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The 2020 Public Services Trust Blog

Tuesday, October 19, 2010

Two missing links – accountability and information

By Charlotte Alldritt

Until this morning I had thought I’d understood the general gist of the Government’s White Paper, ‘Liberating the NHS’.  Even if, as Sir David Nicholson admitted, the Department is still “working on the detail” I thought I had a fairly firm idea of the direction of travel. 

But now – after four of the most senior managers of the NHS tried to explain it to the Health Select Committee inquiry on commissioning – I’m more confused than ever.  While the devil will indeed be in the detail, it is not clear how the whole system will align the incentives and levers of finance, clinical expertise and commissioning for quality care.  Add the need for £20 billion in productivity savings and a 30% cut in management costs, and it’s a significant mountain to climb.

A first step will be in making clear the relationships between the Department, local authorities, GP consortia, the NHS National Commissioning Board, primary care inside and out of the remit of GP commissioners, social care, Health and Wellbeing Boards, individual patients, GPs disengaged or disinterested with the new system architecture, and the whole range of other stakeholders.  Without clarity on these relationships, as Rosie Cooper, Labour MP for West Lancashire asked repeatedly “Where is the accountability”?

Accountability is one of my two prime concerns for the new system of commissioning for healthcare.  How will providers be held to account for the quality of their outcomes for individual patients in the new system?  How will commissioners be held to account for the outcomes they achieve for their communities?  To what extent are local authorities to take the rap?   Where will discussions on competing ideas of ‘appropriate’ resource allocation take place? 

We know that the NHS National Commissioning Board will have ultimate authority.  But, as each of the four witnesses this morning (Sir David Nicholson, Dame Barbara Hakin, Dr. David Colin-Thome, and Ben Dyson) intimated, the local dynamics of the system will be key to delivering efficient and effective healthcare.  Appropriate accountability structures and incentives need to be in place to engage both clinicians and patients to achieve this.

The second of my prime concerns underpins the first; information and data quality.  For providers, commissioners and individual GPs to be held to account there needs to be a body of credible information on comparative outcomes, inputs and transaction costs.  ‘How much would the new Commissioning management system cost per head?’ asked Chris Skidmore, Conservative MP for Kingswood.  The Department does not know yet, but is determined to see it “significantly below 5%” of total costs.  Who will be monitoring those costs and outcome measurements?  David Nicholson says that the NHS Information Centre will – for the first time – be a hub collection point for Commissioning Boards to submit their standardized data.

However, it is not yet clear the extent to which the Information Centre will prescribe data standards or data requirements (e.g. and especially in primary care where it is almost entirely lacking).  As Dame Hakin and Dr Colin-Thome suggested, peer-based scrutiny and competition on outcomes can be a powerful lever for improving quality amongst clinicians.  But will this data be collected and made available for comparison?  Furthermore, in the new age of transparent government, will this data be openly available to the public?

The 2020 PST Information and Technology Group have submitted a formal response to the Health Select Committee on the role of information for commissioning.  We believe that that the White Paper does indeed hinge upon the ‘information revolution’ that the Secretary of State speaks of. 

The absence of accurate data on performance, spending and costs leaves commissioners and the public blind when crucial decisions have to be made about investment in, or closure of, services.   When the DH refers to high levels of patient satisfaction with their health professionals, to what extent do patients know how their GP compares with others?  Since patients and the public cannot get the answers to simple questions like, ‘How good or bad is my local GP?’ or ‘Which local provider organisations provide the best care?’ they can’t make informed choices about where to get care.  And they can’t make an informed contribution to local health discussions such as the merger or closure of services. 

We therefore recommend, for example:

  1. Standardised national data sets need to be developed urgently for episodes in primary care and community services, similar to the routine data set on episodes of hospital activity.  These should be done incrementally so that that striving for ‘perfect’ does not extend the existing delay of many years.
  2. It should become a legal duty of all providers who are funded by the NHS – including individual clinicians – to collect standardised, high quality data on their individual patient activity and outcomes to meet the national standards
  3. Commissioners should have the power to require addition local data access and suspend providers’ NHS funding or referral of patients for failure to comply.

 To be a truly devolved system as the Government envisages for the NHS, requires publicly available, high quality data across the full range of health services.  Only then will we be able to build a system which engages clinicians and citizens to work together, and so delivers quality care for patients at lower cost.


The 2020 Information and Technology Group submission has been lodged with the Health Select Committee, which will report later in the autumn.  For all enquiries on our recommendations and other work, please contact Charlotte Alldritt ( 

Monday, May 17, 2010

A vision for 2020 information and technology: Part 3 – healthcare

By Charlotte Alldritt

The year is 2020. Over the past decade, simple online technologies have transformed the way we access data and information, hold public services to account and engage with government. Transparency is the watchword of the day. The ultimate prize? Renewed political legitimacy and public services finally fit for purpose. In the third and final installment in this series, I look at how technology and information can transform healthcare through online ’self-services’ and open data.

Sally – 55, living in South East England, understands that technology represents at once a challenge and an opportunity. Ten years ago, the increasing cost of more effective treatments would have prevented Sally’s local PCT being able to prescribe the drug she needs to combat her cancer. Forunately, a switch to online service delivery through an extended, more comprehensive NHS Direct has enabled money to be diverted to frontline treatment.

A presumption of online ’self-service’ for primary care and follow up treatment means that patients can access detailed online health information supported by remote multi-channel consultations with a range of healthcare professionals (via 24/7 telephone, videophone, email, text and instant messaging) with a range of healthcare professionals.

There are also outreach services available via high traffic forums (e.g. Family Planning Association, Mumsnet and Bebo) to encourage user-led discussion forums and support networks. These are particularly useful for helping people to access information and advice from trained professionals in a readily accessible, anonymous way. Sally finds this particularly helpful when talking about more sensitive issues pertaining to her illness.

By sharing her unique health identification number, authorised clinicians can have access to relevant sections of Sally’s medical records. This tailors the service provided so that individuals receive the highest quality care.This information is automatically uploaded onto Sally’s ‘My NHS’, a with a customised and customisable homepage acting as a single portal access to her NHS health and social care records.

MyNHS also features:

  • a list of her relevant health professionals with links to openly published performance data
  • details of medication/prescriptions
  • useful reference information and learning resources
  • links to her GP practice website and reviews, and
  • a record of all of her upcoming appointments.


Sally’s daughter, Helen, is 27 and has registered with the national ‘virtual GP practice’ designed for patients who choose to engage primarily through telephone and digital channels. This means that Helen can access healthcare in any part of the country as and when she moves or travels with work. While this arrangement wouldn’t suit her mother, Sally, Helen finds it a convenient way of speaking to a GP on the rare occasion she has a health concern that needs face to face consultation/treatment.

Prior to her visit, Helen looks up comparative data on local GP practices and doctors on a single, government established website.  This website is a hub for information from across the market in healthcare informatics involving private and third sector organisations, as well as public sector agencies/providers.  This comparative website means that Helen can make an informed decision which clinician she chooses to consult.  She can then book her appointment online and all parties involved (the locum GP, MyNHS, and NHS Direct) receive information (including test results and next steps) automatically through the end-to-end, network of local IT systems.   

Sally and Helen find the online ’self-services’ and open performance data a convenient way of accessing a rich supply of healthcare information, diagnostic tools and – in some cases – prescriptions (e.g. repeat prescriptions).  Occassionally things go wrong, but there are clear procedures in place which allow patients to give their feedback, for this to be incorporated in the appropriate performance dataset, and for clinicians and/or managers to be held to account.  For example, Helen had a bad experience with her maternity ward as a first time mother.  She posted her dissatisfaction on the hospital ward’s website and received a response from the ward sister through her MyNHS account as to how they had since rectified the situation.  This reassured Helen and Sally that they weren’t battling ‘The System’, but that their views counted, and quality and patient experience were truly at the heart of the NHS.

Wednesday, March 3, 2010

Deep Impact

By Henry Kippin

Todays figures on NHS primary healthcare trust overspends are a sharp corrective to the idea that cuts to public spending will hit the back room only.  Chief Secretary to the Treasury Liam Byrne is apparently impressing upon department heads the need to find big savings, but the scale of overspend in some trusts (Enfield being the largest) illustrates the challenges of making this happen – and the likelihood that institutions will feel the pain as well as service users. 

In the same article, the Kings Fund’s John Appleby uses Manchester as an example – “in Manchester you have 25 acute hospitals.  That is probably too many and it underlines what big questions the real funding cuts entail.” 

These are massive choices to be made, with real human consequences and long-term (social and behavioural) impacts for communities.  

This speaks to a key tension in the current debate on public services – and one that has not really been explored in depth by any of the parties.  Cuts as an end in themselves seem to be necessary in the short term.  But the question is: how do they fit into a longer term perspective? 

In the next couple of weeks the Commission will publish its interim report, which will set out such a vision.  It wont be everyone’s cup of tea, but it will at least try to force a conversation that gets beyond the short term, and asks politicians and the public to think about ten years time as well as tomorrow.  If this really is a ‘moment of historical discontinuity’ as Vernon Bogdanor has said, we need to do both.

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Posted by Henry Kippin at 11:26 am
Friday, May 29, 2009

Health-Check for a Responsible Britain

By Henry Kippin

The RSA hosted a packed lecture yesterday from Andrew Lansley, Shadow Secretary of State for Health.  He talked on the subject of ‘Improving Health Outcomes for All’, sketching out a blueprint for a future Conservative Party policy agenda. 


Overarching themes were ‘responsiblity’, ‘reform not reorganisation’, ‘choice and empowerment’ and ‘efficiency’.  Some were better explained than others.  Anyway, here are my quick reflections on the main points:   


Empowering Frontline Professionals

The Shadow Secretary placed considerable emphasis on the need to empower frontline professionals – the most obvious example being GPs who, under Conservative plans, would be far stronger guardians of quality control, holding hospitals (for example) to account.  Questions here concern potential variation in service levels, and the potential capacity of GPs.      


From Targets to Outcomes

This shift of responsibility downwards would be representative of a broader move towards an outcomes-driven approach to public services.  Mr Lansley was unequivocal about the need to do away with top-down ‘tick box’ targets, and towards broad public health outcomes.  But as Matthew Taylor notes, one danger is that broad outcomes can simply become umbrellas for ‘proxy targets’.  And some targets may be necessary - does the Shadow Secretary’s position risk throwing the baby out with the bathwater?


Choice & Competition

The Shadow Secretary talked about the need for more and better in this area, as a means to make essential efficiency savings, and to drive up quality. There is broadly consensus across parties on this.  But this will be contingent upon…


Access to Information

The lecture set out access to good quality, comprehensive information as key to making a choice agenda work.  But as my colleague Matt Grist pointed out, Robert Shiller and even George Osborne have recently spoken on the need to get past the assumption of rational, economic decision-makers.  I can’t help feeling that more thought needs to be given to appropriate choice architecture in this area. 


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Posted by Henry Kippin at 2:41 pm
Wednesday, April 29, 2009

Media pandemic

By Charlotte Alldritt

Whilst happily sitting in the doctor’s surgery this morning, my short wait was interrupted by a man rushing into the clinic in a state of panic – feeling a slight temperature and a sore throat he demanded to see a doctor immediately. On hearing that there were no more appointments available until the next day, he declared (in a very loud voice, not unlike someone who wasn’t struck with a lethal virus) that he had swine flu and he could be dead by tomorrow. He then followed this declaration with an impression of a pig – I kid ye not.

My utmost apologies in advance to this man if it transpires that he actually has contracted swine flu, which – ‘is all over London’ he told the whole waiting room…but I must agree with Simon Jenkins in the Guardian today, that the media hype surrounding the potential pandemic illustrates the very real effect that news editors have on the public’s perception of risk. Whilst I do not think it a conspiracy ’stoked in order to…spend’ our way out of global recession, the issue highlights the impact the media can have on our expectations of, and demand upon, public services.

This man thought himself an emergency case and the surgery could do little to refuse him. In previous blogs I have discussed people turning up to A&E; to see hospital practitioners about a small graze or slight ear-ache. As ever, I firmly support the availabilty of public services for all, free at the point of need in the case of the NHS – but essential reductions in the cost of running these services puts a even greater onus on the media to help people make informed decisions. Further to Henry Kippin’s blog (The Meaning of (post-Budget) Life, 28/04/09), hyperbole for the sake of a headline is not the way to start having a sensible debate on what can and cannot be afforded in the austere years ahead.

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Posted by Charlotte Alldritt at 3:50 pm
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