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Reorganisation is not the key to change


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Thursday, 19 May 2011

Reorganisation is not the key to change

Sir Muir Gray, who has seen more than his fair share of NHS reforms in a career spanning 40 years, is not a big fan of reorganisations.

He cites a chief executive who declared: “I would like to reassure you that the reorganisation will make no difference.”

Being sceptical of reorganisation is not the same as being anti change.

It remains true that the way the system is organised can have a big impact on cost. The McNulty review of the railways has identified that the UK system costs the rail traveller about 40% more than rail systems in other parts of the world.

Since operational responsibility for tracks and trucks were separated and the network thrown open to competition, the public subsidy to the railways has increased in real terms from around £1bn to £5bn a year. The obvious solution is to reduce fragmentation by cutting the number of operating companies and franchises.

Some people make similar arguments for a monolithic NHS, but the comparison is false. The fact that some train services may rise about the standard of the average is not an effect of competition but of plurality of provision. All people care about is that the trains run on time and that services are safe and affordable.

Train travel would almost certainly be cheaper if the railways were reorganised.

The difference in the NHS is that cost is only part of a more complex equation and the real determinant of success is value.

According to Muir Gray, value = outcomes/costs, where outcomes is the benefit produced by a treatment minus the cost of delivery. Moving the costs up or down doesn’t tell us anything about the rest of the equation. If you don’t know what the outcomes are then you can’t tell what effect the money is having.

According to Muir Gray, “After 20 reorganisations we still don’t know whether care for people with diabetes is better in Liverpool or Manchester…Or what we spend to the nearest hundred million on epilepsy or bi-polar disorder.”

Most of our attempts to describe outcomes are based on descriptions of what we have spent money on. No one will ever argue with the headline figure that £xbillion was spent on CHD or £ybillion on cancer and in an ideal world neither x nor y would ever be enough, but where there are finite resources the question is whether the money is being spent on the right thing. And it’s not enough to ask the question at national scale. The right thing will depend on exactly where you are geographically and demographically.

Muir Gray’s Right Care team is doing valuable work mapping healthcare variation and providing the evidence against which healthcare investment decisions can be assessed dispassionately.

Those in the NHS providing poor value for patients and taxpayers have every reason to fear the Atlas of Variation and other attempts to introduce scientific rigour to the collection and dissemination of evidence.

Wherever there are choices to be made about healthcare investment there will screaming tabloid headlines and politicians running for cover.

That will never change, but unless commissioners have the evidence to make tough decisions and the courage to explain them to patients, we can reorganise forever and still expect no change.

SJBurnell says:
May 19, 2011 11:58 PM
Actually, as explained in the last sentence of the blog, Effective Reorganisation can be an important part of the fix, but we must make Honest & Intelligent Choices:

Cooperation or competition? Design or denial? Evidence or evasion? Facts or fiction? Consensus or conflict? Optimal or obstinate? Patients or profits? Balanced Care Service or Blunt Cost Savings? Resourced or rationed? Success or failure?

This requires better decision-making processes & the Tools to support them & the extra effort needed to inform better Resource re-Allocation Decisions & good Investment Choices with strong evidence & sound experience. Boards must Demand the Evidence & denounce pure rhetoric.

Big, risky, or difficult to reverse Future State changes need to be Modelled & Simulated. Effective Reorganisation is Designed & Consensual & tried & tested before it impacts Patients & Staff. I can show you how.
georgewilliams says:
May 20, 2011 12:31 PM
There is clearly a need for GP Practices within each regional GP Consortia to be able to collaborate with each other - to share documents, share meeting notes, messaging each other and so on. What software tools have you found useful?

jpatterson says:
May 23, 2011 03:21 PM
Hi George
There is nothing to stop GP consortia creating networks on the NHS Networks site to share documents and set up private discussion boards. We don't yet support person to person messaging, but we're thinking about it.