Roundtable: Jeremy Hunt's HSJ annual lecture debated

Opening a roundtable convened to reflect on this year’s HSJ annual lecture, HSJ editor Alastair McLellan admitted it would be somewhat different from other such events.

“Normally when I chair these roundtables, I say everybody keep your feet firmly on the ground because otherwise what we talk about won’t reflect the reality of healthcare in the here and now,” he explained. “But this roundtable is to reflect on the lecture, and that is deliberately something which asks a policy maker to look into the future. It is a platform for a bit of blue sky thinking, rooted in reality we hope.”

‘There’s an interesting psychological difference in terms of how people see schools versus how people see health’

He urged the panellists at the roundtable – run, like the lecture itself, in association with FTI Consulting – to aim for a similar balance. Yes they should think broadly, just as Jeremy Hunt did when delivering his speech, but they should also remain firmly focused on the real world.

Ratings, and Mr Hunt’s specific pledge to introduce Ofsted-style assessments for clinical commissioning groups, attracted most of the headlines after the lecture. It was therefore a natural place to begin the roundtable discussion.

Mr McLellan asked panellists if an Ofsted-style model could and should be applied to the NHS. This would be a system, he said, “in which regulation produced ratings which are acted on by the public as well as by the service”. A Department of Health press release had said that giving patients access to CCG ratings would make “healthcare services in local towns and cities… much more accountable to their local population than previously”.

‘A lot of people aren’t able to exercise choice or look at ratings when they start to access healthcare because they’re in the back of an ambulance’

It was a point somewhat rowed back from during the lecture itself, Mr McLellan noted. During a concluding question and answer session, Mr Hunt had essentially suggested a good rating would be reassurance to the public and a bad rating a recognition that improvements were needed. The refinement of this message was perhaps sensible considering the number of roundtable participants who saw limits to the parallels between school choice and healthcare choice.

“One of the things I think is interesting about the parallel to Ofsted is that we don’t have a national schools service,” pointed out Anne Rainsberry, regional director for London at NHS England.

“So baked into that is the fact that already people expect differentiation in schools. We do have a national health service, and the concept is that you have a similar offer wherever you go. Now we all know that isn’t true, and it’s highly variable for all sorts of reasons, but I think there’s an interesting psychological difference in terms of how people see schools versus how people see health.”

Context of care

Different too, she argued, was the scope of choice available in healthcare in comparison to education: “A lot of people aren’t able to exercise choice or look at ratings when they start to access healthcare because they’re in the back of an ambulance, and at that point you’re unlikely to say: ‘I was reading the ratings the other day, and could you turn left here?’ Figures vary, but it’s going to be 50 to 60 percent [of people] who are accessing healthcare who are in the urgent and emergency care pathway.”

‘My view is that [ratings] are inevitable, it will happen, and we have to do something that makes it translatable to the public’

Sarah McBride, director of delivery at North East Hampshire and Farnham CCG argued: “Anything that puts more information and control into the public domain is the right thing to do. The challenge is an Ofsted rating about a school in comparison to a vastly complex [healthcare] system that’s got huge influences and interactions within it. Being able to consolidate that into one system-wide rating, I think, is going to be tricky.”

Mike Bewick – until recently deputy medical director at NHS England, now senior clinical adviser at FTI Consulting – also emphasised the challenge of creating a rigorous system-wide ranking for healthcare.

“My view is that [such ratings] are inevitable, it will happen, and we have to do something that makes it translatable to the public so they understand what they’re dealing with,” said Dr Bewick. “But please let’s get the metrics right and get the assessment right, because if we’re using aggregate data that looks across a whole wide range of things that’s affecting that system, I think we’re in danger of polarising the view of an organisation based on untrustworthy evidence.”

Unintended consequences

The impact a negative rating can have on an organisation and its staff has been well rehearsed, and one roundtable member had personal experience of what he called the “unintended consequences” of ratings. David Loughton is chief executive of The Royal Wolverhampton Trust which has, since last year, run Cannock Chase Hospital – formerly part of Mid Staffordshire Foundation Trust.

“It will be many, many years and definitely not within my time before we actually make some significant progress, because that organisation was so damaged, and people just don’t want to work there still to this day because they don’t want it on their CV,” he said.

“So I think you’ve got to take a great deal of care when an organisation goes into special measures – what is going to be the impact on that organisation’s recovery. Mid Staffs is an extreme example, but you can go back many, many years – events at Bristol Children’s Hospital, for instance; they struggled with recruitment there for many years.”

‘I think your ability as an individual to use ratings is dependent upon the choice available to act upon them’

Outside of such prominent and serious stories, Lucy Moore said she was not entirely convinced patients pay all that much attention to healthcare rankings in any case. “I’ve just come from an organisation which has been at the sharp end of ratings” – Dr Moore was, until recently, interim chief executive at Colchester Hospital University Foundation Trust – “and my initial response is it’s interesting how the public try quite hard not to pay too much notice of ratings. It’s also easy to argue that in many parts of country actually people don’t have too much choice.”

“I think your ability as an individual to use ratings is dependent upon the choice available to act upon them,” agreed Sir John Oldham, adjunct professor in global health innovation at Imperial College London and chair of the 2013-14 Independent Commission on Whole Person Care. “In some areas, like conurbations, it may be more possible than it would be in Cornwall. In those areas, maybe the ratings are a pressure on the system to improve – though the evidence isn’t great that would come about.”

Conor Burke, chief officer at Barking and Dagenham, Havering, and Redbridge CCGs, was also keen to understand what was trying to be achieved through the CCG ratings, suggesting the lecture had not made this clear. In principle, however, he declared himself a fan of such information. “I think ratings are a fantastic thing, because I use them all the time in things like TripAdvisor – I choose where I want to go [based on] other people’s experience of those services. So I think implicitly, it’s something that is attractive to us as people and humans because we want the best,” he argued.

Purpose of CCG ratings

“The challenge here is what’s the purpose behind the rating. TripAdvisor creates a market, so is that the purpose through this – the poor providers actually go and the prime providers or commissioners succeed?

“Or is it about regulating an individual commissioner? Or is it about system improvement, could that be the opportunity, could it be about trying to drive forward something?”

Whatever the purpose – Mr McLellan suggested it was to reduce the number of CCGs without being accused of unhelpful structural tinkering – some panel members felt there could be benefits. Miles Scott, chief executive at St George’s University Hospitals Foundation Trust, took “a very positive and enthusiastic view” of ratings.

“It seems to me they have enormous potential for engagement: engagement of patients and the public but actually also – perhaps almost more importantly – engagement of staff,” he said. “My experience of working in hospitals is that staff can get very engaged by rating systems, and it’s a really good way of talking to people and pulling together programmes for improvement within an institution.”

‘I actually found [ratings] the least interesting bit of the speech in some respects’

There were caveats. Like others, he argued any rating needs to be easily comprehensible. “I think you have to rate things, often institutions, that both staff and patients understand,” Mr Scott said.

Professor Cathy Warwick suggested it would also be a case of taking care to rate those things which actually matter to patients. “Very often in maternity, what women and families care about is not always what different professional groups care about,” said Professor Warwick, chief executive of the Royal College of Midwives. “So I think the issue of what a CCG is being rated on and who will produce the data for the ratings is incredibly important. Women often rate respectful, considerate, transparent care over and above things like mortality data, because it means more to them.”

It was a comment that explicitly moved the debate onto the idea of patient power. The focus of post-lecture headlines may have been CCG ratings, but it very explicitly was not the focus of the speech itself. Mr Hunt’s key theme was patient empowerment, particularly through technology, and so he may be pleased to know this was the area of the lecture which most engaged our roundtable panellists. As Sir John Oldham put it: “I actually found [ratings] the least interesting bit of the speech in some respects.”

Digital revolution

Sir John’s interest was instead piqued by the secretary of state’s “strong advocacy for the healthcare system to embrace the digital revolution, in a way that changes the service delivery, not just adds on to the existing model of service delivery. And in doing so, actually empowers the users of the service to get involved but also to manage things for themselves.”

He continued: “[The digital revolution] lowers the power gradient between the user of the service and the professional providing the service in a way nothing else does. We shouldn’t forget that most people with long term conditions actually spend 8,000 hours in a year having to manage their own condition, and yet interface with the health service for, on average, three or four hours. But we spend 99 per cent of our management time on the three or four hours, not the 8,000.”

‘For me, the most interesting part of the lecture was this issue about empowering and engaging patients, but it’s also about the difficulty of actually doing that’

Mr Burke also found the most compelling part of the lecture to be “the potential for the empowerment and liberation of patients, or people”. However, “the downside I felt was actually not everybody wants to be liberated. So one of our areas, Barking and Dagenham, is a very, very deprived area, it’s very industrial – we have the highest cardiac mortality in the country, we have the highest obesity rates in the country, people aren’t choosing to actively manage their healthcare.

“So for me it could create a two tier system – so there could be people that are capable of taking that approach, but there are other people who choose not to for whatever reason. And so that does worry me about the most vulnerable and disadvantaged, and how do we take an approach when people don’t want the power, they actually they want to be told.”

Mr Loughton echoed this. “For me, the most interesting part of the lecture was this issue about empowering and engaging patients, but it’s also about the difficulty of actually doing that with certain groups. Because if I go outside my maternity unit this afternoon, I’ll have someone with a big bump puffing away on a cigarette. So I think the thing we really have got to try to do is engage with these people that we have failed to engage with, to actually take some responsibility for their own ill health.”

Mr Scott deepened the point, saying: “It’s not just the question of maybe there are some people who don’t want all this choice. It’s more a question of how do you ensure those people who are articulate get to express their choice, and you react, but you don’t necessarily distort priorities for everybody else based on those people’s choices.

“You can’t design the system around the minority. We need to facilitate the minority choices, but we mustn’t design the whole system around them.”

Embracing partnership

Professor Warwick felt there was a long way to go before healthcare professionals become entirely comfortable with this sort of partnership approach. “Over the last couple of years, I’ve been starting to really challenge midwives on this, because we think we’re very women-centred, we consider ourselves to be at the vanguard in fact of being patient-centred. And I think it’s a lie, actually.

“I think we pay a huge amount of lip service, not just in maternity but across the health service, of being user-centred, and I don’t think we’ve even begun to think what that really looks like. I think it’s actually a really big challenge, and I just see people’s care driven by the needs of the institution on a daily basis.”

‘When I started out as a doctor, the definition of professional was a possessor of knowledge. Now I am an interpreter of knowledge, because that knowledge is available in a much more widespread way’

Professions “are profoundly nervous of handing over care”, she added. “In my own area, people still can’t bear the idea that a woman who in our minds isn’t suitable for a home birth will choose one, or indeed a woman who we think shouldn’t have an elective [caesarean] section actually wants one. We really struggle I think with [the idea] people might make the wrong choices, and I think we’ve got a lot of education to do to help people start to feel comfortable with this. So we use the words, but we’re scared I think.”

Some panellists did feel progress had been made in changing the patient/professional balance of power. Mr Loughton remarked on how the nature of complaints and complainants had changed in the time in which he has been a chief executive: “Years ago if I saw a complainant, they’d be complaining about the catering, the car parking. If I see a complainant now, it’s usually with a consultant, a member of staff, and the complainant walks in with a lever arch file of information they’ve got off the internet. And that has really changed now – people complain mostly about clinical care now, not support services. And they are informed, a lot more informed.”

Sir John agreed. “When I started out as a doctor, the definition of professional was a possessor of knowledge,” he reported. “Now I am an interpreter of knowledge, because that knowledge is available in a much more widespread way.”

The key, he suggested, was for the NHS to properly engage with that reality. “The NHS can act as the accreditor if you like, the mechanism, the route by which people can access information, be the facilitator. I don’t know anybody, including my own relatives, who if they have been given a new diagnosis don’t Google immediately to find out what’s gone on where. So let’s embrace and formalise that.”

If Jeremy Hunt can preside over such a feat, Dr Bewick suggested the current secretary of state’s legacy would be secure. “I thought it was incredibly well crafted, the speech,” he said. “Because he did say at the beginning, once we are past the hot topics of the time – and then he listed, to be honest, quite a lot of the Five Year Forward View.

“I think he was knitting a legacy together there that it’s about patient empowerment, it’s about the growth of tech, it’s about the changing attitude towards measurement in the system and how we use that. And I think that will be his legacy and he should be proud, because I think he’s stuck to it when a lot of other secretaries of state have been deflected.

“[And I’m not saying that] in a sycophantic way. Because the money has been a big issue, and he’s not really made it a big issue – I think others have done. The money will have been forgotten because there’ll be a solution; there will have to have been a solution. If what he does [on patient empowerment] comes to fruition, that will be remembered in 25 years’ time.”