Thread by @axelheitmueller

#NHSBill due in the HoC in the coming days. It's complex and the biggest change since 2012. Difficult task for a new SoS to get to the bottom of the detail quickly. Not understanding the detail outside the Lansley circle was the biggest issue in 2012. What to focus on? 1/

There is the obvious: NHS will not succeed unless social care does. There are some tangible leavers to pull about funding and rules and most of the policy work has been done. Just ask @RichardnotatKF. It's now about politics 2/

On the core NHS changes, it will be hard to find anyone who disagrees with the direction of travel i.e. more integration. However, the concept has been around for more than a decade and many £m have been spent on NOT achieving it. 3/

Fundamentally, have we learnt the lesson that structural change is easy (but expensive £4bn in 2012), what matters is whether new duties, boards etc actually drive behavioural change? Judging from the early ICS days, this is questionable (exceptions exist, see @NHS_RobW) 4/

All change is about anthropology rather than legal frameworks, paragraphs or tech (a big issue in the realm of innovation too). What will appeal to hearts & minds, how best to enable (or at least not hinder) that through a Bill? @HPIAndyCowper's musings hsj.co.uk/workforce/cowp… 5/

From what I have seen, successful integrated systems around the world (and there aren't that many) have have one thing in common: a very HOT burning platform (in most cases related to hard budget constraints). I'm unclear what the equivalent is in the NHS 6/

This might feel counterintuitive given millions of patients on waiting lists and poor care outcomes compared to most OECD countries. But ironically, this is merely a central, political constraint i.e. will mean HMT finding more money for the NHS to do more of the same. 7/

Of course more money is needed. Question is how can it be made to work in more innovative ways? What could create the spark and energy on the ground to work and behave differently (a duty to collaborate is unlikely to get people out of bed and how will it be measured)? 8/

Change has happened over the past 12 months because there was an inevitability/unavoidability - an existential threat. Change has also happened in areas with a degree of competition (e.g. see sexual health economist.com/britain/2019/0…). 9/

There are broadly four policy leavers to drive change:
✅targets: delivery unity is back! Mixed success
✅competition/contestability: counter-cultural to NHS and mixed results elsewhere
✅OD work e.g. QI programmes: important but marginal
✅transparency, choice & voice
10/

It's the fourth that has most potential in my view and is unfinished business in the NHS. Choice exists and to some extent voice as well. However, it is exceptionally hard to compare specific care outcomes between different providers or clinicians to make informed choices. 11/

Previous attempts by e.g. @Jeremy_Hunt were met with significant pushback from Royal Colleges arguing that it is simply too hard to measure outcomes in a fair way. I think this is fundamentally lazy, ICHOM ichom.org are a good place to start from. 12/

Overall CQC ratings are just not actionable enough for patients in the way that Ofsted reports drive choice in education given the complexity and diversity of healthcare. 13/

Focusing on meaningful outcomes would also have a beneficial impact on data sharing and quality and might be able to achieve much of the @NHSDigital data strategy in a less top down way. 14/

If we want to transform healthcare, we have to give everyone a reason to change. Bills rarely do that as they fail to connect emotionally. They merely set the guardrails. Is the change in SoS a chance to reflect? 15/END