Why we should reimagine rather than reopen

This article was first published in HSJ

Over the last two months, the NHS has shown its incredible ability to tackle a crisis. Depending on the next steps we take, there could be positive, lasting consequences as a result of this crisis. We should identify these now and take action to embed them. We see three key opportunities to reimagine healthcare.

Market design

As we know, the NHS payment system is prefaced on hospitals competing with one and other to increase market share and income by performing as much activity as they have capacity for. This market design (sometimes characterised as “competition and contestability” in the 2000s) was introduced by past governments as a way of achieving productivity in the NHS by using quasi-market mechanisms, mirroring those underpinning private sector markets. The shortcomings of this approach are now apparent. Importantly, it doesn’t address key outcomes such as reducing inequalities, improving healthy life-expectancy, and facilitating the necessary collaboration to deliver integrated care.

Changing the focus of the payment regime from competition to collaboration has been a goal of system leaders for some time, but progress has been slow in many areas. Coronavirus has made it essential to move much faster, and providers have embraced the change. The new financial regime has allowed hospitals to focus on rapidly freeing up capacity and directing the right level of resource to meet demand. The announcement to wipe all historic debt further enables trusts to come together to share financial risk without the cloud of large debts undermining confidence in collaboration. These two significant changes are helpful steps towards a new market design that incentivises outcomes and population health over competition and units of activity.

We should not underestimate what a significant shift this is; it’s the beginning of a very different NHS. One that has huge potential to reduce inequalities and create a healthier population. It also presents a strategic challenge to hospitals requiring them to reimagine how they do business. Trust leaders need to be preparing for this change now. Importantly, they need to be able to answer the question, what would I do differently if I was only paid for keeping people well?

Digital delivery

People and organisations across the country are discovering how to communicate, collaborate and do business virtually. Massive strides have been made in a short period of time on virtual consultations. Patients are seeing the benefits of this in terms of convenience, safety and speed at which they can get an appointment. This is something that will surely continue.

The real question for the NHS is, what else? What else could be done virtually? And how does the move to virtual appointments free up capacity and space to re-organise other parts of the system? We need to think beyond virtual consultations to other technologies such as wearable devices and how these further enable patient activation and population health management; electronic at home diagnostic devices that feed live data into online care management systems; better leveraging existing technology that helps people live in their own homes for as long as possible and many others. These technologies have huge potential. Connected diagnostic devices in people’s homes could alert healthcare professionals when someone’s condition is escalating, allowing real time action to be taken to prevent a hospital admission.

A new level of appetite and appreciation of technology is growing. The NHS needs to work with this to drive the changes necessary to reduce inequalities and improve outcomes. As trust leaders create their new business and operating models, they will need to identify partners they can work with to deliver services differently, such as technology partners. This is an opportunity to explore what pharmaceutical, medical device and other companies have to offer in terms of services that improve outcomes. One of the new roles of a trust or system leader will be to cultivate a vibrant supply chain of providers that are enabling people to stay at home, stay well, and avoid or delay acute care.

Social care reform

We knew it before, but it has become clearer that the social care system in the UK is localised, sub-scale and under-resourced. The government has also recognised that this has an emotional angle to it. While there has been so much praise for the NHS, the social care sector has lacked that same collective identity that people can engage with.

This is a social care inflection point illustrating more than ever the need for large scale reform. There has been a string of reviews of social care that have gone nowhere. This time must be different and must look at the market design fundamentals. Central to this is deciding the state’s role in commissioning and paying for services. The social care construct of paying for units of time (for domiciliary care) and beds (for residential care), is increasingly and obviously out of date and is leading to poor standards. Health systems around the world are making decisive shifts towards outcome based, large scale, geographically focused contracts. Why should the same not be true for social care?

In deciding what to do next, we should consider sector-wide reforms outside health that have gone before and what we can learn from them. For example, the introduction of academy chains in the education sector; the successful and safe growth of the early years and nursery education service over the last 30 years. We learnt the benefit of scale, high quality professional development and standards, efficient inspection, consumer choice and incentives, sharing resources across geographies, providing greater autonomy and a viable model for public and private sector collaboration.

Bringing it all together

These changes are all opportunities; all acceleration of creative thinking that existed before the coronavirus. When cities were rebuilt after the Second World War, designers and planners drew up blueprints which combined the best of the old, with the promise of the new. We should do the same for our future healthcare system: preserve the best parts of the system while finding new, imaginative ways to draw on the innovation we now all know can come about as a result of collaboration. The people of the UK deserve – and will expect – nothing less.