Health and health services: the next 20 years

The NHS is currently enduring the most radical reform of its services since its birth 64 years ago. This is compounded by the most austere financial conditions ever imposed in its history (1). The uncertain present preludes an uncertain future. No doubt the future holds great challenges for health and social care, but also with uncertainty comes great opportunity.

‘Defining success in healthcare is more difficult than in commercial business’

This paper begins by defining success based on the key challenges and opportunities for health and social care organisations in the next 20 years, focusing on political, economic, social and technological factors. The authors then describe how health and social care services need to change to achieve success within the context of quality, cost and innovation. They argue that successful organisations will utilise new technologies to monitor the quality of the care they provide and hence deliver better value health and social care.

Finally, using the domains of the NHS Change Model, the authors create a framework identifying what leaders at different levels, particularly patient leaders, need to do to enable and sustain the change essential for success.

What success in health, wellbeing and health services will look like in 20 years’ time

Defining success in healthcare is more difficult than in commercial business where the unifying goals are increasing profits and market share. In the NHS financial success is framed in terms of operating within budgets. Any additional activity, which might normally generate additional revenue in business, could potentially result in overspend and poor financial performance. Therefore rather than focusing solely on finance or activity, success is better defined by the four domains of quality: patient experience, clinical effectiveness, safety, and efficiency (2,3).

The quality, innovation, productivity and prevention programme was launched in 2010 in response to increasing demand and costs, flat real terms funding for the NHS and a £21 billion re-investment required to meet Wanless’ aspirations for the “solid progress” scenario by 2015 (4).

It is now estimated by the Office for Budget Responsibility that it will take until 2037 to achieve a health care expenditure equivalent to that of 2010 (5; figure 1). Therefore the productivity challenge is here for the foreseeable future. Successful organisations in health and social care need to maintain their focus on quality (6) in order to meet the needs of the population in the tough financial climate. The next sections outline some of challenges and opportunities associated with this.

Challenges

The supply of resources for health and social care services will struggle to meet demand. Revenue from general taxation will diminish as a higher proportion of the population retire and pay less tax. By 2035, the number of people of pensionable age is projected to increase by 28 per cent, whereas the number of people of working age is only projected to increase by 16 per cent (figure 2). Furthermore the population aged 80 and over is projected to double (7).

Even the current health and social care delivery system, despite recent progress, has failed to keep pace with the needs of an ageing population, the changing burden of disease, and rising patient and public expectations (8).

‘Efficiency will be found in new ways of working; changes in skill mix; training; and responsibilities of clinical staff’

Reductions in premature deaths from causes such as cardiovascular disease have contributed to increased life expectancy. Growing numbers of older people and carers with multiple conditions will require greater support for their complex needs (9). The additional cost of care for people with dementia alone is predicted to increase from £15 billion in 2007 to £24 billion in 2026 (10). Managing long-term conditions will be a major source of pressure on the health and social care systems. Success will be demonstrated through empowering more patients to take control of their own treatment.

The next 20 years is likely to see ongoing public health challenges such as the rise in obesity, physical inactivity, harmful use of alcohol, hepatitis C and the ongoing need to reduce smoking rates (9). The role of prevention in primary care will become increasing important in the future. Currently, 90 per cent of healthcare interactions are with primary care (11), whereas the greatest proportion of resources is currently used by secondary care.

There are also significant challenges ahead for the NHS workforce as the average age increases (12). Workers could also be lost to other countries such as Australia and Canada (8). This means less NHS workers per head of the population and a potential skills imbalance. Efficiency will be found in new ways of working, changes in skill mix; training of healthcare professionals; and responsibilities of clinical staff (13).

Given these challenges, maintaining quality will become more challenging as resources are stretched across competing needs..

Opportunities

Within the context of a constantly changing system and in the face of all these challenges there are also opportunities for success. Given that 83 per cent of health care expenditure in the UK is publically funded (14), the political environment is a major influencing factor over the health and social care systems. Recent major reconfigurations have included the introduction of general managers into the NHS (15), the separation of purchasers from providers (16), the establishment of primary care trusts in 2000 and their planned abolition in 2013 (17).

The Health and Social Care Act 2012 has started to take impact. New clinical commissioning groups are likely to commission services more focused on clinical outcomes. The act also has a strong emphasis on supporting integration of health and social care. NHS organisations will be held more accountable for their financial performance.

Pluralism will increase, with NHS organisations permitted to perform more private work, and the private sector allowed to tender for NHS services. If managed correctly, this will provide opportunities for organisations to become more business focused, investigating new revenue streams, including those in emerging markets.

‘Following the Olympic opening ceremony, the government announced they would support NHS organisations set up global brands and franchises’

Technological change is a key area in which successful organisations are already investing. Success will be based on using new technologies to generate new opportunities, rather than implementing as late adopters. One theorist has attempted to tie together the major global shifts to predict future trends in technology (18), shown in figure 3. A common theme running through many of his predictions is the power of information.

Electronic access to health care records is growing (19) and organisations that provide this will benefit most. Done well, it empowers patients to be better informed about their health and treatment needs, improving the dialogue between clinicians and patients. When combined with telepresence, an immersive videoconferencing system, new opportunities in e-health will be possible.

Being fully internet-present and able to deliver care remotely will allow organisations to more easily provide care across geographical boundaries. Not only will this improve patient care but will also widen the market available. For example, a foundation trust could provide specialist medical services remotely to developing nations, thereby generating a lucrative healthcare export.

Another opportunity for public health is the possibility of using meta-data. As more data becomes connected to the internet, and platforms become more compatible, it becomes possible to mash many datasets together to create meta-data (20). From this will arise new insights into disease patterns and susceptibilities.

In the UK, meta-data from patients known to have colorectal cancer was used to create algorithms to risk-stratify healthy individuals. The algorithm was able to identify the 10 per cent of the population that had a 70 per cent risk of developing colorectal cancer in the next two years (21). This technology relies on clean data being available to public and private researchers. Successful organisations will secure this access and utilise meta-data to identify their patients’ treatment needs early.

How health and social care services will need to change to achieve success

There are three intertwined areas where services need to change: quality, cost and innovation (figure 4).

Quality and cost

Organisations in health and social care will need to be more innovative to survive the financial constraints. Setting up foreign business ventures is one example of generating a separate revenue stream and has successfully been deployed by institutions such as Moorfield’s Eye Hospital (22). Following the London 2012 Olympic opening ceremony, which featured one of the biggest ever global marketing campaigns for the NHS, the government announced (again) they would be supporting NHS organisations to set up global brands and franchises (23). Furthermore, as NHS organisations are now permitted to generate up to 49 per cent of their income from private care, they should expand to provide additional non-NHS services for a premium, such as life-scans and personal health checks.

‘Unfortunately the NHS is well known for being risk-averse and innovation-hostile’

The quality agenda is shifting focus from a predominantly activity-rewarded to an outcomes-rewarded system. Organisations that measure and improve on outcome and balancing indicators rather than process indicators will be best placed to capitalise on these new incentives when they arise. Information systems that can capture the right data, share it freely and provide real-time benchmarking need to become widespread (24).

The drive for quality is also an opportunity to improve efficiency. There is evidence to suggest that doing the right thing the first time not only delivers better quality, but can also lead to reduced cost (25). Although this notion arose in healthcare, the principle applies to social care, which needs to offer more support for people’s wellbeing and independence instead of only responding to a crisis point (26).

Recently the concept of value-based health care has tried to reconcile the quality and cost objectives of an organisation, which can sometimes pull in opposite directions (27). In VBHC the overarching goal is value for patients, defined as quality over cost, and not access, cost containment, convenience or customer service. Quality improvement then becomes the most powerful driver of cost containment and value improvement.

If the health and social care system is to create a VBHC delivery system, the infrastructure would need to change in several ways including: organising care into integrated practice units around patient medical conditions; measuring outcomes and cost for every patient; and building an enabling information technology platform.

As highlighted by the Nuffield Trust (28), electronic patient-level costing systems bring a distinct advantage in finding greater efficiencies, and their use should be disseminated. However, transparency, benchmarking and communication between commissioners, policy makers and providers will be the key to even greater success with these systems across the NHS.

Innovation

Innovation is the only way by which the NHS can continue to improve on quality within the current real terms funding (29). Innovations arising from empowered frontline staff can offer the radical patient-centred service redesign and savings (30). Unfortunately the NHS is well known for being risk-averse and innovation-hostile (31). Recent research has helped understand the determinants for innovation in healthcare (32). The model is shown in figure 6.

If health and social care organisations are going to deliver step changes in efficiency and effectiveness, so as to improve quality and reduce cost, they will have to change how innovation is fostered and supported. The system and individual components of the above model need to be optimised, and then the interaction between them needs to be facilitated (33).

One system innovation that has spanned several government reforms and recently gathered momentum is integrated care. The Nuffield Trust recently sought to define this as “an organising principle for care delivery that aims to improve patient care and experience through improved coordination. Integration is the combined set of methods, processes and models that seek to bring this about” (34).

There is no single model of integrated care in the UK, however Torbay is one that has demonstrated the most measurable progress, by reduced use of hospital beds, lower than expected use of beds for emergency admissions in people aged 65 and over, the virtual elimination of delayed transfers of care, and improved access to immediate care (35).

‘There are many barriers to integrated care and they vary in different areas of health and social care’

Their success has been attributed in part to tight integration of health and social care, with co-location of services, pooled budgets and dedicated coordinators. The potential of an integrated approach to health and social care to create efficiencies and savings was also supported in a systematic review by Turning Point (36).

There are many barriers to integrated care and they vary in different areas of health and social care. Broadly they fall under: inter-operability between IT systems, operating procedures between health and social care, transfer of funds, tariff concerns, risk aversion, providing patient choice, governance, clinical practice and cultural differences (37).

Despite the increased “fragmentation” of the commissioning system, health and social care will need to drive forwards the recommendations made by three recent national reports to enable dissemination of integrated care: the Future Forum Report, the King’s Fund and the Nuffield Trust response to DH and Health Select Committee report (38–40).

What leaders can and should do to enable and ensure substantial and sustainable improvement

As evidenced above, there a number changes that health and social care services need to make to meet the challenges of the next twenty years. However, successful change will not be possible without strong and effective leadership.

The NHS Change Model was recently developed with hundreds of senior leaders, clinicians, commissioners, providers and improvement activists (41). Using this model, the authors of this paper have developed a matrix to describe what leaders at different levels of the health and social care system (patients, policy makers, commissioners and providers) should do to enable and ensure substantial and sustainable improvement in the next twenty years (figure 8). These are described in following section.

Patients

Formal development of healthcare leaders has grown in recent years with schemes such as the National Leadership Council’s clinical leadership fellowship. However the notion of patient leaders has arisen too. Many patients are already involved in shaping care services, yet their leadership potential is not often harnessed, particularly in decision making (42). This will provide opportunities to define what good care looks like in partnership with health and social care leaders.

An example of successfully fostered user-innovation comes from Ryhov County Hospital Jönköping, Sweden, where a dialysis patient initiated his own patient-led dialysis facilitated by the nurses. Within five weeks he was managing his dialysis independently and before long the patient was training other patients to manage their own treatment, which brought a fall in infection rates (43).

Providing patients with more leadership opportunities in service delivery also has the potential to deliver cost savings. An Australian study of a consumer-led service evaluated the effectiveness of peer mentors, who provide support to patients recently discharged from mental health inpatient care. Over three months, a reduction in readmissions saved three hundred bed-days and almost AUS$100,000 (44).

Leading large-scale change requires leaders to connect with people on a values level. Harnessing emotional energy is a powerful means of motivating people and stories that describe user and patient experiences play a key role. The Welsh Ambulance Service used patient stories to convey the impact that long delayed journeys had on patients attending dialysis units. This created an emotive case for change (45). Emotive patient stories were also a significant component of the Lord Patel review of drug treatment in prisons, which led to wide scale change to the way drug treatment services in prisons are commissioned (46).

Policymakers

During these times when the focus is so much on the finances, leaders at all levels need to strongly defend the shared purpose of the NHS and remind everyone of the values that motivate change and improvement. In particular leaders at the national level need to ensure that the policies clearly communicate a vision of high quality care for all and that legislation supports organisations in doing this.

‘Leaders at all levels will be responsible for driving changes, but patients in particular will need to take on an increased role’

Leaders at the legislature and policymaking levels have a particular challenge in balancing the benefits that improved data sharing can provide while protecting the confidentiality of patient information. In the US, the government started publishing the average one-year graft survival for kidney transplants in each centre on a funnel plot. Without any further interventions, one-year graft survival increased from 80 per cent in 1987-9 to 94% in 2008-10 (27).

Ensuring the information is communicated to patients in a way that is useful to them and that they can use is of paramount importance. As highlighted in Ben Goldacre’s ‘Bad Science’ column (47), ensuring this data is portrayed by the media in an informed way is just as important.

Leaders need to be competent in the use of data to underpin all improvement efforts. Links with public health at all levels need to be strengthened to allow greater use of health intelligence on which to base decisions on health and social care provision.

Commissioners

Commissioners need to make tough decisions to decommission services that are not value-for-money or evidence based. Centralisation of stroke services in London was an example of successfully implementing a new whole system of care. Within a year, mortality rates and cost per patient per admission for stroke fell (48). Convincing units that they needed to close to make stroke care better was tough, but in the end successful as the clinical leaders across the network shared a common purpose and strongly believed that it was the right way forwards.

Commissioners also need to work together to share resources. When five PCTs in Leeds merged, they implemented a new project and programme management framework to provide access to project management resources and consultancy type services (49).

Providers

Leaders in provider organisations need to learn from commercial businesses such as Apple and Nissan, where they turned financial trouble into worldwide success. Improvement methodologies such as Six Sigma and Lean are now being utilised by NHS Trusts. In Ipswich Hospital, Lean was used to improve the care for emergency surgical admissions. Compliance with certain process measures was significantly improved and transfers to other wards were significantly reduced (50).

At all levels, leaders need the courage to have difficult conversations in order to change the way that services are delivered, particularly through new ways of working and models of care. Leaders need to encourage collaboration and a greenhouse for innovation to take hold, and then be prepared to take risks in executing them. Vertical integration of care as a way to reduce healthcare costs was originally proved at Kaiser Permanente. The funding and establishment of NHS Kaiser beacon sites, of which Torbay was one, facilitated diffusion of this innovation into the NHS (35) and further dissemination was facilitated by the Integrated Care Pilots scheme (51).

Conclusion

It is clear that the challenges facing health and health services in the next 20 years are great. Success for the system will be sustaining progress in all four areas of quality. Evidence suggests that organisations that focus on quality also improve on productivity and therefore increasing value.

The changes most likely to deliver these successes for health and social care will include developing innovative revenue streams, using a value-based healthcare approach to enable quality improvement to drive cost reduction, fostering user-innovations to deliver radical service redesign and spreading the vertical integration of health and social care services.

The leaders at all levels will be responsible for driving these changes, but patients in particular will need to take on an increased role in health and social care in the UK if the system is going to achieve success during these challenging times. 

James Haddow is a specialist registrar in general surgery and Dominique Allwood is a specialist registrar in public health at the Whittington Hospital. Rachael Hunter is a health economist at University College London

Acknowledgements

The authors would like to thank Professor Martin Marshall, Professor Steve Morris and James Mountford for providing their invaluable comments.

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