Does our NHS need radical reform? A discussion with Lord Victor Adebowale

In my introductory article I provided context to the question at hand, ‘Does our NHS need radical reform?’. To contribute to this discourse, I have recently sat with three different healthcare leaders, all of whom I have been personally inspired by, to acquire some of their thoughts based on their extensive professional experience. 

Last month I sat down with the Chair of the NHS Confederation, Lord Victor Adebowale. Posing the above question to him, he had a series of thought-provoking opinions that made for a great conversation about the future of our health system. As always, more time would have allowed for a more detailed exploration of his thoughts. But I hope you as the reader will find the issues we discussed to be of interest, despite the brevity.

So Lord Victor, I have set the scene and provided you with context for the question at hand. Given the ongoing crisis faced by the NHS, do you think that the NHS needs radical reform to protect its future? 

I think the NHS does not need redesigning, nor does it need reform. The question really should not be about reform but rather how do we make the NHS work in its current model . 

As opposed to ‘radical reform’, we should focus on addressing three key challenges that I have seen so far: Equity, Access and Digital health. 

Okay that's interesting, could you expand on what you mean by equity?

Equity is not the same as equality. Equity is the fact that a woman in Barking and Dagenham has an approximate healthy life expectancy of 55 and in Richmond Upon Thames it is 70. So the first challenge is how do we increase equity in the health system. Because unless you create equity you will continue to observe differential outcomes between populations.

Yes that makes sense, so how do we go about improving access to healthcare and promoting more equitable health outcomes?

Firstly, defining this area can sometimes be a problem. However, I believe improving access requires a focus on three elements: commissioning, workforce design and service design. 

Okay, how would you improve our current processes for commissioning?

Unfortunately, commissioning is poorly defined, meaning different things to different people. But fundamentally commissioning is the means by which you understand the needs of an individual and/or community such that you can build a platform for procurement, contracting and purchasing. But that is not currently how commissioning works within the NHS. 

Commissioning is unfortunately primarily seen as a purchasing exercise rather than an understanding exercise. 

This is why you can have a cancer programme that costs millions in funding, yet black people are more likely to find out that they have cancer through Accident and Emergency. And that's because we have missed out the essential piece of understanding the needs of the community before procurement. Commissioners should thus be held accountable to the outcomes of their commissioning due to the fact that they are spending mine and your tax dollar.

How about workforce design?

At the moment we have a workforce crisis. I speak to junior doctors who for a variety of reasons tell me that after undergoing training which costs nearly £250,000, they are now only prepared to work for the NHS for two days a week. If you underwent training in another sector, and had your training paid for to the same degree, for example a law firm training a lawyer, the employer would likely insist on acquiring a minimum number of years to reap their investment. We do not do that in the NHS.

Furthermore, we assume clinicians are leaders by default. Going to medical school does not make you a leader. It makes you a clinician. To become a leader [in healthcare] requires a different kind of training and development. In my view this should in fact run along undergraduate training, not least because clinicians are the most expensive resource in the NHS. And if clinicians only see and treat patients and do not get the opportunity to coordinate the care of patients at a population level, then I think that is a little bit of a waste.

A people plan is therefore needed. We need to look at the future requirements, skills, availability and vacancies within the NHS. Not just doctors. Nurses, the whole MDT! We need to get this in place.

And service design?

The principle of NHS services should be positive value transfer. We waste billions sending people from one service to the next, because they haven't accessed all that was required from the initial service. A lot of resources are particularly required to support  those from deprived backgrounds in this area,  as they lack the necessary social and economic capital to navigate the health system. This has also been  seen in the elective care backlog where the poorest people, generally those from ethnic minority backgrounds and individuals with disabilities, are waiting the longest for treatment. These individuals also lack the capital to negotiate with primary care providers, whom we still do not invest enough into, in securing the care they require. As a result of waiting for longer they are thus more prone to poorer outcomes, requiring further resources of the health system.

This all makes a great deal of sense. A three-pronged approach of improving commissioning, workforce and service design would have such multifaceted benefits for our NHS. You also mentioned digital health, should we talk a little bit about this before you offer some closing thoughts?

I think our approach to improving digital health could be simplified. I always tend to ask if the use of technology is not improving equity and/or access within our system, then why is it being adopted?

Unfortunately, as many other terms, we typically generalise what we mean by digital health in the NHS. This can refer to at least five areas: 1) clinical technology 2) patient technology 3) workforce technology 4) environmental technology and 5) infrastructure. All of which require a strategy and a plan. And at the moment the NHS lacks the necessary level of confidence to define what those plans are and to negotiate with the appropriate vendors. 

We need to be able to negotiate with these vendors with much more confidence and clarity concerning our boundaries and where we will not compromise.

Really interesting thoughts Lord Victor, so much to unpack. Do you have any closing thoughts on the overall question at hand?

I believe we need to firstly get these three areas right: Equity, Access and Digital health. If we can get these three areas right, we will have an NHS that works a lot better. 

I do not believe the NHS requires radical reform. 

Often the people who are calling for reform are asking for changes in how we fund the health system, such as the introduction of insurance payment systems. We do not have the infrastructure for this. America has spent decades trying to create a system funded in this manner. Yet, with all of the investment that has been placed into trying to manage, control and regulate an open market, healthcare cost is still a leading cause of bankruptcy.

Additionally, people often quote Germany and France's health system [as models for the NHS to aspire to]. But we must realise that they spend significantly more on health as a % GDP as compared with the United Kingdom. We are still substantially behind them. 

I don't buy that we need restructuring. I feel very strongly that the NHS can work if we are committed to investing more money and better using the resources we already have. 

I found this to be a really thought-provoking conversation. It was a privilege to speak with an individual who has made such a positive impact on wider determinants of health and health inequalities in the UK. I am excited to see how he will bring these experiences to his current role as NHS Confederation chair. 

From the three themes we discussed, I was most intrigued by his thoughts on access to healthcare, and will be looking forward to further exploring his thoughts in our next conversation. A three pronged strategy of improving commissioning, service and workforce design would result in a multitude of benefits for health outcomes. However, such improvements will require both additional financial investment and political will. Both of which, unfortunately, seem to be currently lacking. This therefore puts many healthcare leaders, such as Lord Victor, in an incredibly difficult position- possessing an understanding of possible solutions to system issues, yet severely restricted by the availability of resources. 

This, in turn, raises more questions for me than answers. (Which is okay, as I have come to understand that the complexity of the issues that face our NHS firstly requires thoughtful questioning as opposed to ill-informed solutions). 

• How do we continue to increase political will to secure the additional financial investment that is needed to address the complex issues that befall our NHS?
• How do we navigate the tension between solving crises in the short term and investing for the long term?
• Is it at all possible to balance such a tension given the current political and economic climate?
• And does the continued requirement for such additional resources make our NHS a ‘bottomless pit’?

These are just some of the questions that lie at the heart of my thinking concerning if our NHS requires radical reform, and if so, what should this look like.