Doing what we do, better

The next government will inherit challenges in the public sector, the likes of which haven’t been seen for a generation. The Institute for Fiscal Studies forecasts that public sector net borrowing will be 11 per cent in 09/10, 12 per cent in 10/11 and 10 per cent in 11/12, meaning that the national debt will have grown from around 40 per cent of national income in 2005 to around 80 per cent in 2015.
    
The consequence of this is a real reduction in public spending of around £35bn over the next three years projected in the Pre-Budget Report – just over three per cent per annum on average. Yet, despite these constraints, the PBR announced protection for health, with a guarantee to maintain the level of real spending, as well as Overseas Development, schools and Sure Start. Ring fencing these budgets will mean that the annual real cut in everyone else’s budgets – particularly defence, higher education, transport and housing – will be nearer to 6.5 per cent per annum.
    
The implications of this for the NHS are obvious. As health is the largest spending delivery department in Whitehall, the impact of a real increase in health service funding would be catastrophic for other departments, and therefore very unlikely. An extra one per cent for the Department of Health would equate to a 10 per cent cut in the budget of the Home Office or the Ministry of Justice.
    
However, maintaining the real level of funding in health is not the triumph it may seem to other government departments. The King’s Fund in their report, “How cold will it be?”, has shown that the NHS has the expectation of real growth hard-wired into its DNA. The NHS has seen average real growth of three per cent per annum since 1948 and seven per cent per annum since 2000. Zero real growth will feel like a cut, and even after the recently announced constraints on pay rises. The NHS will need to achieve 15-20 per cent productivity improvement over the next five years if it is to meet the growth in demand for its services and maintain public confidence.

The political challenge
As a result of this financial context, the next government will be caught in the cleft stick of having told the public that it will protect the NHS, whilst the NHS itself will be behaving as if it was being cut. Many observers of health and education would argue that the rapid increases in funding have resulted in improved services, but not proportionate to the increase in level of funding. Not unreasonably, they conclude that if public services could make the step change in productivity that has been seen in successful private sector organisations, they could protect, or even improve, the quality of their services, even during a period of tight financial constraint.
    
Furthermore, the public know that the NHS budget has doubled in real terms since 1999-00 and will not expect the NHS to start dismantling services the moment the going gets rough. If the learning of the past ten years is that the NHS can only succeed when its mouth is being stuffed with gold, we could find ourselves back in the position we were in 2000, with the fundamental concept of the NHS being challenged again.
    
So the challenge for politicians and the NHS is how to create an acceptance of the need for change in the minds of the public and staff, where there is a general distrust that change equates to cuts, and be seen to be delivering improvement in difficult time, without drawing the anger of the public and professions by being the ones to deliver bad news.

Reform in an information age
The key contribution of informatics to this challenge, so far, has been to make the “sleight of hand” approach to health service management more difficult. When the NHS was last under serious financial pressure, in the 1990s, it was not subjected to real scrutiny. Hospitals would close wards in the winter to save money. Waiting times weren’t published, no one knew about hospital acquired infection and in-hospital mortality rates were only studied by academics. Public opinion was that the NHS couldn’t be any better; only the patients themselves knew that they’d spent 12 hours on a trolley waiting for a bed.
    
This is not the case now. The government publishes a waiting time, quality and satisfaction data on a monthly, quarterly and annual basis. Dr Foster exposes unsafe hospitals, even when CQC doesn’t, with the help of the national media. Patients are invited to seek out information about their GP or hospital and make choices.
    
In facing up to the future financial pressures, none of the traditional levers are available. Pleading for more money will be beyond even a sympathetic government’s ability to deliver, but slipping back in standards will be immediately visible to the public: cutting quality will be exposed by Dr Foster and the CQC, lengthening waits will be exposed by Minister’s own transparency. The choice is now stark, transform productivity or be seen to fail.

What must informatics offer?
Informatics has two crucial roles to play in transforming the NHS – firstly to help create the conditions for radical change and secondly to make a real contribution to making NHS better and cheaper.
    
Creating the conditions for change through information: Many of the changes that the NHS needs to go through have the potential to provoke public outcry. Consolidating services, closing inpatient facilities and changing the model of care all create resistance in local communities. Transparency of information has the potential to inspire the public to make demands for radical changes that by-pass traditional vested interests. This is a crucial role for informaticians within and outside the NHS.
    
Think of the power that public opinion could have on health, if campaigning organisations and the local media were able to discover the fact that your chances of dying in hospital after being admitted with a heart attack are three times greater in one NHS hospital than in similar hospitals in the same city and that these two hospitals have very similar costs. This information could challenge the public perception that services can only be improved with more money or that every penny is being well spend. They might move from demanding that their A&E Department be protected at all costs, to demanding to know why the NHS has been so complacent in allowing such variation to occur.
    
The challenge for informaticians looking in on the NHS is to unleash the challenge that transparency brings and help liberate a force for change which may be the catalyst needed to create a better, cheaper NHS.
    
Enabling the transformation of services: Unleashing a force for change is of no help if the NHS doesn’t know what to do in response. The challenge for CIOs is to be at the heart of the design and delivery of that solution. If an organisation needs to reduce costs by 25 per cent over the next five years, as many will, then non-critical but ‘nice’ upgrades to systems and business as usual will not be acceptable. Hospitals and PCTs will be attempting to deliver a set of operational, tactical and strategic changes, all of which need informatics to support them if they are to be successful.

Meeting the operational challenges
In hospitals, the heart of the changes will be clinical operational performance. Hospital managers need real-time operational information on the flow of patients into, through and out of the hospital so that they can see where the problems are arising, as they happen – not when it seizes up from excess patients. And, crucially, they need timely data on quality fluctuations so that they can see quickly if the changes they are making are putting patients at risk, not three months down the line.
    
PCTs need to be able to track referral patterns as well as how their money is being spent, both by GPs and provider arms: there is a multitude of productivity opportunities in community hospitals and district nursing services. Hardly any hospital has the information that it ought to have to run a £200m business and even fewer PCTs are really applying the information that they should to spend upwards of £1/2bn of taxpayer’s money.

Meeting the tactical challenges
Driving productivity and reducing waste are crucial to the future of any hospital or PCT, but they are not enough. Gathering data must support improvement as well as demonstrating failure.
    
A crucial step is creating real ownership and leadership from hospital doctors and GPs for the changes that are needed. It will be up to informatics and finance staff to provide these clinician-managers with timely, accurate information on finance (service line or practice budgets and spend), activity and quality if they are to take on the burden that their chief executive asks of them.
    
The hypothesis that too many patients are in hospital will need to be turned into a change in practice in every PCT and hospital. If this is to be safely and effectively done, informatics will need to provide an evidence based utilisation tool to support the assessment of whether a patient needs to be in hospital or could be cared for in a lower intensity and lower cost environment.
    
Increases in community based care and reduced hospital admissions will inevitably result both in clinical services being consolidated onto a fewer number of sites and in patient care being shared between multiple locations and providers. PCTs and hospitals should be investing in electronic document management systems, recognising that, outside of the GP surgery, paper will be the primary form of clinical data capture for many years to come and that the inability to move this around electronically is a blockage to change and puts patients at risk.

Meeting the strategic challenges
Hospitals and PCTs need to realign whole health economies to ensure that money is spent to maximise health gain rather than simply fund the services that were delivered last year, the year before that and so on.
    
Firstly, basic core data needs to be accurate: good quality clinical coding, to a depth that is clinically meaningful, with complete use of the NHS number. Information must be shared between organisations; no patient benefits from NHS institutions squabbling over data.
    
Beyond this, it requires the NHS to focus on keeping people well and to view an admission to hospital by a patient with a long term condition as a service failure. This will require tools to undertake population segmentation, risk stratification and pro-active targeting of the patients to help them manage their illness better. It will almost certainly require the provision of composite primary and secondary data to allow nurse led call centres to coach patients remotely; and it will involve the integration of home based assistive technologies to be linked to NHS information systems.
    
And, of course, real transformation of the health system only comes when we recognise that information needs to be clustered around the patient, not the institution. The involvement of multiple institutions in the care of an individual (eg hospital, GP, polyclinic, private provider, social services etc) will increase in the future; informatics will need to decide whether it wants to continue to be a drag on progress or become part of the solution.

Conclusion
The NHS is about to go through one of the biggest upheavals in its history. This time, it won’t be driven by political decisions but by hard economics. The NHS has two potential responses. One is to declare a financial crisis, start cutting services and reduce the quality and quantity of what it offers to the public. The other is to declare an efficiency crisis and focus on achieving a step change in the effectiveness with which it buys services and productivity of those services. The former needs very little data. The latter is an information led response, which will require the informatics profession to be at the heart of transformation.
    
If your organisations don’t sit with data in front of it to make key decisions and doesn’t require the CIO to be part of the decision making process, then informatics hasn’t made itself crucial to the improvement of the organisation and the services probably faces cuts not improvement.
    
That is the challenge to the informatics profession for 2010. Be relevant, be essential and be right!

About the author – Professor Matthew Swindells
Matthew joined Tribal as managing director of Health in June 2008 from the Department of Health. During his three years at the Department of Health he worked firstly as the senior policy advisor to the Secretary of State and then joined the NHS Management Board as the NHS’s first chief information officer.
   
Prior to his period at the Department of Health, Matthew has 18 years experience in the NHS: in procurement; as head of Information Technology at a large teaching hospital; in general management; and, ultimately, as chief executive of a large acute hospital, where he lead the turn-around of one of the worst performing hospitals in England to becoming one of the best.
   
Matthew is a visiting Professor of Management at the University of Surrey, a Fellow of the British Computer Society and Chair of the Charitable Trustees at Imperial College Academic Health Sciences Centre.