......

There are only two employers in the world that are bigger than the NHS. One is the Chinese Red Army

What or who is the other one?


How is the NHS performing?

  • 98% patients can get a routine appointment with their primary care physician/General Practitioner (GP) within 48 hours or with another primary care professional within 24 hours
  • 97% people with cancer start treatment within 32 days of referral by their GP
  • 92% patients get surgery in <18 weeks of GP referral
  • 98% patients get through the emergency room in <4 hours (either treated/discharged or admitted to a bed)
  • Cancer mortality rates fallen by 19.3% since 95-7
  • Biggest reductions in recorded hospital infection rates in the world
  • (Currently) highest recorded improvements in public satisfaction with NHS since surveys started

Everyone (54 million) gets this. No-one pays!

the population of great britain
The population of Great Britain


Source: The Times, August 2009




















the english nhs today a complex system
The English NHS today: a complex system
  • 1.4 million employees
  • 55 million patients (population)
  • 1 million patients every 24 hours
  • funded directly by tax
  • 10 Strategic Health Authorities (each
  • covering a population 2.5 - 7 million)
  • Primary, secondary, tertiary care
  • Ambulance services
  • Mental health
  • Dentists, Opticians, Pharmacies
  • (drugstores)
  • Population/public health
  • School health
  • Sexual health
  • etc
the lifecycle of a system
The lifecycle of a system

Source: adapted by John W Kenagy from Brenda J Zimmerman

innovation characteristics
Innovation characteristics
  • Disruptive innovation
  • Simplicity; unattractive, overlooked providers
  • Our capabilities are our disabilities.
  • Reliability, access, customised care, lower cost
  • Improve to meet the needs of new, more demanding users

Sustaining innovation

  • Better services, best for our customers
  • Making better use of existing capabilities
  • Better functionality and new features
  • Adapting current ways we do things to meet population and patient needs

Source: adapted from John W. Kenagy, MD, MPA

the lifecycle of a system1
The lifecycle of a system

Source: adapted by John W Kenagy from Brenda J Zimmerman

why was the nhs established in 1948
Why was the NHS established in 1948?
  • Cataclysmic effects of the war made it possible to have a massive change of system, rather than incremental modification.
  • The combination of the state and the people had won the war. Together they could do anything
  • The population had rights healthcare is a right, not something bestowed erratically by charity
  • Bipartisan agreement that the existing services in a mess and had to be sorted out
  • Financial difficulties for the voluntary hospitals
  • Creation of an emergency medical service as part of the war effort
  • Increasing view among younger members of the medical profession that there was a better way of doing things
launch of the nhs july 1948

“It will provide you with all medical, dental and nursing care.

Everyone - rich or poor, man, woman or child – can use it.

There are no charges… There are no insurance qualifications.

But it is not a “charity”. You are all paying for it, mainly as taxpayers, and it will relieve your money worries in time of illness.”

Launch of the NHS, July 1948
The underpinning philosophy to the formation of the NHS; In 2010, 85% of the English population agree with this principle

The collective principle asserts that the resources of

medical skill and the apparatus of healing shall be placed at

the disposal of the patient, without charge, when he or she

needs them; that medical treatment and care should be a

communal responsibility that they should be made available

to rich and poor alike in accordance with medical need and

by no other criteria. It claims that financial anxiety in time of

sickness is a serious hindrance to recovery, apart from its

unnecessary cruelty. It insists that no society

can legitimately call itself civilized if a sick

person is denied medical aid because of lack

of means.

Aneurin Bevan, In Place of Fear, p100

universal coverage is not a panacea to the health of a nation
Universal coverage is not a panacea to the health of a nation
  • It helps, but…..
  • After 61 years, significant health inequalities exist

London Underground:

the Jubilee Line

table question
Table question

How would people react to this in your country or setting?

the lifecycle of a system2
The lifecycle of a system

Source: adapted by John W Kenagy from Brenda J Zimmerman

before the nhs has its 50 th birthday
Before the NHS has its 50th birthday…

1984 – Introduction of “General Management”

1987 – big rises in demand, health authorities in debt, waiting lists growing, hospital beds closing

1991 – introduction of “Internal Market”; “purchaser/provider split” and “GP Fundholders”


What event happened in 1997

that was seminal to the NHS?

How was the NHS viewed by the

people at this point?

the lifecycle of a system3
The lifecycle of a system

Source: adapted by John W Kenagy from Brenda J Zimmerman

The transformational programme has two stages:stage 1: creating a system from an organisationstage 2: using the levers in the system
  • 1997-2007 creating a system from an organisation. Developing geographically based commissioners to buy the care
  • Developing separate providers to sell the care
  • All within a system that has open access for all with no payments for care
the architecture of the new nhs from 1997
The architecture of the new NHS from 1997

1. Developing better value in demand

Local population based commissioning through PCTs; (GP) Practice Based

Commissioning; Patient Choice enshrined in the NHS Constitution

2. Developing better value in supply provision

Public hospitals with more independence (Foundation Trusts); new

private providers; new forms of primary care provision and polyclinics

3. Pricing: transactional relationship between demand and supply

National tariff which ensures providers have to earn money rather than

just spend ii covering 70% of hospital work; commissioned contracts for all

health services

4. Putting the N back in the HS

National contracts for staff; national frameworks for major disease groups;

national agreements for which drugs can be used; national independent


5. Linking investment with reform, quality and improvement

National improvement programmes to support nationally determined

performance goals;

nhs plan 2000 was the biggest change since 1948
NHS Plan (2000) was the biggest change since 1948
  • 20,000 more nurses; 2,000 more GPs, 7,500 more hospital specialists; 6,500 more therapists; 100 more staff childcare facilities
  • challenging national targets for patient waiting times, backed by clear accountability and performance management regimes
  • Expansion in services for cancer, heart disease and mental health
  • “earned autonomy” for local hospitals that perform well (“Foundation Trusts”)
  • National Institute for Clinical Excellence (NICE) to end the “postcode lottery” of drugs and treatments
  • New contracts for hospital doctors and GPs
  • 85% of NHS budget given to Primary Care Trusts to determine where it should be spent rather than giving money straight to hospitals
  • bigger role for the private sector within the NHS
  • In real terms, 50% extra in funding over five years
a considerable increase in resources flows through the reform levers
A considerable increase in resources flows through the reform levers
  • Over 10 years, commissioners learn how to construct a market in care
  • Providers learn how to provide to that commissioning and be responsible for their own organisations
  • The national system learns to construct contracts and pricing relationship
  • We learn to use national contracts for staff to change behaviour.

Commissioning is the process of determining:

the health needs of the population

the resources available

how to organise service provision for this

buying the resources from local providers

Commissioning occurs:

mainly by Primary Care Trusts

for rarer conditions, at PCT group, Strategic Health Authority or national level

© NHS Institute for Innovation and Improvement/ DH, 2009

a short history of nhs improvement
A short history of NHS improvement


Pre 1997

  • national task and finish teams
  • “waiting list busters”

projects and programmes at local level




  • first national Collaborative programme
  • Cancer Services Collaborative
  • establishment of NHS Modernisation Agency
  • national body to support improvement
  • 151 national improvement programmes
  • >800 national improvement staff



  • delivery agenda for cost and quality
    • refocus on implementation support; “alliance” of improvement organisations
  • establishment of NHS Institute for Innovation and Improvement “design” rather than “delivery” organisation; 50 improvement staff; 6 Priority Programmes

The focus is on direct patient care

“Everything I need to do my job is conveniently located”

‘The paperwork is easy to understand and quick to complete’

‘We have the information we need to solve our own problems, and find out if we were successful”

I am not interrupted by people requesting information or looking for things

‘It is clear to everyone who is responsible for what”

‘’Handovers are concise, timely and provide all the information I need”

Opportunity to increase safety and reliability of care

Role Time (e.g. nurse)

Total Time







Direct Care Time





Control of the processes





Commitment of the people

Where we are trying to get to…

Lean organisation alignment

Source: Wickens

what we are learning from releasing time to care
What we are learning from Releasing Time to Care
  • How much energy can be unleashed by encouraging front line teams to question how they work and providing simple tools and skills to do this
the productive ward the evidence
The Productive Ward - the evidence

Research study from NHS London

  • Releasing Time to Care has been a significant catalyst for change
  • It has resulted in measurable, positive impacts.
    • 13 percentage points increase in median Direct Care Time
    • 7 percentage points increase in median Patient Satisfaction Scores
    • 23 percentage points increase in median Patient Observations

Source: NHS London 2009

This equates to having an extra 255 full‑time nurses….while an equivalent level of service improvement without the programme would cost an estimated £7.5 million a year

Nursing Management July 2009

practices use nonphysician clinical staff for patient care
Practices use nonphysician clinical staff for patient care

% reporting practice shares responsibility for managing care, including nurses, medical assistants

Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

a career framework for the nhs


More Senior Staff


Consultant Practitioners


Advanced Practitioners


Senior Practitioners/Specialist Practitioners




Assistant Practitioners/Associate Practitioners


Senior Healthcare Assistants/Technicians


Support Workers


Initial Entry Level Jobs

A Career Framework for the NHS
profile of current nhs workforce
Profile of Current NHS Workforce

Senior specialists and managers










Source: Department of Health

major opportunities to improve skill mix
Major opportunities to improve skill mix

Senior specialists and managers










Source: Department of Health

case study endoscopy technician
Case study: Endoscopy Technician
  • Benefits:
  • significant reductions in waiting times for patients
  • better patient experience
  • safe, effective care
  • improvements in staff recruitment and retention
  • increased flexibility of service provision
the lifecycle of a system4
The lifecycle of a system

Source: adapted by John W Kenagy from Brenda J Zimmerman

the qipp challenge for the english nhs
The “QIPP” challenge for the English NHS
  • Realise a savings gap of $25 billion between 2011 and 2114, whilst improving quality
  • Achieve these outcomes at a scale and pace never seen before in any industry

Quality, innovation, productivity and prevention

what should our response be
What should our response be?
  • Since in the past financial resource has risen with demand, if that does not happen now, how do we realise (bring into reality) other sources of value?
  • Other industries use new technology to wipe out old technology. Health services are bad at doing that as the old technology makes sense in the hands of very powerful professionals
  • How do we transform by finding new value relationships and stopping old value relationships?

A transformational response

The area under the curve is likely to reduce, with the care models fundamentally shifted, to enable resources to be redeployed more effectively.

£ and/or demand

Community Public Health

Individual Prevention

Long Term Condition Management

Avoiding Hospital Admissions

Hospital Care


End of Life care

a different future 1 commissioning a new pathway
A different future:1. commissioning a new pathway
  • Currently we typically commission episodes rather than pathways of care.
  • A year in diabetic care pathway would provide better joined up care
  • But the care commissioned also needs to contain the buying of much more support for self management and primary care.
  • And buying less secondary care
a different future 2 providing a new pathway
A different future2. providing a new pathway
  • The pathway needs to have very proactive primary care with the family practitioner finding the diabetic much earlier
  • The practitioner then directs the patient to nurse supported patient groups
  • The emergency care beds need to be decommissioned as a part of this process
a different future 3 building will and capability
A different future3. building will and capability
  • Creating a common narrative based on core purpose and future direction; not just “improve quality and save cost”
    • “reconnect with the fundamental mission of the NHS in a modern way for a modern world”
  • A mobilising call to action at every level of the system
  • Accelerating skill building for NHS commissioners
  • Building pathway redesign capability
  • Redesigning new, more flexible job roles
  • Co-create with service users and citizens
  • Technical AND allocative efficiency
a different future 4 realising new value
A different future4. realising new value
  • In the current model, healthcare only provides value when a patient comes into contact with staff or kit
  • The patient is a sponge of value not a co producer. Other industries have been revolutionised by the customer co producing value alongside the provider
  • Patients with long term conditions have the possibility of adding considerable value to their health care if the provider will allow them to do it.
  • A new business model, new mindsets and new providers?
the lifecycle of a system5
The lifecycle of a system

Source: adapted by John W Kenagy from Brenda J Zimmerman