That has been an error on my part. It is obvious that the cuts in social care would have an impact on the work of the NHS and this is starting to happen. Some parts of the country in which I work have over 120 older patients whose discharge from hospital has been blocked by social care problems. Given this is May and not December these numbers are bigger than the health care system would like and foretell bigger problems by the winter.

Yesterday saw a report drawn from Freedom of Information requests from 120 different local authorities showed that in 2011 there were 11% fewer older people that had completely free home care services than in 2009.

The average charge per hour for those having to pay the full cost has gone up by 10% over the last two years. On average older people have 10 hours of home care a week and would therefore have seen their home care bills rise to £7077 by next year.

The rise in the threshold for free care and the rise in price will inevitably mean that some older people who would have had care will not be getting it.

The point for the NHS is that the older people who would have been relying on these services are also some of the core customers of the NHS. This demographic group have to use a lot of NHS services and on occasions will be spending time in hospital with inpatient care. The decision that the hospital will make about their discharge will depend on the level of care available at home and some of that care will have gone missing. People will stay longer in hospital than they would have.

The Alzheimer’s society has the right comment.

 “Many people with dementia and their carers are already struggle to pay for home care. The extraordinary costs in some parts of the country don’t even guarantee good quality care. This is disgraceful. Home care services are vital in helping to maintain quality of life for people living with dementia”

And, they might add, will lead to increased use of hospitals as places of safety even though these are probably the most disturbing environment for people with dementia.

The real problem is that the cuts in the social care budget have only just started. There are cuts of 28% in the funding of local authorities over the coming four years.

Over that period of time the rise in demand for health care from older people is likely to be in the order of at least 10%. If, because of social care cuts in services, that 10% of new patients stay in hospital for just a little longer than current patients the NHS with a flat budget is going to be in even more trouble than we thought…

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It was always going to be interesting to see how the Coalition government would live with this pledge.

Over the last weekend, just prior to its conference, the Royal College of Nurses published a survey of its members reflecting their experience of patient waits in A and E. Their President was on the airwaves saying that the progress that had been made on speedier and better working with A and E patients was being lost as more were being treated on trolleys.

The Government Minister replied that “action would be taken against hospitals” who, in some unspecified way, failed to treat patients in A and E well.

Readers may remember that there was a target of a 4 hour wait for 98% of patients in A and E.

Most will also recall how between 2001 and 2006 – when this target was achieved – many clinical leaders were attacking the very idea of there being such a target.

It was during these years that Andrew Lansley worked out, with those clinical leaders, his line against ‘politically motivated targets’. It all seems a long while ago – when most medical leaders took up rather different positions from those they do now.

It is interesting, going through the BMA press releases now, to note how often they attack the Government for failing to meet targets that they themselves had said were wrong in the first place.

In the light of the politics of the recent Health and Social Care Act, and the belief of so many that the Secretary of State (a politician) should remain responsible for the NHS; it’s interesting to raise the question of exactly what is meant by ‘politically motivated targets’.

In my own experience of the 2001 election, the Labour Manifesto, and the immediate aftermath of that election when I started work in the DH, political motivation was very simple.

The question that had to be asked and answered was – Were maximum waiting times for operations and A and E treatment what the public wanted?

The answer was always crystal clear. Long waiting times specifically, and access to services in general, was the main concern of the public with regard to the NHS.

To that extent targets were indeed ‘politically motivated’.

To that extent it was correct to set such targets for a service that was paid for by the public out of their taxation and where they had a right (politics) to have what they collectively wanted. This wasn’t a slight whim on the public’s part. It was what they asked for year after year after year – and what they felt they were paying for.

What was interesting was how some staff in the NHS felt it was a really bizarre thing to worry about. Time and again the Government would be attacked for imposing these targets. Yet we knew that this was the prime thing the public wanted from the NHS.

It may have looked like a fierce debate was talking place but the experience that we had was of receiving an instruction from the public and, through the manifesto, a requirement to get this done.

So what intrigues me is how the Coalition Government by ‘abolishing politically motivated targets’ such as the 4 hour maximum wait at A and E have now managed to rehabilitate the idea and practice of targets within elements of the NHS itself.

The public have never been in doubt. They have been constant. Maximum waiting times have always mattered to them in the past and if they increase it will matter to them once again.

And yes, listening to the public is after all what politics is.

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Famously he had said that when he came into Government he intended to be the Chair of the Government and not its Chief Executive. He had thought that as Chair you could appoint competent Executive Directors and let them get on with the hard work. In this case he would chair the cabinet and his Cabinet ministers would get on with running the country.

Last April it was the failure of his Health Secretary to explain and develop his Government’s health reform policy in a coherent way, that led to David Cameron letting it be known that he was going to become CEO of his Government. To assist him in this process he appointed a number of staff as special advisers to help him with this more arduous task.

Over the year since those of us interested mainly in health policy have not felt that a noticeably surer hand was at the helm of Government policy in this area. In June and July 2011, and later in February 2012, the Prime Minister became animated about his Government’s NHS reforms. However, as was said to me at the time, he kept coming on the field of play as a substitute Secretary of State. His aim was to help his team out, rather than play the captain – on the pitch all the time.

By the end of March 2012 the Health and Social Care Bill became an Act, and whilst he knew that one of the aims of his Act was to give front line medical staff more say  one never really formed the impression that he really knew what was going on in the detail of his policy.

In recent weeks, as what correspondents now seem to be calling the “omni shambles” of the budget, has layered bad news upon bad news, we have heard once more of his intention to be the CEO of the Government and not the chair.

(What’s interesting to note is that I have not read of anyone who recognises that this intention to work a lot harder to run the country is now used by the Prime Minister as a sort of annual New Year’s spring resolution. One he makes every year, only to forget about when the long evenings beckon and someone comes round asking if he will come out at five o’clock to play tennis in the sun. All the good resolutions to “buckle down” and stay in to spend the evening working  out which set of fighters to buy for our aircraft carriers seem to fly – unlike the fighters – right out of the window when there is something interesting to do).

Last Friday the Financial Times published a leader about this phenomenon.

“Mr Cameron, the self styled chairman of the board, has allowed ministers too long a rein. He should not for instance have allowed his Health Secretary Andrew Lansley to press ahead with his flawed and unnecessary NHS reform Bill.” (It goes on for a few paragraphs listing further problems).

“All this requires Mr Cameron to get a grip. After 2 years it is clear that some of his Ministers are not up to their responsibilities….Mr Cameron, who does not instinctively seek conflict, should realise that from time to time a Prime Minister needs to display a ruthless streak. …  He is not a Chairman .  He is the Chief Executive Officer. His government would run better if that was beyond doubt”

(Financial Times 10/05/2012)

As the FT notes this year’s promise to get a grip on government policy is too late for NHS reform, but it would be useful if there was some coherence about all other aspects of public service reform.

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On 25 April a report was published in Diabetic Medicine, co-authored by York Health Economic forum, Diabetes UK Joseph Rowntree Development Fund and Sanofi Aventis. One aspect of this report were the frightening statistics showing how much more will be spent on diabetes in 2035 if current trends continue. Whilst I never find disease-specific trends over 23 years convincingly accurate – it is a lot.

More specific was the fact taken from the resources spent on the current service which showed that 79% of NHS spending on diabetes is spent on the cost of caring for complications. This is an enormous amount and graphically makes the point about the expense of a failed long term condition pathway that I made last week.

The vast proportion of the money the NHS spends on diabetes is spent as a result of failures in other parts to stop these complications happening. Without getting too dramatic what we mean by complications in diabetes are truly horrific. They are lifestyle and life threatening.

Of course if a patient needs an amputation as an alternative to death they are grateful for the best amputation service in the world, but what the patient really needs is not the best amputation service in the world, but the best amputation prevention service in the world.

If a CCG were to let a pathway contract for the 1000 sickest people with diabetes in their area, they could incentivise providers to limit the number of complications. If the service could guarantee, by much better home care management of the disease, to cut the number of complications over two years by 20% the sums of money that could be invested in better self and community assisted care would be vast.

But attempts made up and down the country aimed at achieving this have been much more concerned with the sanctity of the organised structures of the NHS than with driving towards the outcomes that very sick patients need and want.

There are now sufficient voices demanding something different.

• UK Diabetes will work with patients to develop with them a progressive approach to self and community care.
• Clinical Commissioning Groups recognise that they need to develop an ambitious new commissioning drive that transforms outcomes for these very sick patients.
• The “Year of Care” approach to care has demonstrated how this works on the ground and how different finances could be constructed and,
• As I will explain next week there are a number of new approaches to contracting that will help to make that happen.

This has to be the year that we start to really make this happen for both patients and NHS finances.

But this article in the Lancet makes a similar case about patients and self care, but with a very different set of medical outcomes.

For some time now it’s been clear that whilst, as I have argued above, it is essential for health care to organise itself in pathways for conditions and not episodes of care, for those patients with multi and co-morbidities this would not solve the problem.

I was carrying out some work with a hospital that had succeeded in developing its main consultants to begin work on pathways that would have patients receiving integrated care along the various morbidities. The diabetes pathway recognised that most care took place in the home and tried to link the primary and secondary care into that strong pathway. It recognised the importance of self care by including an exercise regime to improve the general fitness of the patient with diabetes. All important stuff.

Similarly the muscular-skeletal consultant was creating a pathway that had an exercise programme – as was the cardiac consultant etc. etc.

But most of the older people in a locality – Scotland in this article – have more than one morbidity. This means that they are moving up and down several pathways at the same time – different nurses, different clinics and of course different exercise programmes.

Luckily patients have some common sense so they won’t carry out all three or four exercise programmes but if they were we would be getting 80 year olds to run through a combined exercise programme that would get most of us ready for the Olympics.

So what we need is not a number of condition specific pathways – although this is much better than episodic care – but a flexible long term condition pathway that will have specific interventions and small and specific branches off of the pathway.

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But creating this value for the NHS, as with most value creation, actually costs some real money. I am certain that the value that patients could create for the NHS far outstrips the amount that would have to be spent to create it, but there is a concrete economic case that needs to be made.

And it is here in 2012, within the detail of the case for creating more value than it costs, that the co-production of value in health care needs to make its case.

Co-production of health care is a good thing for patients. It empowers them and gives them more influence over their health care.

Co-production of health care creates economic value in health care which will eliminate expensive costs that the NHS cannot afford.

It is this last point that needs the most attention now, in the summer of 2012.  Over the last few years there have been several hundred offers made to the NHS promising to save it money. Very few of them have done so.

This is not to say that the economic hypothesis upon which they were based was necessarily wrong. Many of them indeed contained a strong economic promise that they could save money and were a good investment, but when applied on the ground they just seem to cost money rather than save it.

There are two reasons for this that the case for spending scarce resource developing patient value needs to avoid.

First the implementation of the new money-saving service did not have, as an integral part, a method through which the savings would be realised. So, for example, the NHS would buy a new cardio-vascular prevention service in the community – which would of course cost some money. The promise would be a reduction in spending on CVD services in the hospital as a result, but when the new community service was up and running no-one would actually save that money from the hospital.

So the NHS pays for the new but goes on paying for the old as well. In most other industries and services this is called ‘benefits realisation’ and is an integral part of any new intervention. The new knows that it needs to stop the old to realise the benefits – otherwise it cannot make an economic case.

In making the case for NHS investment in the development of patient-based value in health care by spending resources on patient’s capacity to better manage their conditions, we not only need to make the case for how this will save more money in other parts of the NHS, but we need to actually save that money. If that doesn’t happen, the creation of this new value does not increase the capacity of the whole NHS to get through difficult times.

This will call for a different kind of funding mechanism for the NHS. One that is now actually being developed through the year of care pilots. One where there will be clear financial incentives to keeping people out of expensive emergency beds by improving the secure management of their conditions in their homes. That is in hand, but it must be made to work.

The second reason why these interventions have not made their economic case is that they have only rarely been introduced into that segment of the health services where the economic case can be made most forcibly.

What do I mean by this? Many of the best examples of where new value has been created by patients have been at the point of diagnosis. People with long term conditions, say diabetes, when diagnosed go on one of the really good courses that have been developed by patient groups. They learn how to manage their new condition.

Nearly all of these courses increase the capacity of the patient to manage their condition and there is clear evidence that the patient’s vital signs are improved by the courses.

So they add value. But the problem is that for this group of patients, those that are newly diagnosed , the real costs that the NHS would otherwise have to pay out – the emergency bed stays in intensive care – are much less likely to have occurred in any case. It is almost certainly true that over 20 years this investment will have a big impact. But we need the value added and cost reduction to take place now.

That means that to make the economic case needed in 2012, the value added from patients’ capacity to better manage their own health care needs to come from those that are much sicker.

I was in Ontario a few weeks ago and there they had computed that 1% of the population consume 43% of the health care resource. The figures will be similar in England.

So to deal with the economic problem that the NHS has today, the value developed by patients to better manage their own condition needs to demonstrate its case not with those that are mildly sick, but those that are very sick.

This is a different proposition in so many ways. Most importantly the patients we are talking about are quite ill and will have been in and out of hospital for emergency beds on 3 or 4 occasions in the last year. They will have come to treat that sort of illness and life as if it were normal. If you are in and out of emergency beds you live your life at an understandably high level of anxiety and you don’t feel that you have very much capacity at all to invest in self management. It seems like an absurd possibility.  Their condition is in charge of them, it seems impossible that they could be in charge of their condition

With such ill people what is there to build on? The answer to this is that in nearly every person there is a fervent wish that their lives were better. They want to be a bit more in charge of their condition rather than the condition being in charge of them.

One of the successes of the 1997-2001 government was the rough sleepers’ initiative where two thirds of rough sleepers stopped sleeping on the streets and moved into a variety of hostels. The people in charge of this initiative believed that inside people, who everyone else felt were without hope and capacity, there was an aspiration to live a better life together with the capacity to do little things to do it. Getting in touch with that capacity and aspiration is not at all easy and is usually met with a number of rebuffs.

But for hundreds of people who seemed without hope or resource, it was there. And of course it is these same people that are also very frequent and expensive users of health services. Their chaotic lives lead to very expensive use of health care – sometimes over 100 annual visits to A and E.

Increasing the capacity of people who live chaotic lives to manage their own health is an enormous prize both for themselves and for the NHS as a whole.

For investment in such capacity to demonstrate its economic worth, firstly the investment in the patient’s capacity to better manage their health care has to actually work. That is to say that the intervention really does have to create value for the person. They actually have to manage their health together with the NHS in a better way that adds more value to health care outcomes.

But the project also has to secure the savings that would otherwise have gone into expensive emergency beds. The money that would have been spent without the value that comes from the patient will really have to be saved.

In this way investment in a group of patients who would otherwise cost a lot of resource can demonstrate how it will save the NHS real resource.

I will return to this theme later using the example of how we have been able to increase the capacity of the frail elderly to manage by using the NHS in a different way from spending so many spells in emergency beds.

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To rehearse the argument so far. Given that the percentage of GDP spent on the NHS will not rise very fast and the demand for health care will, those of us that want to save the NHS will have to help it find new sources of value to develop significantly more health care outcomes from the same resource.

Given that much of the current spend and most of the future demand will come from people with long term conditions it is important, if we are really to develop new forms of value in health care, that these come from this area. We need significantly better health care outcomes for people with long term conditions from the same resource.

My suggestion is that this extra value will come by increasing the efficiency with which the patient with long term conditions adds to their own health care during the 5795 waking hours they spend looking after themselves.

Yesterday I suggested that the best way of doing that would be to ensure that the very few hours that medical professionals spend annually with the patient were spent trying to increase their capacity to more efficiently self-manage their conditions.

Today I want to discuss what NHS commissioners can do to buy services that better add to the capacity of patients to look after themselves – thereby creating better value than at the moment.

A few weeks ago when I blogged on a similar topic one person posted a comment saying that this was all well and good but with only 15% of people over retirement age being health literate what hope had they of increasing their capacity to self-manage?

But what public policy in all other areas shows us is that the percentage of the population that are literate in all areas of life is there to be improved. There was a  time when most of the population were functionally illiterate in terms of reading and writing but over time the state and civil society came up with the practices of teaching and learning literacy.

At the time improved general literacy was seen as an outcome that improved not just the lives of newly literate citizens but helped to transform the value that those citizens could create in our economy and society. Of course there were debates at the time about whether this was a worthwhile use of public and private resource; and of course there were always those that said it would never work because some people just cannot learn.

It has not been universally successful, but functional literacy it is now above 90% and we know that a lack of literacy can be tackled with really good teaching and learning.

My main point here is completely the opposite of viewing the fact that only 15% of older people are health literate is a major problem. History shows us that this is not an insuperable problem. For me such a low percentage makes the point that we in the NHS have simply not understood that value can be created from the capacity for older people to add value to their own health care. Now we are hitting an economic crisis, increasing the proportion that possess health literacy three or four fold  is the way in which we can increase value to increase health care outcomes for the NHS.

In a previous life I was involved in the development and delivery of materials for improving functional literacy. What was obvious was that people learnt a lot more and a lot more quickly if the topic that they were learning to read and write about mattered to them. (Let’s face it, Jack and Jill going up some hill never really cracked it).

The topic that most motivated people to learn to read and write was health. People who had been illiterate were motivated by concerns about their own and their family’s health and this motivation gave them the impetus to learn to read.

This is an obvious truth but people learn much better when they are motivated. When people are sick they are much more likely to learn about their behaviour and their health than when they are not sick. So people are much more likely to acquire health literacy when they are diagnosed as sick. Of course it would be much better if people were to learn about their health care needs when they were well, but their motivation will be different when they are sick.

We have some experience of this across the NHS. The expert patient’s programme provides excellent general and specific courses which add to the patient’s efficacy in managing their health care. There are courses run by specific patient groups which add to the ability of patients to better manage their care.

If you feel that patients cannot add value to their health care then these courses are seen as being in some way surplus to requirements – as a ‘luxury’. This means that in some parts of the NHS they are being cut because they are not seen as economically viable.

However if you view patients as being able to add value to their own health care then such courses also add value to the NHS

The problem for the NHS is that to realise the value that patients can provide to it you need to spend some resource.

And if you cut the resource you can’t realise the value.

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One of the most significant arguments is around whether people can self-manage without interventions from the health service.

Let me make it clear from the start that this is NOT what I am suggesting.

There are all manner of arguments from people arguing for alternatives to western medicine. There is indeed some evidence that some of these alternatives can be beneficial, but to be clear that is not the thrust of my argument in this series of posts. Homeopathy and other complementary medicines may well create new value for people who are ill and need more health care, but I am not arguing for that in this piece of work.

Here I am arguing that better deployment of the very considerable resources that the NHS has at its disposal can help patients themselves create better health care value. NOT that the better value can be provided by the patient on their own without the NHS.

The co-production of value in health care is not an alternative to the NHS. It is the NHS working differently with patients to develop greater value.

What does this mean in practice?

If you are a person with diabetes you are managing your own health care in your own life for about 5800 waking hours a year. You have a set of symptoms that you try and think through, and a set of interventions that you try and make, to manage your life.

There are a significant number of people with quite severe diabetes who have not been diagnosed. These people are very tired, very thirsty and feel very bad. And sometimes they ‘black out’ in what they may call a faint. For hour after hour they try and look after themselves. In the language that we use in the NHS they self-manage their condition – but without knowledge they don’t do it very well.

They struggle through their lives talking to relatives and friends about how rotten they feel and what they can do to treat their feeling very sick – as a normal part of growing older.

But this is pure self management. It doesn’t add much value in health care terms. The person muddles through being very ill.

Take another person with diabetes that has been diagnosed as being quite severe.  Since they have had a diagnosis they are clearly a patient. They will also be managing their condition for 5800 waking hours a year. But they will also be seeing NHS health care professionals for about 5 hours in that year. Within those five hours there will be some time spent on regular testing and diagnosis and some time spent discussing drugs, diet and exercise. Those 5 hours might be spread over 2 GP visits, 2 hospital visits, 2 sessions with the nurse and 6 discussions with the pharmacist.

The impact of these five hours upon the 5800 hours is the crucial issue which determines the amount of health care value that is created.

For it is in those 5795 hours that most health care value is created NOT in the 5.

This is quite a difficult concept for the professional who works very hard for that succession of 5 hours with different patients. They see patient after patient after patient – giving diagnosis, prescriptions and advice.

But if they hand out that advice, deliver their health care value, with no real thought about the 5795 hours the patient is looking after themselves, while they will still add value it will be much less.

The professional can realise that the major value creation for health care happens when they are not in the room with the patient. So in economic terms the most value for people with long term conditions is created in the 5795 hours when they feel they are looking after themselves. If NHS professionals recognise this and view their 5 hours as an investment in the patient’s, and their carers’, ability to add value during the 5795 hours the NHS is not present in their lives, then  much greater value is created.

What might this mean? There is a lot of evidence now concerning care planning. Care plans can be created in a variety of ways. For example a patient can have a care plan created in the following way.

The diagnostic tests that the patient may have, perhaps every six months, will be collated. They will be sent to the doctor before the consultation with the patient about their care plan.

Medical staff will draw up a care plan for the patient. The patient will come to the consultation to meet a doctor who will outline their diagnosis – and their care plan. This care plan may well be handed over to the patient at the end of the consultation and the patient walk away with a personal care plan – created by the doctor.

The only part the patient has played in developing that care plan will have been to be the body from which the diagnosis has been drawn. If we categorise the patient’s involvement as activity and passivity, the extent of the activity in drawing up their own care plan is to have the diagnostic test. But over the next 6 months they spent 2897.5 waking hours trying to improve their health care and following the plan.

The doctor will feel they have done their job. They will have described the condition, and the activities that the patient must and must not carry out, and they will communicate that both verbally and in writing.

This is why the language that some medical staff use to describe what the patient must do next is the language of compliance or adherence. “I have described what you need to do to keep healthy and now it is up to you to comply with my plan.”

The biggest problem for the health service is the problem of long term conditions. The failure of the NHS is that so many patients with long term conditions cannot adhere or comply with the plan drawn up by the doctor.

Framing the problem in this way is itself the problem.

Contrast drawing up this care plan beginning with an interaction where the patient is also sent the results of their tests. Having been a patient with a long term condition they may have had such diagnostic tests over several years. They go to see the doctor and at the very least say, “what does this mean? Is it good, bad, better, worse or the same?” Crucially they start the interaction with questions about what it all means.

The doctor recognises that the drawing up of the care plan in this situation has to be a joint project. It may be joint with the practice nurse, the patient’s carer and the patient. But if the 5795 hours that the patient is looking after themselves are to be affected by the plan then it is certain that worries, fears and successes from those 5795 hours must enter into the discussions with the health professional.

Too many patients are left thinking of the question they wished they’d asked after the end of the consultation. If the care plan is going to be one that truly influences the life of the patient then it needs to be drawn up jointly, so that if the problem is one of compliance the patient is much more likely to comply with something they have helped to draw up.

These posts are trying to make the case that patients with long term conditions can add considerably more value to their health care if they can actively use the knowledge they have created during their few hours of consultations to improve the thousands of hour’s value creation when they are looking after themselves.

There are already some good ways of achieving this that I will talk about tomorrow.

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The aim of the second post was to ground the first in the ‘real world’ of today’s NHS drivers. Of course If the NHS is going to work towards health care outcomes it  will need a great deal of change in the way in which staff and patients work together. The good news is that there are many patient organisations that really want to make this happen.

Today I want to consider those thoughts in the context of the economics of the NHS. We know that the NHS is in the midst of reworking about 4% a year of its budget moving from one form of care to meet the new demand for health care. We are told that this will be the task for the next 5 years.

Some of us have said that the ‘Nicholson challenge’ of £20 billion over 5 years is only the start of a longer historical period of time lasting for at least the next decade. There is no new money – there will be no new money. Given the economics of the future, the NHS is going to need to rework this 4% every year for the foreseeable future.

That means that over 10 years the NHS will have to deliver significantly more health care outcomes from the same resource.

Readers will remember that a couple of weeks ago the question, what do we want to save when we say we want to save the NHS was the subject of several blogs and comments..

Those of us really wanting to save the NHS will have to engage every day with the changes needed to deliver significantly more health care outcomes from the same resource.

If this process fails the NHS will no longer be able to serve the whole population with resources from national taxation, with equal access to all free at the point of need.

How do a couple of posts on health care outcomes fit into such a large and ominous worry?

The Nicholson challenge – when faced with this economic problem  - has asked the question, what elements of the current NHS produce health care outcomes, and how do we get more out of these value producers?

The answer is that the NHS produces value because patients who are ill come into contact with medical staff, their kit and drugs. In the past to produce more value we needed to have more medical staff, their kit and drugs. To get more of them we needed more money to buy them.

But given there is no more new money, the current challenge is to work the value producers better and harder to get more value. This involves a wide range of activities including, most significantly for the last 2 years, the pay freeze. This may continue to work for a few years but cannot be an answer for every one of the next ten.

Apart from getting the current value creators to work harder for the same resource, the Nicholson plan also will rework how those value creators create value. This will be done through labour substitution. Nurses will do what doctors do now, and health care assistants will do what nurses do.

There will also be big changes in the settings where care takes place, moving from locations where overheads are high – the hospital – to places where the overheads are lower – the community.

All of this will squeeze new value out of existing value creators and will succeed only through an enormous amount of change in the way in which the NHS works.

If the NHS has to do this for a decade, it will be one of unprecedented and difficult change. For 10 years nearly every part of the NHS will have to change again and again to deliver significantly more value for the same resource.

And – big deep breath here – all of these efficiencies will not be enough to save the NHS.

Improvements and internal efficiencies can only go so far. Continually getting the current value producing machine to work harder and better will not fill the gap for the whole decade.

Other industries and services, when confronted with a long term problem of a lack of resource and a rise of demand, have to look for a new source of value.

So whilst it is true that the current method of developing value is inefficient and needs to be made more efficient, we also need to find new value from somewhere that has previously been unrecognised.

For me this currently unrealised value will have to come from the same place that it does in other industries, consumers of the services who co-produce new value. In the case of the NHS it will be patients who will co-produce health care value.

Over the next ten years the NHS will be saved if it can realise much more of the value that patients can contribute to their own health care.

At the moment most of the NHS sees patients as a drain on value. It is the medical staff, their kit and drugs that provide the value and patients that consume it.

So when, over the next decade we need more health care, we look around for the resource to create it, it will come from patients contributing more themselves.

What if those patients and existing patients are not simply seen as a drain on value but rather as contributors – possibly significant contributors – in creating it?

The fact that patients self-manage is not of course a new idea. In one way or another, putting patients at the centre of the NHS and health care has been talked about for a very long time.

There is also a strong moral argument for the idea that nothing should be done to a patient without their involvement.

What I will be suggesting over the next few weeks is that this strong moral argument is matched by a strong economic one.

Consider the two thirds of expenditure that the NHS spends on long term conditions. If we can develop much more value from patients for this expenditure then the NHS will see out the next ten years within its current set of principles.

It’s also the case that it is the patients with long term conditions that will form most of the new patients (over 85 years old) that will lead to the increase in demand over the decade. It is this increase in demand that threatens bankruptcy.

So find new value from patients with long term conditions? Stop seeing what may be the 18 million patients with long term conditions in 2022 as simply a cost for the NHS. See them instead as a major contributor of the value that creates health outcomes and the NHS will have sufficient value to survive and thrive.

Over the summer I want to demonstrate that economic argument both in both general and specific terms.

Tomorrow I’ll begin with the difference between value derived from self-management alone and from the co-production of value

When faced with an economic challenge of this size, we need to completely rethink how our service produces health care value.

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Over the last 18 months too many  of us have been consumed with the structural and political dance that became the Health and Social Care Act, but luckily these patient groups have kept their eye on the ball and concentrated on real patient-centred care. A few days ago they published the latest instalment of their work.

I really commend the entire 21 pages of the document from From Vision to Action available from the Kings Fund and patient group web sites. If we are very lucky and these patient groups hold their nerve, then in those Clinical Commissioning Groups that have the ambition to become active commissioners patient health care could be radically improved.

Today I want to pick up on one aspect of this report that follows on from yesterday’s post about the importance of developing care that improves health outcomes.

Of the five issues that the report feels are important, the first concerns,

Measurement monitoring and public accountability   

and they say,

“…the NHS is awash with data about clinical activity and to some extent about clinical outcomes and patient experience. Information about whether people are accessing the service and how they are experiencing the sorts of services we prioritise in this report are much more limited”

How true. The important point is that the data has not been created to allow us to hold the service to account in ways that patients want and need. Patients are asking for this to change and for there to be some recognition that we really need to know how the NHS is performing from the patients’ point of view.

The report makes some suggestions for the kind of information that will clearly reflect the patient experience:-

• The percentage of patients with long term conditions reporting that their health professional worked with them to produce a written document recording decisions about managing their health condition
• The percentage of health care professionals undergoing regular reviews of their skills in supporting shared decision making
• The percentage of patients with long term conditions successfully completing a self-management programme
• The percentage of patients who feel that services are available to them at points of crisis and know how to access them
• The percentage of patients who feel that their emotional, psychological and practical needs were fully discussed during the care planning process
• The percentage of patients or carers reporting that they were as involved as they wanted to be in their care and treatment.

This would be a significantly different set of indicators to the ones collected at the moment. Yet they represent what modern medicine needs to understand about how the service works with its patients.

Each of them underlines the point that I was trying to make yesterday. If for example patients do not, to quote the first suggestion, report “that their health professional worked with them to produce a written document recording decisions about managing their health condition”  then the fact that they cannot remember engaging in such a discussion will mean that the work, even if it had taken place, would not have been effective.

Professionals will recognise that the care planning document must at least be a part of the memory of the patient for it to have a long lasting impact on their health care.

As I noted yesterday, this places any measurement of outcomes in the hands of the patient. Communication from the health care professional in, for example, a long term condition must become a part of their daily lives if it is to be effective in impacting on their welfare.

The argument goes something like this.

If you have a long term condition, the key phrase is ‘long term’. On many occasions you will have it for the rest of your life.  In an average year you are awake for about 5800 hours – and for all of that time you are self-managing your condition.

Everyone with a long term condition self-manages all the time. They might be doing this well or they might be doing it badly, but this is the reality of their waking hours.

Most people with long term conditions will see a health care professional for, at best, 5 out of those 5800 hours. If those 5 hours work very, very well they will have an impact upon their capacity to self-manage the remaining  5795.

This potentially increases the efficacy of the patient’s self-management over those 5800 hours.

What might this mean? Let’s say that the efficacy of self-management over waking hours is improved 2% by the impact of the skilled 5 hours that health care professionals spend with them in the year. They work hard in those five hours at understanding the life of the particular patient and how health care could improve their capacity to self-manage for the rest of that year.

A 2% improvement in self management for 5800 hours would be a major impact.

But to achieve that – to take this first indicator as important – the patient must be able to “report that their health professional worked with them to produce a written document recording decisions about managing their health condition”.

If the patient cannot remember whether the health care professional actually did work with them then the efficacy of that work is very greatly diminished.

In this way outcomes will only be successful for most health care for people with long term conditions if they are actively involved in their health care over that year.

It seems worthwhile then to be able to hold the NHS to account for the success or otherwise of how that communication is experienced by the patient.

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We are now a few weeks on from the passage of the Act. The glimpses of the direction of its implementation that we have had since then are as contradictory as the Bill itself. The Secretary of State writes to the NCB saying that they must ensure that there is autonomy for CCGs and the Chair of the NCB responds by saying that it will be some time before the NHS will be liberated from its centre.

What should a growing CCG make of this confused messaging? The answer must be that if you wait to be told what to do, the centre will issue instructions that will firmly contradict itself and tell you (very loudly and with force) to go in the opposite direction from the previous instruction.

So the lesson from this is? Best not wait to be told what to do.

Over the next few weeks I want to share some of the developments that are happening on the ground which in my opinion are progressive NHS activities that local people can carry out.

What is my definition of progressive? An activity which will improve the lives of NHS patients and improve the impact of NHS care on their lives.

But many of my readers may say, “Don’t you think that the Act is a shambles? How is it possible within that shambles to do anything progressive? “

The answer of course is it’s difficult to do progressive things from within this shambles, but it will be possible to develop progressive practice precisely because it doesn’t know what it is doing.

Today I want to concentrate on the possibility in local health economies of developing health care that is incentivised to provide health care outcomes. Why do I think health care outcomes are more progressive than say, inputs? And what do I mean by ‘outcomes’?

The best way I can explain the difference between inputs, outputs and outcomes comes from my time in local Government in the mid 1990s. One of the biggest issues in local government at the time was how can we know whether the school dinners in one local authority are as good or better than another. As I hope readers will know we can always make a joke or two about school dinners, but for many children they are a vital part of their nutrition and many schools recognise that without good school dinners the afternoon sessions at school are worth very little.

In the early 1990s local authorities judged their dinners to be better than others because they paid more for them. “Our school dinners have had more inputs in terms of cost and are therefore much better than yours”. It wasn’t difficult to point out that a school dinner could be expensive and wasteful while another could be cheaper and better. So if measuring input – what you paid for the meal – didn’t work local government moved on to look at outputs.

This was the beginning of the argument about the importance of much better nutrition in school meals. So some local authorities said – “Of course inputs are not a good way of measuring success. We need to move on to outputs, and the output that really matters is the nutritional content of the meal.” – Some local authorities were certain that their nutritional content was not only better than others but could be demonstrated to be better. Chips gave way to brown rice; trifle to a piece of fruit. It was clear that one school dinner was better nutritionally than another and therefore one output was much better than the other.

However the problem was that even if the output had improved a lot and was providing really great nutrition – what if the children didn’t eat them? In that case a very good output created zero ‘outcome’. A high nutritional meal which stayed outside the child would meet all the output criteria but as a way of getting nutrition into the child and creating an outcome was of no use at all.

So high outputs could still lead to zero outcomes. And this is the trick. This is why, for me, outcomes are inherently more progressive than outputs or inputs. Outputs and inputs can be measured and delivered without the public being involved at all. A service can be doing really well with either but it doesn’t involve the child. Only outcomes do that.

An outcome is different from an output because it must involve the member of the public in some part of the delivery of the outcome.

Yet the professionals – in this case the people who created the school meal service – always felt it was unfair because they could their job very well. These were great dinners, but they were ‘marked down’ if the public did not engage with these wonderful outputs. That wasn’t fair. We do all that brilliant work and just because the public didn’t like it we’re told it wasn’t good enough.

This is my point as to why outcomes are inherently progressive. The only way that a successful outcome can be constructed is if the members of the public do their bit in its delivery too. But the professionals say, “That’s not fair! We’re judged not just on our work but on whether the public do some work as well. That’s not fair because we don’t control that part of the outcome!”.

And yes, that’s true. Professionals don’t control the outcome – but they need to persuade the public to do their part or there is no outcome.

What might this mean for health care?

Readers will have heard of PROMS (Patient Recorded Outcome Measures). These contain outcomes that go beyond the particular intervention that the health service has carried out. So, for example, a hip replacement is an operation which can be carried out well or badly.

If it is carried out badly in the operating theatre it will have a big impact upon the mobility of the patient and if, as a part of a PROM, the patient is asked whether they can get up the stairs or down to the shops after a certain period of time, they are likely to say they find it difficult.

But it is also the case that the operation might be carried out in the operating theatre well, but the aftercare would be such that the outcome of ‘getting to the shops’ still can’t be achieved. So if the surgeon is worried about the impact of outcomes on their work, it is in their interests (and the patient’s) to ensure that the aftercare is very good.

So measuring professional staff on outcomes directs the professionals to concern themselves beyond the specific moment of their work. It involves them much more in the ensuring that the patient’s lives are improved by the intervention.

This is a very considerable change for a public service such as the NHS which, until a few years ago, was not measured very much at all and which since then has been measured mainly by inputs and a few outputs.

This will not be an easy shift for the NHS, but I do think it is a progressive shift.

The government’s outcomes framework stresses five things that the NHS should be measuring,

1. Preventing people from dying prematurely
2. Enhancing quality of life for people with long term conditions
3. Helping people to recover from episodes of ill health
4. Ensuring patients have a positive experience of care
5. Treating and caring for people in a safe environment and protecting them from avoidable harm

Success in each of these will need patients to be involved in their NHS health care.

At its crudest there is a great deal of evidence that people are much less likely to die if they have something to live for. The same is true for those who recover more speedily from episodes of ill health.

The quality of life of people with long term conditions will depend upon a range of factors that will involve their NHS treatment, but on other issues as well.

What does this mean for local health economies? I know that many patient groups are working with the NHS to work out what a good outcome might be for, for example, a muscular skeletal disorder. These need to be picked up by clinical commissioning groups and discussed as a part of the commissioning process with NHS provider organisations.

As next year’s commissioning negotiations start in the autumn I think there will be a number of health economies that will be commissioning for some pathways towards outcomes.

This won’t happen everywhere. It won’t happen with every condition. But it will happen in some places and for some conditions – and it will be a good thing.

Over the next few weeks I will return to this with examples of how this can work for patients in a progressive way.

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