What can England teach us about changing healthcare? Final version of the presentation

1. A16/B16 What can England teach us about changing healthcare? Helen Bevan @HelenBevan Steve Fairman @SteveFairman1 Crystal Ballroom, Salon A-C @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

2. 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 • Strategy at system level versus frontline reality • Case study of “discontinuous innovation” @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

3. The English NHS: facts and figures • Provides comprehensive healthcare to 51 million people • Funded by direct tax • It’s free at the point of delivery • Virtually EVERYONE uses it @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

4. at h W ta ri B @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS lo in s ve

5. @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

6. The NHS is highly valued by the public – we love it! Source: Ipsos Mori 2013 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

7. If there was one thing that the British people took from the [World War II] experience, it was a health service free at the point of use...... And no government of any stripe has dared to try to take it away from us since..... Andrew Marr History of Modern Britain @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

8. The British people have the NHS in place of fear Aneurin Bevan Founder of the NHS @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

10. The NHS belongs to the people It is there to improve our health and well-being, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of our lives. It works at the limits of science – bringing the highest levels of human knowledge and skill to save lives and improve health. It touches our lives at times of basic human need, when care and compassion are what matter most @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

11. Patients have a legal right to: • Access to health services • Nationally approved treatments, drugs and programmes • Respect, consent and confidentiality • Informed choice • Involvement in their healthcare and in the NHS • Complain and to have that complaint redressed @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

12. Populations served by British health systems (as a % of total population of Great Britain) ENGLAND SCOTLAND 84% 51,446,000 people Source: The Times August 2009 8% 5,169,000 people WALES @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS 5% 2,993,000 people NORTHERN IRELAND 3% 1,775,000 people

16. What do we know about how our NHS is performing? Some great news! 16 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

17. 17 NHS | Presentation to [XXXX Company] | [Type Date] @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

20. What do we know about how our NHS is performing? Some less great news! 20 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

25. Challenges facing the NHS today Future pressures • Improving outcomes against the NHS Outcomes Framework • Ageing population and rising birth rate • Significant inequalities in health and life expectancy • Increasing burden of disease – e.g. by 2035 46% expected to be obese with 550,000 extra cases of diabetes • NHS performance on certain diseases lags behind the rest of Europe • Patient and public expectations rising • Burden of long term conditions increasing • ‘Flat real’ financial settlements expected (i.e. only in line with general price inflation) • Demands on hospitals, emergency admissions and readmissions rising • Costs expected to keep increasing with new and more technology • Patient experience is too variable • NHS productivity difficult to increase – grew only 0.4% between 1995 and 2010 • Unacceptable safety failures 25 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

26. We could adopt this view… 26 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

27. “Be ambitious – you can’t take two steps over a gap” David Lloyd George

28. The role of NHS England • To allocate resources (£63.4bn in 2013/14) to clinical commissioning groups (CCGs) • To support CCGs to commission services on behalf of their patients (according to evidence-based quality standards) • To have direct responsibility (and a £24.7bn budget in 2013/14) for commissioning services: • primary care (£11.1bn); • military and prison health services; • high secure psychiatric services; and • specialised services (£12.0bn). 28 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

29. The role of NHS England (2) • To create the conditions for value for taxpayers and turn their money into good clinical outcomes through strong and well-directed commissioners • To ensure that everything that NHS England does: • contributes to continually improving outcomes; • has been clinically-led; • promotes equality and supports a reduction in health inequalities; • is informed by the needs, views and wishes of patients and the public; and • promotes innovation and puts research into practice. 29 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

30. “What do you mean, you don’t have real authority, you only have influence?” 30 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

31. The history of the NHS in a triangle… QUALITY STANDARDS TENSION MONEY 31 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS ENTITLEMENT

32. NHS England and transformational change All our work on the ‘Case for Change’, the ‘Call to Action’ and further work to come, must be: •Based on clinical arguments about improving outcomes •Underpinned by a sound evidence base •An integral part of every local plan •Something that appeals to both the head and the heart… 32 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

33. The NHS Change Model www.nhschangemodel.nhs.uk @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

34. What do we need to do? 1. 2. 3. 4. 5. 6. 7. 8. Understand the scale of the issue Work with patients and be transparent Shift public expectations Shift from the current clinical model (Primary/Community/Secondary….Integrated) Be relentless on efficiency Get the incentives right Find, understand and implement best practice Encourage innovation 34 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

35. 1. Understand the scale of the issue 35 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

36. The Gap… 36 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

37. Why do we have a growing financial challenge? Because the equation… Demographics + Patient/Public Expectations + Quality Money …doesn’t work unless we have transformational change to the current way of delivering health care @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

38. The Dependency Ratio is rising alarmingly 38 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

39. 2. Work with patients and be transparent AND 3. Shift public expectations 39 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

40. A Call to Action @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

41. Preserving the values that underpin a universal health service, free at the point of use, will mean fundamental changes to how we deliver and use health care services. This is NOT about: • Privatising the NHS • Charging for services • Restricting access

42. What are the engagement themes?

43. Current challenges We know there is more to do and recommendations for improvement already exist

44. What the people we serve want…. My goals/outcomes Communication Person centred coordinated care Emergencies Transitions “My care is planned with people who work together to understand me and my carer(s), put me in control, co-ordinate and deliver services to achieve my best outcomes” Care planning Information Decision-making

45. 8 high impact interventions • Early diagnosis • Primary care referrals and prescribing • Self-help: patient-carer communities • Telehealth/telecare • Case management and coordinated care • Mental health • Dementia pathway • Palliative care 45

46. 4. Shift from the current clinical model 46 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

47. Why working across organisational boundaries is important The core area for effective integrated care

48. 5. Be relentless on efficiency 49 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

49. The Magic Box “Clinical Development” Cost “Drift” “Cuts” Reduced hospitalisation Standardisation Technology / innovation Time saving Reducing clinical error Waste reduction Improved quality With thanks to Jim Easton @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

50. 6. Get the incentives right 51 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

51. Commissioning

52. 7. Find, understand and implement best practice AND 8. Encourage innovation 53 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

53. The Academic Health Science Networks 54 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

54. Core objectives for Aims of NHS EnglandAcademic Health Science Networks 1. Focus on the needs of patients and local populations 2. Build a culture of partnership and collaboration 3. Speed up adoption of innovation into practice to improve clinical outcomes and patient experience 4. Create wealth through co-development, testing, evaluation and early adoption and spread of new products and services

55. 56 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

56. John Kotter: “Accelerate!” • We won’t create big change through hierarchy on its own • We need hierarchy AND network • Many change agents, not just the usual few • Changing our mindset • From “have to” to “want to” • Head and heart, not just head and @helenbevan @HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents

57. The largest simultaneous improvement initiative in the history of the NHS @helenbevan @HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents

58. It started with a tweet! Trainee doctors and improvement leaders started to talk about how they could build a social movement to improve care Damian Roland Stuart Sutton Helen Bevan Source: @NHSChangeDay @helenbevan

59. A 189,000 pledge mountain! @helenbevan 60 Source: @NHSChangeDay

60. People took action all over the country @helenbevan

61. Probably the only winner of a global challenge to develop leaders in the corporate world that names Saul Alinsky and Marshall Ganz as major influencers @helenbevan

62. Change Day 2013 was an extraordinary moment in the history of the NHS. It taught us that large-scale improvement is possible in the NHS and that the best way to do it is through collective commitment, action and by keeping it simple. @helenbevan

63. 3rd March 2014 www.changeday.nhs.uk @helenbevan

64. @helenbevan

65. ....the last era of management was about how much performance we could extract from people .....the next is all about how much humanity we can inspire Dov Speidman @HelenBevan

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