By Dr Graham Martin, University of Leicester
Graham Martin argues that whatever the rights and wrongs of current health care reforms, they make the need to find ways to improve clinical collaboration among NHS staff more urgent than ever.
The government’s proposed health care reforms have stirred considerable controversy. For critics, they threaten the fundamental principles of the NHS; for advocates, they bring change that is crucial for the service’s survival. There is no doubt that the current changes are significant. The proposed reforms strip away two levels of NHS organisation and management, devolve responsibilities for planning and purchasing health care services to GP-led clinical commissioning groups, move much of the NHS’s responsibility for public health into local government, and open the way for greater involvement of the private sector in providing NHS services. Perhaps most controversial of all has been the increased emphasis on competition as a means of improving effectiveness and efficiency.
Political and academic debates rage about the use of market forces to drive change in health care and other public services. For its proponents, competition, if properly regulated, helps to improve quality by incentivising providers of care to respond to the needs and preferences of patients. For critics, market forces result in a ‘race to the bottom’ where providers try to undercut each other on price without regard for quality of care, and where private-sector providers can ‘cherry pick’ lucrative services while traditional NHS providers deal with unprofitable complex cases.
In truth, evidence about the effectiveness of competitive markets in improving health care is ambiguous. One possible risk of increased marketisation, though, is the potential for damage to co-operation and collaboration across organisational and institutional boundaries. A concern of many is that in a more market-based system, clinicians may view each other as competitors rather than as colleagues, and co-ordination across organisations may be treated not as sensible collaboration but as anti-competitive cartel.
Yet collaboration and co-operation —among individual clinicians, across professional groups, and across different parts of the health service—are essential to modern health care provision. Doctors and nurses work in multidisciplinary teams; generalists and specialists need to collaborate; managing people with chronic illnesses requires joined-up working across hospital and community settings. Even commissioning—the process whereby GPs and managers plan, purchase and review care for their patients from hospitals and other providers—involves collaboration to work properly: it is not a simple consumer transaction in an open market.
The NHS reforms may make it more difficult to foster these collaborations. Even under the existing system, though, it has been challenging to make collaboration work well. Things like managed clinical networks—introduced to facilitate collaboration among commissioners, doctors providing care, health service managers and others—have sometimes been characterised more by in-fighting and micromanagement than by co-operation towards shared goals.
Clearly, what is needed is more effort to foster collaboration among clinicians and others to make health care better. But where in the new NHS will this encouragement come from? Strategic Health Authorities—the organisations previously responsible for ensuring strategic integration of services—are being abolished, and even the future of managed clinical networks is uncertain. That said, evidence suggests that the most effective collaboration needs to be driven by the collaborators themselves, rather than imposed by organisations. New leadership for collaboration is evidently required.
One promising approach has been led by The Health Foundation, a charitable organisation that works towards improving health care quality in the UK. It has provided start-up funding for 11 ‘clinical communities’—groups of clinicians, patients, managers and others with a shared commitment to improving health care—to work collaboratively to improve quality in a range of NHS services. The communities draw on the intrinsic values of health care professionals—something so easily sidelined in an NHS of competition and targets—to make change happen. They use the collective power of professional groups to bring people together, gain consensus on how to improve care, and—when necessary—enforce change if more recalcitrant clinicians resist. Rather than relying on managerial edicts or market incentives, they harness the collective will of alliances of staff and patients for change: a force to be reckoned with. Clinical communities are also being deployed to improve care outside the NHS, for example in the Johns Hopkins Medicine system in the United States. The University of Leicester is carrying out an ongoing evaluation of the clinical communities programme, and early findings suggest that this can be an effective way of achieving change—even when the wider organisational context is one in which uncertainty, reorganisation and static budgets dominate the concerns of staff.
No matter how the organisation of the NHS changes, the need for collaboration to provide care of the highest quality will remain. The potential fragmentation that might result from the current reorganisation should not be ignored, but nor should the inventiveness and determination of doctors, nurses, patients and managers in making the NHS ever better. The key is to find ways, such as clinical communities, to nurture this will and overcome resistance in a context that can sometimes breed cynicism and fatigue.
Dr Graham Martin is a Senior Lecturer in Social Science Applied to Health, at the University of Leicester.