Chris Ham

Improving the performance of health services: the role of clinical leadership

VIEWPOINT Reform of health-care systems in the past decade has been driven by ideas such as public/private partnerships, managed competition, managed care, and integrated care. These abstractions betray the grand nature of ambitions harboured by reformers. Faced with funding pressures on the one hand, and failures of service delivery on the other, policymakers have entertained radical solutions in the hope they will lead to improvements in health-system performance. In practice, reform has generally fallen short of both rhetoric and expectations, leading to reappraisal of the strategies pursued and a search for new policies. The failure of radical solutions stems in part from their limited effect on clinical practice. Improvement of the performance of health care depends first and foremost on making a difference to the experience of patients and service users, which in turn hinges on changing the day-today decisions of doctors, nurses, and other staff. Reforms based on ideas like managed competition and integrated care might have some effect on clinical decisions, but in professional organisations like hospitals and primary-care practices, many effects on decision-making exist. In these organisations, policies initiated by health-care reformers have to compete for attention with established ways of working and other imperatives, which may result in a gap between policy intent on the one hand and delivery on the other. A key feature of professional organisations, as Henry Mintzberg noted over 20 years ago, 1 is that professionals have a large degree of control. As a result, the ability of managers, politicians, and others to influence decisionmaking is more constrained and contingent than in other organisations. Thus, ways have to be found of generating change bottom-up, not just top-down, especially by engaging professionals in the reform process. This includes recognition of the importance of collegial mechanisms in professional organisations and the role that leaders from professional backgrounds themselves can have in bringing about change. Mintzberg’s insights into the nature of professional organisations have been reinforced by studies of the effect of quality-improvement initiatives in healthcare organisations in several countries, and we now draw on findings of these studies to explore the challenges entailed in improvement of performance.

Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data

Abstract Objective To compare the utilisation of hospital beds in the NHS in England, Kaiser Permanente in California, and the Medicare programme in the United States and California. Design Analysis of routinely available data from 2000 and 2001 on inpatient admissions, lengths of stay, and bed days in populations aged over 65 for 11 leading causes of use of acute beds. Setting Comparison of NHS data with data from Kaiser Permanente in California and the Medicare programme in California and the United States; interviews with Kaiser Permanente staff and visits to Kaiser facilities. Results Bed day use in the NHS for the 11 leading causes is three and a half times that of Kaisers standardised rate, almost twice that of the Medicare Californias standardised rate, and more than 50% higher than the standardised rate in Medicare in the United States. Kaiser achieves these results through a combination of low admission rates and relatively short stays. The lower use of bed days in Medicare in California compared with Medicare in the United States suggests there is a “California effect” as well as a “Kaiser effect” in hospital utilisation. Conclusion The NHS can learn from Kaisers integrated approach, the focus on chronic diseases and their effective management, the emphasis placed on self care, the role of intermediate care, and the leadership provided by doctors in developing and supporting this model of care.

Priority setting in health care: learning from international experience

Priority setting in health care is not new but it is an issue of growing importance. In publicly financed health care systems, the combination of constrained resources and increasing demands has led policy makers to address this issue more directly than in the past. This is exemplified by experience in Oregon, the Netherlands, New Zealand, Sweden and the UK. In each of these systems, policy makers have taken the initiative to set priorities on a more explicit basis. This paper compares and contrasts experience in these systems and identifies a number of emerging themes. The work done so far can be likened to an exercise in policy learning in which policy makers have tried out a range of approaches and have adjusted course several times in the process. Priority setting is not amenable to once and for all solutions and the issues involved must be kept under continuous review.

The medical profession, the public, and the government

The old implicit compact between doctors, patients, and society has broken. Chris Ham and George Alberti want to write a new one The world is changing rapidly—probably more so than at any time since the industrial revolution. This applies to the professions as much as any other sector of society. So how has the medical profession altered and how is it responding to these societal pressures? In the 19th and early part of the 20th century British physicians were private practitioners and functioned independently. There was a strong moral and ethical background to medicine and a tradition of voluntary work in the poor law institutions as well as in the community. Self regulation began in the 16th century with the foundation of the Royal College of Physicians. This functioned both as a setter of standards and as a closed shop. The Royal College of Surgeons followed two centuries later. Learning at that time was based on a few medical schools and an apprenticeship system. Self regulation and a more uniform educational approach were strengthened in the 19th century with the establishment of the General Medical Council (GMC) and the introduction of royal college examinations. Throughout this period, standards and quality were implicit rather than explicit, with government and society trusting the medical profession to protect the public and granting the profession considerable autonomy in the process. #### Summary points The NHS was established on the basis of an implicit compact between the government, the medical profession, and the public This implicit compact has been undermined over the years and needs to be updated A new compact is needed spelling out the rights and responsibilities of the government, the medical profession, and the public This will not be easy to agree but is essential to enable the different partners to make an effective contribution …

The ten characteristics of the high-performing chronic care system

The purpose of this paper is to describe the characteristics of the high-performing chronic care system and the four implementation strategies needed to achieve such a system. The paper starts with a description of the Chronic Care Model and summarises evidence on its impact. This is followed by a review of international evidence on gaps in the quality of chronic care. These gaps suggest that, useful and influential as the Chronic Care Model is, more is needed to help health care decision makers bring about the reorientation required to meet the needs of populations in which chronic diseases predominate. The second half of the paper therefore sets out the ten characteristics and four implementation strategies required to achieve a high-performing chronic care system. In doing so, it provides practical guidance to policy makers and health care leaders on the most promising strategies for improving the provision of chronic care, drawing on evidence from the experience of England, New Zealand and USA.

Explicit and implicit rationing: taking responsibility and avoiding blame for health care choices.

Rationing health care in publicly funded health care systems is becoming more challenging because of the growing gap between the possibility of effective medical intervention and limited resources. This poses both an economic challenge and a political puzzle. On the basis of experience in those systems that have adopted a systematic approach to rationing, it can be suggested that the dilemmas involved should be addressed by strengthening both the information base to support decisions and the institutional framework in which decisions are taken. The contribution both of experts and of lay people is needed to inform decision-making, and the processes adopted need to allow for this as well as being transparent and accountable. In practice, rationing is likely to combine explicit and implicit decision-making and to result in the exclusion of services at the margins and the development of guidelines in the mainstream. The politics of rationing may favour muddling through and the evasion of responsibility but this will be difficult to sustain in an environment in which public awareness of decision-making in health care is growing.

Rising to the challenge: will the NHS support people with long term conditions?

The NHS is waking to the challenge of chronic diseases. Three researchers who have worked in the Department of Health discuss how the NHS might rise to the challenge of better supporting people with long term conditions The health gains experienced over the past 50 or so years are now presenting health systems around the world with a new challenge: how best to support people with long term conditions. An ageing population is testimony to improvements in public health through improved housing, sanitation and diet, and better health services—resulting in more patients surviving previously fatal events like serious infections but creating increasing numbers with long term conditions (fig 1). Over the past few years the British government has responded to issues that are foremost in the minds of the electorate, such as access to specialist services, especially in patient waiting times. This has evidently paid off.1 Now the NHS is waking to the challenge of chronic diseases. The NHS Improvement Plan, launched in June 2004, outlined the importance of supporting people with long term conditions. In the foreword, John Reid, the secretary of state for health, outlines how a “major investment in services closer to home will ensure much better support for patients who have long-term conditions, enabling them to minimise the impact of these on their lives.”2 We discuss how the NHS might rise to this challenge. Fig 1 Percentage of respondents to general household survey 2002 (n=13 000) reporting a chronic condition. Data from 1998 onwards are weighted Analysis of the British household panel survey (2001), the health survey for England (2001), and general household survey (2002) has given us a great insight into how long term conditions affect people in England.3–5 The data show that:

Tragic choices in health care: lessons from the Child B case

Four years ago the case of Jaymee Bowen, more commonly known as Child B, captured the newspaper headlines. The coming together of a father who was determined to seek the treatment he believed was best for his daughter, doctors who disagreed about what treatment was appropriate, health service managers who were prepared to take a stand on the use of resources on services of questionable effectiveness, lawyers willing to test the decision of the health authority in the courts, and journalists who saw the case as exemplifying the dilemmas of health service decision making meant that Jaymees story caught the public imagination and highlighted the challenge of rationing.1 The way in which the case was handled contains important lessons for decision makers in health authorities and primary care groups charged with making difficult choices in health care. #### Summary points The Child B case showed that decisions on funding experimental and costly treatments raise ethical and practical dilemmas Concern to use resources for the benefit of the whole population has to be weighed against the urge to respond to the needs of individuals The decision making process must be rigorous and fair Decision makers should explain the reasons behind decisions, show that these are relevant, give the opportunity for appeal, and ensure the process is regulated Not all these conditions were fulfilled in the Child B case—health authorities and primary care groups should learn from this experience To understand the significance of the case it is important to recount some of the detail of what happened at the time. Jaymee Bowen was an articulate and lively 6 year old when, in 1990, she was diagnosed as having non-Hodgkins lymphoma. She was treated at Addenbrookes Hospital in Cambridge, but in 1993 was diagnosed as having a second cancer, acute myeloid leukaemia. Jaymee underwent …

World class commissioning: a health policy chimera?

The health reforms in England have entered a phase in which greater emphasis is being placed on market-like mechanisms. The ability of the commissioners of care to negotiate on equal terms with providers will be of critical importance in the emerging market. The government has set out plans to develop ‘world class commissioning’ and this essay reviews experience in Europe, New Zealand and the United States to understand what is involved in working towards this goal. The evidence reviewed shows that in no system is commissioning done consistently well and highlights the obstacles to the development of world class commissioning. The reasons for this centre on the complexity of health care and the inherent difficulty of commissioning health services in publicly financed systems. Commissioners will need to be able to access a range of expertise and are likely to incur significant expenditure in so doing. There are warning signs from other systems of health reforms that result in adversarial and legalistic approaches, and do not give sufficient attention to relational contracting. Even if world class commissioning is developed, it may fall short of its potential in the absence of other changes in the design of the reforms, such as autonomous providers and appropriate payment systems. In view of these challenges, a more promising alternative would be to develop competing integrated systems.

Doctors who become chief executives in the NHS: from keen amateurs to skilled professionals:

Summary Objectives To investigate the experiences of doctors who become chief executives of NHS organizations, with the aim of understanding their career paths and the facilitators and barriers encountered along the way. Design Twenty-two medical chief executives were identified and of these 20 were interviewed. In addition two former medical chief executives were interviewed. Information was collected about the age at which they became chief executives, the number of chief executive posts held, the training they received, and the opportunities, challenges and risks they experienced. Setting All NHS organizations in the United Kingdom in 2009. Results The age of medical chief executives on first appointment ranged from 36 to 64 years, the average being 48 years. The majority of those interviewed were either in their first chief executive post or had stepped down having held only one such post. The training and development accessed en route to becoming chief executives was highly variable. Interviewees were positive about the opportunity to bring about organizational and service improvement on a bigger scale than is possible in clinical work. At the same time, they emphasized the insecurities associated with being a chief executive. Doctors who become chief executives experience a change in their professional identity and the role of leaders occupying hybrid positions is not well recognized. Conclusions Doctors who become chief executives are self-styled ‘keen amateurs’ and there is a need to provide more structured support to enable them to become skilled professionals. The new faculty of medical leadership and management could have an important role in this process.