NHS chief executive Sir David Nicholson told last year’s NHS Confederation conference that the health service was on a “burning financial platform.”
Yet, as he prepares for this year’s event in Liverpool, the organisation’s chief executive frets that it may “not yet have burned enough” to persuade managers to face up to some of the big challenges ahead of them.
On a train from Yorkshire, where he spent most of his managerial career, Mike Farrar says there is no doubt that trust finances are now under strain, with two acutes in administration.
At the same time, there is evidence that quality and patient experience is starting to deteriorate, with ‘risk summits’ being held on A&E departments that are in regular breach of the four hour treat or admit target.
Yet big chunks of the health service are still being distracted by the reorganisation imposed by the ‘Liberating the NHS’ reforms, while the acute sector is “reeling from the Francis report [into the Mid Staffordshire NHS Foundation Trust scandal].”
Overall, Farrar says, “the NHS is still struggling, and perhaps struggling a bit harder”, but it is “still not transforming the system.”
Getting into the I of QIPP
Farrar gives a couple of reasons for this. Some areas, he suggests, are still managing to squeeze just enough out of short-term changes – a reduction in the NHS tariff here, a clamp down on wages there – to put off big internal changes or reconfiguration.
And there is a lack of political leadership. Since last year’s Confed conference, Andrew Lansley has been replaced as health secretary by Jeremy Hunt.
Judging from the past few weeks, his instinct is to set up taskforces and find small sums of money to address “crises” like the one in A&E, even though NHS England is now, theoretically, in charge of the day to day running of the health service.
It does not seem to be to back the kind of reorganisation across health economies that might start to head off demand and make services more sustainable.
“We were hoping that, in the middle of a Parliament, we might see some acknowledgement that we need to change things fundamentally – that, with two organisations bankrupt we need to avoid failure – but it hasn’t happened,” Farrar says.
The NPfIT legacy
Farrar started his career at Rochdale Infirmary, and worked his way through the management ranks to become a health authority and then strategic health authority chief executive.
In his last post before joining the NHS Confederation in October 2011, he was chief executive of NHS North West, which created the Advancing Quality Alliance or AQuA programme to collect and spread best practice about how to improve quality in the health service.
AQuA puts a focus on using information and IT systems to drive change, and Farrar has broken new ground for the NHS’ biggest management body when it comes to urging its members to get to grips with the IT and information agenda.
In the early findings of a ‘bureaucracy and regulatory review’ that he was asked to conduct for Hunt, he notes that a third of NHS staff spend up to three hours a day just collecting and recording data.
So “just getting electronic patient records in place that are shareable and allow information to be collected once and used many times should be an easy win.”
He also argues that IT is needed to shift care across boundaries and to refocus it on patients.”We need to be more transparent, and that means giving people access to their records, and using services like digital booking.”
Farrar sees more political leadership in this space – with Hunt calling for a ‘paperless’ NHS by 2018 and national director of patients and information Tim Kelsey “bringing huge energy” to the patient agenda.
But he admits that, on the ground, this is another area in which the pace of change is too slow. “The reasons are multifactoral,” he says. “The NHS lost confidence in NPfIT.
“There is lack of demand from the service, so industry has to spend a lot of time selling into it. It is hard for industry to sell at scale; telehealth, especially, remains a minority sport, so of course it is expensive for those who do try it.
“Clinicians are not connected to the process, so decisions are made about software that are bad for the people who have to use it.”
Investing and finding clinical leaders
The NHS Confederation itself is trying to address some of these problems. For example, it has been working with the ABPI to highlight innovations for which there is a good evidence base, and it is setting up an innovation equity fund.
“We are just in the process of finding a fund manager for that,” Farrar says, adding that the fund is likely to have £250m available to attract further money and invest in promising ideas.
“The fund is all about quality improvement, which might come from investment in IT, the pharma industry, or other areas,” he says. “It could fund anything from an app it likes the look of to a major system.”
Farrar also remains committed to the idea of introducing chief clinical information officers to the NHS. “I am still a great supporter of that because it tackles the gulf between clinicians and those buying IT.”
He sees a particular role for clinicians in taking forward some of the early findings of the bureaucracy review, which called for a fundamental rethink of the information that the NHS collects, focused on “a single, shared definition of quality” that can be used as “the basis for a single data set.”
“We need to have clinicians drive that data set,” he argues, adding it is “remarkable” that, at the moment, only a fraction of the data items collected for clinical audit are part of the NHS’ minimum data sets.
“You cannot leave technology to technicians and you cannot leave information to informaticians. We need to get everybody involved.”
Remaking the market
The bureaucracy review published some early findings in March, and will now go on to undertake more detailed work on first national and then local demands for data.
However, it has already recognised that it will also be necessary to “invest in and incentivise the NHS to adopt digital means of data collection and input.”
Since its first report came out, NHS England has turned its attention to getting electronic patient records into trusts. EHI has been running The Big EPR Debate to collect views on what is needed, and the commissioning board is due to issue guidance for trusts in June.
Farrar has been talking to NHS England about this work. But asked what he had in mind when he wrote that it would be necessary to “invest in and incentivise” systems, he laughs and admits that it was “money.”
“You need upfront investment,” he says. Unfortunately, Hunt has already indicated that there will be precious little of that – although the Department of Health has just found £260m for e-prescribing.
Farrar suggests that the NHS will need to think more creatively. For example, he suggests that trusts might do deals with suppliers, in which they take on some of the risk of creating systems that deliver savings eventually.
“Some suppliers are heavily backed, and they might be interested if they could see a return,” he suggests. “NPfIT had a very simplistic attitude to the market; it wanted to buy something it thought was in place. We need something more sophisticated, based around risk sharing.”
Burning bright
Remaking the NHS IT market to support new ways of working in the health service feels like a very long-term challenge. Unfortunately, Sir David’s burning platform is burning faster all the time.
Still, Farrar suggests, the sooner the NHS makes a start, the easier things will be. “The longer you go on, the more expensive it becomes,” he says. “Short termism is one of the biggest risks we face.”
The NHS Confederation will hold its annual conference in Liverpool from 5-7 June this year.