Copyright 2018 - Clinical Commissioning Groups Association

70 years on: what is the path ahead?

The National Health Service was founded six years before the first kidney transplant [1], when X-rays were captured on film and moving images and contrast media were still radiological novelties [2]. Meanwhile, a nascent pharmaceutical sector was learning to produce penicillin in quantity while seeking to plan drug discovery rather than waiting for happy accidents.

However, the seminal event of the 1940s was the birth of the NHS with the idea, not of heroic medicine performing miracles for the lucky few, but of mundane medicine that worked for millions. Indeed, the heroic and mundane characterised the next 70 years in a struggle to manage the migration of the heroically expensive to the affordably mundane in delivering mass-medicine.

This quest is a very British story about evidence, social conscience, policy and funding. The British Doctors Study ran for half a century from 1951 but within 4 years had demonstrated the link between smoking and cancer [3]. It confounded popular belief – that smoking was good for you –and established clinical investigation as the way to make medical choices, followed on from Hill’s breakthrough randomised control trial (RCT) of streptomycin in 1948 [4]. Clinical trials typically divide a group of people (e.g. with pulmonary TB) into two groups at random (so that they are as similar as possible). One is given the intervention under test (administrating streptomycin) and other is not, and the outcomes (recovery from TB) are counted. For those interested, the James Lind Library has more information [5]: it is named after the eighteenth century Scottish physician who conducted an early trial to show how citrus fruit could end scurvy.

In 1972, another Scottish doctor, Cochrane, advocated the widespread use of RCTs and that all specialties periodically summarised those RCTs in a systematic way that would inform clinical practice. The global Cochrane Collaboration that aims to produce high quality systematic reviews of healthcare interventions [6] remains to this day and his book [7] is still in print.

With the establishment of NICE (now the National Institute for Health and Care Excellence) in 1999 [8], the struggle between the heroic and the mundane took a new turn as the NHS set the production of guidance upon a combination of trials results and economic principles to assess when society (through the NHS) should pay for a treatment.  The open addition of affordability – alongside safety, efficacy or performance – to the criteria guiding clinical choices, was initially radical, and the role of NICE is now embedded in law through the Health and Social Care Act (2012).

So what lies ahead in the battle between the heroic and the mundane? So far, against a backdrop of incredible advances in what can be imaged, diagnosed, and treated – fields to which NHS staff also contributed – the NHS has applied a combination of clinical evidence and economics to interpret its original mandate in the rough and tumble of care for everyone, free at the point of delivery. With cost and capacity pressures likely to intensify under the heightened expectations of a population that lives longer and with longer periods of illness, we must ask how the NHS can address quality and affordability in new ways.

An obvious challenge lies in converting the best evidence to best practice, itself a twofold problem.  First, doctors do not always implement what is known to be best, especially if doing so presents practical problems.  Thus, prescribing practice tends to comply better with NICE guidelines than surgical procedures or the use of medical devices [9]. Second, guidance is unlikely to be implemented where the doctor is unconvinced by it [10]. We know, for instance, that implementation of evidence rarely follows a linear approach, with doctors typically applying heuristics and “mindlines” [11]. Turning what we know into what we do is thus a second major challenge.

Second, we must look beyond individual clinical decisions, since, even if technology and drugs were free, healthcare costs would still spiral upwards because most of what the NHS spends is on salaries. The efficiency and effectiveness with which the NHS uses the time of its staff is probably the biggest challenge facing it in the 21st Century.  We do not know how much NHS staff time is lost because we do not measure service failure. The next patient may appear because something has gone wrong or simply through the illness: most of the time, it is hard to know without analysis. Nonetheless, the past few decades have seen waves of initiatives to improve the way that care is delivered. However, blockages and overflows persist, despite studies on restructuring the workforce [12], changing hospital flows and/or emergency provision [13]. A second major challenge then, is to design better structures and operational processes and systematically to implement them.

This pair of critical challenges throws a fresh light on the need for evidence.  In our data-rich world – social media, clinical records, pharmacy transactions, transport links, and even the weather – there is information to be mined and turned into evidence to drive better patient experiences and outcomes. Beyond this, healthcare services themselves generate data that can be harvested with smart sensors – smartphones, even – and analysed by information systems to boost both performance and efficiency.  Such information may be used by the system or by patients themselves. A fresh look at the information and data sources available is therefore needed, along with research that enables it to be forged into consistent forms of evidence that can drive service delivery as well as clinical decisions. This represents a third big step to be taken.

The final piece of the puzzle is business models that reward outcomes and better experiences.  Through the Quality and Outcomes Framework [14] and Payment by Results [15], the NHS has experimented with getting value for money. So far, the experience has been mixed and often incentives simply drive more activity. A third challenge, then, is to develop a consistent approach that covers all aspects of provision.

In setting up the NHS, the UK government committed to do something dramatic and to attend to the practicalities afterwards. Seventy years down the line, we are still in awe of this resolve and must not underestimate the many, often hidden, problems that the NHS has solved with innovation and panache. Its back-to-front approach of starting with the dream and then working out how to keep the dream alive has proved remarkably robust.

The question now is whether the NHS continues to retro-engineer fixes or whether it needs something more fundamental.  The dream is viable, but there is a strong case to recast the dream in formal design. We now know enough about quality, evidence and funding models to specify what we really want, and during the same 70 years, industry has taken service design into unimagined realms of performance and efficiency. In doing so has cracked many of the logistics, information management, and process control problems that beset the NHS. We can have a very different NHS.

After 70 years of the NHS, we still face a question of resolve rather than viability: do we really want it?

Acknowledgement

The author thanks Prof Hywel Williams for help with the narrative of the development of trials methods.

References

 

[1]

LiveOnNY, “Organ Transplant History,” Blue Fountain Media, 2017. [Online]. Available: http://www.liveonny.org/all-about-transplantation/organ-transplant-history/. [Accessed 20 March 2018].

[2]

British Institute of Radiology, “1940s diagnostic imaging,” Mentor Digital, 2018. [Online]. Available: https://www.bir.org.uk/patients-public/history-of-radiology/1940s/1940s-diagnostic-imaging/. [Accessed 20 March 2018].

[3]

R. Doll and A. B. Hill, “The mortality of doctors in relation to their smoking habits,” bmj, vol. ii, pp. 1451-1455, 1954.

[4]

L. E. Bothwell and S. H. Podolsky, “The Emergence of the Randomized, Controlled Trial,” New England Journal of Medicine, vol. 375, no. 6, pp. 501-504, 2016.

[5]

I. Chalmers, U. Tröhler, D. Badenoch and P. Glasziou, “The James Lind Library,” Minervation Ltd, Oxford, 2018. [Online]. Available: http://www.jameslindlibrary.org/. [Accessed 4 April 2018].

[6]

The Cochrane Collaboration, “Cochrane. Trusted Evidence. Informed decsions. Better health.,” 2018. [Online]. Available: http://www.cochrane.org/. [Accessed 20 March 2018].

[7]

A. L. Cochrane, Effectiveness & Efficiency: Random Reflections on Health Services, London: Royal society of Medicine Press, 1999.

[8]

NICE, “Who we are,” 2018. [Online]. Available: https://www.nice.org.uk/about/who-we-are. [Accessed 20 March 2018].

[9]

T. A. Sheldon, N. Cullum, D. Dawson, A. Lankshear, K. Lowson, I. Watt, P. West, D. Wright and J. Wright, “What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews,” bmj, vol. 329, no. 7473, pp. 999-1003, 2004.

[10]

C. Heneghan, R. Perera, D. Mant and P. Glasziou, “Hypertension guideline recommendations in general practice: awareness, agreement, adoption, and adherence,” British Journal of General Practice, vol. 57, no. 545, p. 948–952, 2007.

[11]

J. Gabbay and A. le May, “Evidence based guidelines or collectively constructed “mindlines?”,” bmj, vol. 329, p. 1013, 2004.

[12]

R. M. Bohmer and C. Imison, “Lessons From England’s Health Care Workforce Redesign: No Quick Fixes,” Health Affairs, vol. 32, no. 11, pp. 2025-2031, 2013.

[13]

L. S. van Galen, E. M. Lammers, L. J. Schoonmade, N. Alam, M. H. Kramer and P. W. Nanayakkara, “Acute medical units: The way to go? A literature review,” European Journal of Internal Medicine, vol. 39, pp. 24-31, 2017.

[14]

M. Roland and B. Guthrie, “Quality and Outcomes Framework: what have we learnt?,” bmj, vol. 354, p. i4060, 2016.

[15]

A. Street and A. Maynard, “Activity based financing in England: the need for continual refinement of payment by results,” Health Economics, vol. 2, pp. 419-427, 2007.

[16]

L. H. Toledo-Pereyra, “Heart Transplantation,” Journal of Investigative Surgery, vol. 23, pp. 1-5, 2010.

[17]

E. Wolstenholme, “A patient flow perspective of UK health services: exploring the case for new" intermediate care" initiatives,” System Dynamics Review, vol. 15, no. 3, pp. 253-271, 1999.

[18]

D. C. Lane, C. Monefeldt and J. V. Rosenhead, “Looking in the Wrong Place for Healthcare Improvements: A System Dynamics Study of an Accident and Emergency Department,” The Journal of the Operational Research Society, vol. 51, no. 5, pp. 518-531, 2000.

[19]

E. Elder, A. N. Johnston and J. Crill, “Review article: Systematic review of three key strategies designed to improve patient flow through the emergency department,” Emergency Medicine Australasia, vol. 27, pp. 394-404, 2015.

[20]

I. Scott, L. Vaughan and D. Bell, “Effectiveness of acute medical units in hospitals: a systematic review,” International Journal for Quality in Health Care, vol. 21, no. 6, pp. 397-407, 2009.

[21]

S. J. Gillam, A. N. Siriwardena and N. Steel, “Pay-for-Performance in the United Kingdom: Impact of the Quality and Outcomes Framework—A Systematic Review,” Annals of Family Medicine, vol. 10, no. 5, pp. 461-468, 2012.

[22]

M. Roland and S. Campbell, “Successes and Failures of Pay for Performance in the United Kingdom,” New England Journal of Medicine, vol. 320, no. 20, pp. 1944-1949, 2014.

 

 

f t g m