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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
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
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
at
h
W

ta
ri
B

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

lo
in

s
ve
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
The NHS is highly valued by
the public – we love it!

Source: Ipsos Mori 2013

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

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
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
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
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
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
What do we know about how our NHS is
performing?

Some great news!

16

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

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

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

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
What do we know about how our NHS is
performing?

Some less great news!

20

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

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

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

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

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

26

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
“Be ambitious – you can’t
take two steps over a gap”
David Lloyd George
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
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
“What do you mean, you don’t have real
authority, you only have influence?”

30

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
The history of the NHS in a triangle…
QUALITY
STANDARDS

TENSION

MONEY
31

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS

ENTITLEMENT
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
The NHS
Change
Model

www.nhschangemodel.nhs.uk
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
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
1. Understand the scale of the issue

35

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
The Gap…

36

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

38

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
2. Work with patients and be transparent
AND

3. Shift public expectations

39

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
A Call to Action
@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
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
What are the engagement themes?
Current challenges
We know there is
more to do and
recommendations for
improvement already
exist
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
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
4. Shift from the current clinical model

46

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
Why working across organisational
boundaries is important

The core area
for effective
integrated
care
5. Be relentless on efficiency

49

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

51

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
Commissioning
7. Find, understand and implement best
practice
AND

8. Encourage innovation

53

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
The Academic Health Science Networks

54

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
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
56

@HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
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
The largest simultaneous improvement
initiative in the history of the NHS

@helenbevan
@HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents
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
A 189,000 pledge mountain!

@helenbevan

60

Source: @NHSChangeDay
People took action all over the country

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

@helenbevan
@helenbevan
....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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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
  • 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
  • 18. 18 NHS | Presentation to [XXXX Company] | [Type Date] @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
  • 19. 19 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
  • 21. 21 NHS | Presentation to [XXXX Company] | [Type Date] @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
  • 22. 22 NHS | Presentation to [XXXX Company] | [Type Date] @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
  • 23. 23 NHS | Presentation to [XXXX Company] | [Type Date] @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
  • 24. 24 NHS | Presentation to [XXXX Company] | [Type Date] @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
  • 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.
  • 48. Why working across organisational boundaries is important The core area for effective integrated care
  • 49. 5. Be relentless on efficiency 49 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
  • 50. 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
  • 51. 6. Get the incentives right 51 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
  • 53. 7. Find, understand and implement best practice AND 8. Encourage innovation 53 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
  • 54. The Academic Health Science Networks 54 @HelenBevan @SteveFairman1 #IHI25Forum #EnglishNHS
  • 55. 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
  • 57. 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
  • 58. The largest simultaneous improvement initiative in the history of the NHS @helenbevan @HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents
  • 59. 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
  • 60. A 189,000 pledge mountain! @helenbevan 60 Source: @NHSChangeDay
  • 61. People took action all over the country @helenbevan
  • 62. 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
  • 63. 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
  • 66. ....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

Editor's Notes

  1. If we listen to what people want from the NHS it is very clear - but challenges the way we work now - the current approach is hospital centric, not community facing: professionally driven not person centred. We have huge challenges but the digital era offers us solutions to these challenges which we need to embrace comprehensively and systematically.
  2. We have a clear vision - quality has three components, which we have used to define our goals but the most important thing is what this actually means for patients and carers.
  3. Peter