Editor’s blog Wednesday 9 June 2010: Lansleyism - Health Secretary Andrew Lansley's first keynote NHS speech reviewed

So what is Lansleyism?
Now that at last the DH have put it online, we can review 'My ambition for patient-centred care' - the new Health Secretary's first major speech on the NHS.

Lansleyism, as we shall call it, starts with a commendable focus on achieving “health outcomes – and quality health services – as good as any in the world … a unique combination of equity and excellence, including for the most vulnerable”.

It’s easy and tempting to ’Fisk’ speeches and publications, but in the charming spirit of The New Politics™, let us be clear that this is absolutely the right objective. Jolly good show.

Around this point, I would be expecting a bit of flattery of the professions. And lo: “I’m buoyed by the knowledge that we have medics, nurses and scientists as good as anywhere in the world, I know that we can achieve this”.

The five priorities for health policy
Lansley sets out five priorities:
“First, that patients must be at the heart of everything we do, not just as beneficiaries of care, but as participants, in shared decision-making. As patients, there should be no decision about us, without us.

“Second, that if we are to seek to achieve continuously improving outcomes, then that is what we must focus on. Not politically-motivated process targets, not simply measuring inputs or constant changes to structures, but a consistent, rigorous focus on outcomes – achieving results for patients.

“Third we must empower professionals to deliver. This is the only way we can secure the quality, innovation, productivity and safe care, all of which are essential to achieving those outcomes. Engaged and empowered professionals will deliver results. Disempowered, demoralised and demotivated staff will not.

“Fourth, we must, as a society, do much better on the health and well-being of our families and our communities. Only by prioritising health and well-being and by preventing ill-health more effectively, can we achieve the overall health outcomes we seek, not just good health services but good population-wide health outcomes, and reduce the inequalities in health, which so blight our society.

“Fifth, we must see the many links and connections between health and social care, seeing care in its wider aspects. Whether provided by their families, by carers, by support workers or by health professionals, all are part of a spectrum of care for those in need. Health and social care should be integrated more. And so we need to reform social care alongside healthcare, so that we can support and empower people – not least as individuals – to be more safe and secure and, themselves, to be able to exercise greater control over their care”.

There is plenty to unpack here. His first, laudable principle concludes on the note of the title 2001 DH-funded report Nothing About Us Without Us, a strategy for learning disabilities.

This is a fascinating document to revisit, particularly its pages on health. NHS healthcare for people with learning difficulties has not made the progress since then that it should, as you can see here and here and here.

This new focus on outcomes is stated in opposition to “politically-motivated process targets, not simply measuring inputs or constant changes to structures” – targets, budgets and redisorganisation.

It is good to see a mention of targets. The sense must be that we are moving towards ‘good’ targets and ‘bad’, “politically motivated process targets”, possibly rebranded objectives, or some such: a policy homage to Chris Morris’ mordant taxonomy of 'good AIDS versus bad AIDS‘.

Inputs were a valid policy topic under New Labour because they made the politically contended (by the Conservatives, and at times the Lib Dems) choice to greatly increase financial inputs into the NHS. Some of this – our money - has been wasted, in the way that some water is wasted when you pour it into a dried-out pot plant. The focus on NHS inputs in the next five years will probably be about reducing them, whatever the promises now.

There is an irony in Lansley’s comment about “measuring inputs” when his party’s manifesto policy, enacted in the Con-Lib Coaition Agreement document, was to address the inputs of public sector salaries above the Prime Minister’s. An authentic position on outcomes would allow any public sector employee to earn any size of sum – conditional on delivery of outcomes.

And the “many links and connections between health and social care” are quite possibly the reason why ring-fencing the NHS budget while cutting local government’s is particularly problematic.

And detail came there none – but shifting the culture matters
Yet for the implementation and strategy of Lansleyism, we will have to wait. In a Dance Of The Seven Policy Veils, Lansley said he would not discuss “structures, funding or processes”.

Detail matters, but we can wait for it.

He focused instead on culture. Lansley is not a stupid man, and he has realised no matter how smart the strategy, that as the saying goes, culture will always eat it for breakfast. He told the audience,”to put patients first, we need a cultural shift in the way the health service works”.

Lansley the Hippocrate
His first point here was Hippocratic: primum non nocere: “the first principle must be ‘do no harm’. When it goes wrong in the NHS, patients suffer and patients die. Safety for patients is at the heart of quality care and of the professional responsibility of nurses and doctors. So there is no trade-off between safety and efficiency. Good care is safe care. Unsafe care costs more, in lives and in cash … I will not countenance a “production line” approach to healthcare which measures the volume but ignores the quality.”.

There is nothing but sense here. The questions are about the how.

Lansley rightly offers an “information revolution” as one solution: “patients … need to know who is providing quality, safe, effective, accessible services. Information will drive higher standards. It’s not just about choice, although patients value choice, even if the choice they make continues to be to go to their local practice and their local hospital. The combination of information and choice will hold people to account and drive up standards”.

Publishing more data is absolutely the way to go. The emphasis on choice and competition has more challenges, as Kings Fund CE Chris Ham tells The Guardian today, There will be navigation needs, but that is insufficient reason not to put more in the public domain.

Active responsibility
Lansley also proposed “a culture of active responsibility. So that everyone – GPs as local commissioners, LINKs, local authorities and others – will all be empowered to ask, to challenge and to intervene. Those who are charged with managing the care of patients, and purchasing services, must be commissioning for quality.

“The standards that will drive quality accounts and benchmarks of performance, must also be linked to payment, so that we’re not just paying for activity – but for performance and results”.

Much of this already theoretically exists. Primary legislation will be required to bring the balance to reality, but given the need to create the independent commissioning board, that is not a major issue.

He detailed that emergency hospital readmissions within 30 days for a previously-treated complaint will attract no further payment.

Safety culture: a call to whistles
Another policy tick comes on the issue of safety: Lansley called for “reliability, consistency of operating procedures, and a culture of challenge … where the offence is not to make a mistake – to err is human – but the offence is to ignore an error or, even worse, to cover it up.

“So we will work with NHS staff to embed a safety culture across the NHS where instead of thinking of ‘whistle-blowing’ as going outside the organisation, we see challenge of that kind as integral to the safety and improvement within the organisation.

“And in the same way, instead of seeing complaints as a burden, or a distraction or something to be dealt with outside the mainstream of service provision, we must see complaints as integral to the improvement of the service we provide”.

He announced that Robert Francis will have an independent reiteration of his inquiry into the events at Mid-Staffordshire, and a NHS-wide “zero tolerance” on avoidable healthcare-associated infections. There was an emphasis on more choices of process options in childbirth.

The right questions, and “access is not as important as outcomes”
Lansley has also picked up on the bias-ability and incompleteness in patient surveys: “the NHS too often asks insufficiently penetrating questions, insufficiently often, of too few patients. Patient Access Surveys in general practice miss the point of whether patients are doing well and if they have good outcomes, if they required treatment or advice. Access is not as important as outcomes. And the NHS Patient Survey, asking if patients were satisfied with the care they received, is too much like asking patients whether they were grateful”.

He wants to see “more relevant and particular questions, like, “when you pressed the call button, was the response what you expected, better than you expected or worse than you expected?”. That’s how you get real answers about the care that’s being provided.

“Such questions, done frequently and disaggregated to ward-level where possible, give a management focus on what is happening in a hospital; and can be the basis of a much more informed and interactive relationship, with the population that is served by the hospital”.

Anticipating objections about choice, Lansley counseled opponents of this approach to “look at the evidence. Engaged patients are more likely to manage self-care and more likely to be compliant with treatments. Informed patients, expressing choice, are less likely to seek unnecessary intensive and invasive treatments. Informed patients are more likely to have a good patient experience and a better outcome.

“With individual patients, doctors expect to listen to them, to understand their needs and expectations, they know that patients are the experts about themselves, that they have the greatest knowledge about their own experience, and that they have a right to informed choice. Why shouldn’t the NHS as a system do at least as much?”

He should probably have said “good doctors”.

He cited the 2009 Health Foundation report showing that “quality can save money. Because that’s where we need to be – a service which is being supported to meet rising demands. But one which must deliver continually improving quality. Actually the focus on quality and outcomes will enable us to deliver more from the resources we currently deploy. And as we are supported by the taxpayer with a rising budget we must do more with what we already have”.

Shifting the balance of power (again)
Lansley concluded with remarks on the need to “empower patients and health professionals. That means we will have to disempower someone. And I think it might be me! I know that others know better about their care and are better placed to make certain decisions.

“So we will disempower the hierarchy, the bureaucracy, the Primary Care Trusts and the Strategic Health Authorities. I don’t want the whole of the NHS to wait to hear from me. I want it to listen to patients, and to take responsibility for action”.

This action, he promised, would be “to give patients and care-users more control, to exercise choice – from choice of GP to choice of treatment, all the way through to personal budgets … to empower patients collectively in thinking about what quality standards and commissioning guidelines should look like, as well as patients and the public locally, impacting on decisions about access and design of local services to meet local needs … (and) to empower patients through access to information, from a plurality of information providers, with the ability to hold their own patient records, to interact more readily with their clinicians. To be able to use this new information ecology, to secure the quality of care and service we want as patients – and collectively, to drive an improvement in standards and outcomes”.

Nice quote
Lansley also gave a nice quote from the BMJ review of Dick Crossman’s diary: “All Ministers of Health were in the unenviable position of being regarded as the agents of government by the health professions and as agents of the professions by their ministerial colleagues”.

Conclusions, contradictions and key quotes
Overall, the intentions on show are hard to fault. There was little detail, but some interesting contradictions are emerging:

- between an end to top-down reorganisations and the abolition of SHAs.

- between a focus on outcomes, not inputs and regulations about what salaries public servants can earn relative to the Prime Minister’s

- between greater patient consultation and involvement and higher safety – there is much evidence that smaller units (which local voters rarely want closed) can be less safe

A few key phrases also stick out:

“access is not as important as outcomes”

“everyone – GPs as local commissioners, LINKs, local authorities and others – will all be empowered to ask, to challenge and to intervene”

”instead of thinking of ‘whistle-blowing’ as going outside the organisation, we see challenge of that kind as integral to the safety and improvement within the organisation”

There will be interesting times ahead.