A ‘Thought Piece’ – for discussion
by Gordon Stirrat1, David Blockley2, Kirsty Alexander3 & Sabrina Phillips4
1 Emeritus Professor of Obstetrics & Gynaecology, University of Bristol, UK.
2 Emeritus Professor of Civil Engineering, University of Bristol.
3 GP & Chair Bristol North and West Locality Leadership Group at Bristol, North Somerset and South Gloucestershire CCG, UK.
4 Alliance Director (Interim)| Lambeth Living Well Network Alliance
The United Kingdom’s National Health Service (NHS) was launched on 5 July 1948 with three underlying principles – the services were for everyone; healthcare was free; and provision of care was based on need rather than the ability to pay. In the intervening 72 years it has developed into an extremely complex organisation and one of the world’s largest employers. Because of its cost to the national exchequer, its organisation and funding have inevitably become matters of great political significance and debate. The general population has developed a great emotional attachment to ‘the NHS’ vividly expressed in, for example, Danny Boyle’s 2012 Olympic ceremony when, at one point, the floor of the stadium was occupied by a host of angelic nurses and 300 NHS beds filled with bouncing children. On the 60th anniversary of the foundation of the NHS Michael Rosen wrote his poem, ‘These are the Hands’, in praise of the mundane but vital contributions of healthcare workers. It has come back to prominence during our current tragic Covid-19 pandemic made even more poignant by the fact that Michael himself has been very seriously ill due to the virus. He has, thankfully survived and is gradually feeling better. Also, during the pandemic many of us have, along with our neighbours, gone out to clap on Thursday evenings as a sign of our support for ‘the NHS’ and the frontline workers coping with pandemic.
To many people in the UK, those working in GP surgeries and hospitals that deliver health (but not social) care are ‘the NHS’. The reality is far more complex, and we suggest that the structure of Health and Social Care Services UK, including the NHS and social care, and how the system reports and is accountable to Government and the public are all unnecessarily complex and opaque.
A complex structure
The Department of Health and Social Care (DHSC) is the Government body responsible for implementing policy in England. It delegates the work to NHS England. It is accountable to the Cabinet, Parliament, and ultimately to the general public. Health policy and implementation is devolved to the Scottish and Welsh governments and the Northern Ireland assembly. England is the only one of the 4 UK administrations to have a quasi-market but all use performance targets.
The NHS is complex set of organizations which, for the most part, work quite well despite a myriad of sub systems. A number of authors have referred to this complexity (1, 2, 3, 4) and, for example Powell (4) says ‘The leadership of the NHS seems fractured……a system under siege where success isn’t celebrated but failure is catastrophised’ We need ‘to build the confidence of the people who hold the problem.’ Attempts to explain the complex systems are necessarily partial (5, 6, 7). Good people can make a poor system work well but when pressures overwhelm them failure can be catastrophic (8). The NHS England long term plan (9) recognises the issues and states that the NHS will move to a new service model with ‘properly joined-up care…..creating genuinely integrated teams….with Integrated Care Systems (ICSs) everywhere by April 2021. ICSs will ‘deliver the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care………Breaking down traditional barriers between care institutions, teams and funding streams.’ The intention of the plan is that providers, commissioners, local authorities and others will together locally plan and integrate care to meet the needs of their population. This initiative has grown out of sustainability and transformation partnerships and is the latest in a long line of NHS organisational changes. Currently there are 18 ICSs but demonstrations of progress are sparse (10).
How will integration be successful?
What are the incentives that will make integration work? Why should the many providers take responsibility for the total care of the whole population for probably less resource – when they have very little control over all the parts?
Everyone in the NHS shares a strong common purpose of ‘caring for our patients’. But does that translate into more detailed shared purposes at the various levels of the sub-systems?
We suggest that the key to driving change should be ‘influencing from the bottom up’ and not more ineffective ‘top-down’ centralisation (11). When policy decisions for change make sense to those ‘at the coal face’ they will respond. However, that response is conditional on the need for change to evolve up and down through the entire system. Policy makers and those allocating resources should alter, and integrate, some of the factors that will incentivise the ‘coal face’ individuals and organisations to work differently. A particularly important aspect of that incentivisation is that adequate resource follows activity without waste through unforeseen issues. For example, hospitals may initiate medication for a patient for which they have a particular financial deal, but the primary carers are not part of the deal and the medication may become very expensive for them.
The various parties to Integrated Care must also be aware that their potential partners may be fearful of extra work and responsibility being ‘dumped’ onto them. Sometimes, for example, individual GPs may be reluctant to hold challenging risks that hospital staff, with their more collective responsibility, may not be exposed to. If a patient dies during hospital treatment after a late diagnosis of bowel cancer caused at least partly through unintended delays (in the systems and perhaps also by the behaviour of the patient) the GP may find himself/herself in the spot light of blame by relatives, for not diagnosing quickly enough.
Making integrated care work has been variously described as ‘pushing a boulder uphill’ or ‘swimming against the tide. For example, differing financial incentives may produce perverse consequences. The commissioner/provider split and ‘payment by results’ (where income is proportional to activity) sometimes leads to a tick-box culture when used for some parts of the system. Block contracts for others do not incentivise improvements. Payment models have to encourage closer working around the needs of patients by sharing ‘pain and gain’ in an agreed manner. Co-operating organisations in the public and private sectors may have different bureaucratic constraints and work to different priorities and time scales as they attempt to adjust with agility to rapid changes. Organisational culture (in simple terms, the way that things are done – including the unwritten rules that influence behaviour and attitudes) can often dominate strategic aims. Some of the factors that influence culture include: leadership, deployment of resources, clarity of structure and processes, values and traditions. Success rests on leadership that overcomes professional silos and tribalism with good IT and access to targeted data – to harmonise strategy and culture.
There is little evidence of an equivalent attention to the ‘joining-up’ the proliferation of higher level non-local fragmented organisations reporting to or sponsored by the DHSC. The drive for integration ‘at the coal face’ does not appear to be reflected at the top of the NHS. There seems to be no unifying concept around which the integration can coalesce nationally. Without that there is a significant risk of regional ad hoc solutions that may not join-up across geographical/national boundaries.
Understanding the complexity through ‘systemic processes’
We suggest that the entirety of the health and social care system may be better understood by identifying its existing ‘systemic processes’. In saying this we do not imply the need for yet another total re-organisation. Rather we are suggesting an approach that could help the NHS system evolve into a more ‘joined-up’, less fractured and more integrated ‘whole’ across regional boundaries.
First, we need to describe the concept of a ‘systemic process’. This is not a sequence of events as in a flow chart (11). Neither it is simply a series of actions towards an end. Rather it is a reconceptualization of process as a potential that drives a flow of change – just as the volts of a battery drive an electrical current or water pressure drives the flow of water. A systemic process captures what people actually do and how change happens. In human systems the potential is contained in answers to questions ‘why’ – purpose, aims and objectives. The change is contained in answers to questions ‘who, what, where, when’. The transformation of the flow from one ‘state of affairs’ to another is contained in answers to questions ‘how’. The aim is to capture a systemic process as delivering the right information ‘what’ (data as performance indicators, success criteria and shared care records), for the right reasons ‘why’ (purpose), to the right person or organisation ‘who’ (role, stakeholder), in the right way ‘where’ (context) and at the right time ‘when’. Systemic processes are wholes and parts at the same time. They are ‘being things’ that change through natural forces – living or inanimate. You and I are ‘being’ wholes as individuals and yet also parts of family and social groups. As individuals ‘wholes’ we are made of parts such as our muscular skeleton structure and digestive systems. We are as we are because the parts collaborate to form the whole – in other words we show ‘emergent’ characteristics (12).
Applying these ideas to the structure of organisations we see logically related layers of interacting and interdependent systemic processes. For the totality of health and social care services this should encompass all of the organisations in and related to the NHS, including local authority social care and private companies. The successful delivery of a systemic process emerges from the success of sets of processes in the next layer down. An important part of the identification of these lower processes is that their successes are jointly necessary and sufficient for the process above – there is an explicit logical relationship connecting defined success, in all of its manifestations, at every level. It is also important to note that the layers are not hierarchical power structures. Rather they are levels of abstraction from setting policy down to detailed implementation. The attributes of each and every systemic process can be grouped under the headings of why, how, who, what, where and when. At each level the attributes can be identified by multiple players in a common format and implemented on a secure intranet to be accessed by those given authority to do so. Each and every process should have one ‘process owner’ responsible for leading the players involved in that process in detecting and monitoring progress, identifying unintended consequences and agreeing the required actions to steer the process to success (i.e. meeting purpose/aims/objectives) and avoiding failure.
We see the NHS as an ecology of interdependent relations and interactions between systemic processes. Survival and continued success depend on being able to generate an internal ecology of adaptive decision-making at all levels. It may be helpful to imagine each systemic process as a jigsaw piece. The ‘process pieces’ are connected to other pieces not by their interlocking shape but by recording their ‘neighbouring’ connectivity as an attribute and by enacting that connectivity by sharing relevant authorised messages (composed by attributes why, how, who, what, where when). Creating the ecology may then be achieved by identifying, at a particular level, neighbouring processes and building them into clusters – just as you might piece together areas of a jigsaw. Practically it is helpful to name each piece of the jigsaw, each systemic process, using the present participle or ‘ing’ form such as ‘Doing something’ – ‘Testing a blood sample’ or ‘Diagnosing a condition’. An advantage of the approach is that the essence of what people actually do and how change happens is being captured. Then by growing and connecting clusters of systemic processes eventually a ‘whole system’ of layered clusters emerges. What is more during this ‘piecing together’ or ‘cluster building process’ changes and improvements will suggest themselves. For example, points of strategic dissonance may become apparent. This happens when an organisation hangs on to the old ways of doing things for too long because of a disconnect between actions and intent or purpose at any given level. For more on the details of this approach see (13, 14)
The organisations reporting to the DHSC seem to be contributing to seven high level systemic processes as shown in Table 1. There are, of course, many more organisations that cannot be included in the table.
Table 1: The 7 High Level Systemic Processes of Health and Social Care Services UK
|Commissioning care||NHS England, Scotland, Wales and Northern Ireland||Commissions NHS services and is accountable to Ministers of Health|
|Clinical Commissioning Groups (CCGs)||Groups of GPs who purchase acute care on behalf of patients Accountable to NHS England.|
|Public Health England, Scotland, Wales & N Ireland||Arms-length Non-Departmental Public Bodies commissioning services to improve health & address inequalities Accountable to Ministers|
|Providing care||General Practitioners||Provision of primary care to patients under contract to Dept of Health & Social Care (DHSC)|
|NHS Trusts||Acute Hospitals in England & Wales|
|NHS Foundation Trusts||serving either a geographical area or a specialised function. (Do not yet have Foundation Trust status)|
|Supplying (including Special Health Authorities)||NHS Business Services Authority||Supplies business services|
|NHS Blood and Transplant||Supplies Blood and transplant organs.|
|NHS Digital||Supplies informatics|
|NHS Resolution||Deals with legal claims|
|NHS Counter Fraud Authority||Special health authority fighting against fraud, bribery and corruption in the NHS.|
|Regulating||Care Quality Commission||Regulator for health and social care|
|Human Fertilisation and Embryology Authority||Regulator of fertility treatment|
|Human Tissue Authority||Regulator of use of human tissue|
|+ 3 others||Medicines and Healthcare Products Regulatory Agency, Administration of Radioactive Substances Advisory Committee & National Data Guardian|
|Advising||National Institute for Health and Care Excellence||Purpose is to advise NHS on what constitutes good quality care.|
|Chief Medical Officers||Reports to and advises Secretary State for DHSC plus other Government Departments|
|Chief Scientific Officers||Employed by NHS England and leads healthcare science, advises all Government Departments & Chairs SAGE|
|Cabinet Office Briefing Rooms||Advises Cabinet on crisis and emergencies Accountable to Cabinet|
|Commission on Human Medicines||Advises on safety & use of medical products|
|+ 18 others not identified here|
|Educating||Health Education England, Scotland, Wales & N Ireland||Purpose is to support education and training An Arms-Length NDPB (Non-Departmental Public Body) Accountable to DHSC|
|Social Care Institute for Excellence||Independent agency that provides knowledge, evidence and accredited training for social care Accountable to Sponsors?|
|Researching||National Institute for Health Research||Receives funds for research. Accountable to DHSC.|
The success of each of these seven systemic processes depends on (and logically related to) the successes of many lower layers of systemic processes. For example, NHS England allocates budgets to Care Commissioning Groups (CCGs), and so a necessary but not sufficient condition for successful financial outcomes for NHS England depends on successful outcomes for the CCGs. Social care is shared between DHSC and the Ministry of Housing, Communities & Local Government. Advising is delegated to many disparate sources with the consequent risk of inconsistency. Educating is delegated to Health Education England and the Social Care Institute for Excellence which in turn relies on the Royal Colleges and Universities. Research is delegated to the National Institute for Health Research and the Medical Research Council and onto the Universities and research centres. Clearly identifying all systemic sub-processes in the system is a considerable task. But it is a task that can and must be spread across all the players/actors involved in each and every process and captured on a national intranet.
We suggest that by structuring our thinking around these systemic interacting and interdependent processes we could achieve six objectives:
- Provide a simple overview of the whole organisational structure that everyone can understand and appreciate which can be traced right down to the detailed ‘caring for patient’ processes.
- Allow people to identify overlaps and interdependencies. For example, the 23 advisory organisations could possibly be streamlined to co-ordinate advice and avoid incongruity and inconsistency. Could the 8 regulating organisations be consolidated to avoid conflicting data and performance requirements?
- Enable caring for the sick, caring for public health and the vulnerable be under one ‘umbrella’ to avoid inconsistencies of policy over the longer time scales than politicians are typically in post.
- Enable a common data structure for the why, how, who, what, where and when attributes of each systemic process – important to avoid different groups using different data structures that cannot easily be shared and for data exchange via an intranet, with appropriate permissions to sensitive data, and the monitoring of progress and interventions to steer processes towards success.
- Enable all those involved in delivering success for the NHS to identify how the necessary and sufficient conditions for the success of systemic processes at the ‘coal face’ feedback into success and deficiencies at higher policy levels
- Permit us to clarify
- pathways of precise terms of delegation and accountability – in particular;
- how decision makers at all layers of the system delegate responsibilities down through the layers of processes – for example from government to NHS England and others to workers at the ‘coal face’ and ultimately to the patients;
- how decision makers at all layers of the system are accountable up through the layers – for example from hospital ward care to Trust Boards, CCGs, NHS England and to government, parliament and ultimately to the public;
- remove, reduce or ameliorate inconsistencies between policy and practice;
- improve adaptability of response to unintended consequences and future unknowns such as pandemics and potential impacts from climate change.
- The structure of Health and Social Care Services UK reporting to Government seems unhelpfully complex and opaque. We suggest a rationalisation using a ‘systems thinking bottom-up’ approach would be more likely to succeed than yet another top down reorganisation.
- Rethinking the interactions between existing organisations around ‘systemic processes’ could arguably bring considerable benefits including cost savings, better co-ordination, less ‘admin’ stress on staff at the ‘coal face’ and provide more organisational adaptability in an uncertain future.
- Ultimately ‘systemic processes’ could help everyone deliver better patient care because that is the impelling purpose of the NHS.
- Timmins, N (2018) The World’s Biggest Quango: The first Five Years of NHS England, The King’s Fund & The Institute for Government, UK
- Hudson, A (2016) Simpler, Clearer, more Stable: Integrated accountability for integrated care, The Health Foundation, UK
- Powell, M (2016) Leadership in the NHS: Thoughts of a newcomer, The King’s Fund. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Thoughts_of_a_Newcomer.pdf (accessed June 2020)
- Dayan, M., Gardner, T., Kelly, E. & Ward, D. (2018) How good is the NHS? The Nuffield Trust. Available from: https://www.nuffieldtrust.org.uk/research/the-nhs-at-70-how-good-is-the-nhs (accessed June 2020)
- DHSC (2013) The Health and care systems explained. https://www.gov.uk/government/publications/the-health-and-care-system-explained/the-health-and-care-system-explained (accessed June 2020)
- NHS England (2019) Breaking down barriers to better health and care, March https://www.england.nhs.uk/wp-content/uploads/2019/04/breaking-down-barriers-to-better-health-and-care-march19.pdf (accessed June 2020)
- Bristol City Council (2018) Working with Us for Better Lives, https://www.bristol.gov.uk/documents/20182/2678414/Market+Position+Statement/bdd21e05-0a76-94ae-4094-246ad9eb5739 (accessed June 2020)
- Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013), The Stationery Office, London https://webarchive.nationalarchives.gov.uk/20150407084949/http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf (accessed August 2020)
- NHS England (2019) The NHS Long Term Plan https://www.longtermplan.nhs.uk/publication/nhs-long-term-plan/ (accessed June 2020)
- Goodwin N, Smith J (201) The Evidence Base for Integrated Care, The King’s Fund, Nuffield Trust, UK https://www.kingsfund.org.uk/sites/default/files/Evidence-base-integrated-care2.pdf (accessed June 2020)
- NHS Institute for Innovation and Improvement (2005) Process mapping, analysis and redesign, Improvement Leaders Guide, UK https://www.england.nhs.uk/improvement-hub/wp-content/uploads/sites/44/2017/11/ILG-1.2-Process-Mapping-Analysis-and-Redesign.pdf (accessed June 2020)
- Wikipedia (2020), Emergence at https://en.wikipedia.org/wiki/Emergence
- Blockley D I, Godfrey P S (2018) Doing it Differently, ICE Publications, UK
- Engineering Synergy at http://myengineeringsystems.co.uk/