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The NHS’s transformation journey



Healthcare strategy consultant Melanie Relf takes stock of the modernisation journey of the NHS which continues at pace. 

The dictionary definition of ‘transformation’ is “a complete change in the appearance or character of something or someone, especially so that thing or person is improved,” this can lead us to expect transformation to be rapid.

However, this is not always the case and behind what appears to be overnight success is normally 10+ plus years of planning.

This brings the question, where are we in the transformation journey of the NHS?

How transformation began

Transformation began with the government’s Five Year Forward View in 2014 to close the three ‘gaps’ in healthcare: in health & wellbeing, care and quality, and funding and efficiency.

This was reinforced by the NHS Long Term Plan, released in January 2019, which provided a 10-year plan with more wide-ranging healthcare improvements.

The Five Year Forward View and the Long Term Plan emphasised the value of the NHS whilst also highlighting its shortfalls, yet they are limited in that they were written prior to COVID-19.

Although many of the plans articulated in the Long Term Plan are currently paused, it is clear that much of this work will and must continue as the new normality resumes.

The Long Term Plan identifies the following focus areas, chosen to maximise the impact across the population:

  • Maternity: halving still births, maternal and neonatal mortalities, and serious brain injuries by 2025 and increasing the number of neonatal intensive care beds
  • Cancer: speeding up diagnoses, extending screenings, overhauling diagnostic services, and ensuring that an initial yes/no diagnosis is received within 28 days, through the introduction of Rapid Diagnostic Centres (RDCs)
  • Mental Health: additional help for people with depression, anxiety, and severe mental illness, and increasing availability for children and young people’s mental health services
  • General practice: a fundamental redesign of outpatient services through technology,Cardiovascular disease (CVD): improving detection and care of CVD to prevent unnecessary cases of heart attacks, strokes, and dementia.

Why we need to transform the NHS

As a population, we are living longer resulting in more chronic and complex long-term health issues which must be treated over several years.

Increasingly, we suffer from self-created, preventable diseases because of unhealthy choices including obesity, smoking or excessive alcohol consumption.

To prevent but also to treat these long-term illnesses we require tailored and sophisticated treatment.

Therefore, modern medicine must be constantly advancing if it is to keep up with the evolving society.

This brings us to the second point, which is the importance of information and choice when it comes to our own healthcare plan.

To achieve the level of personalisation that is desired, transformation of NHS services is required to collate, compare, predict, diagnose, and treat at unprecedented levels in unprecedented ways.

Furthermore, we expect to be treated equally, no matter our location, with an equal outcome, and we should be able to rely on joined-up thinking between all aspects of the healthcare system.

Finally, there is a well-publicised backlog in maintenance in NHS property, paired with a lack of staff to fill vacancies, and long waiting lists for certain services which must be resolved.

What is needed for effective transformation?

For transformation to be effective, we will need:

  • New, easily cleanable, sustainable, efficient, bright buildings that help staff deliver the new models of care and give patients the confidence that they are in the best possible place.
  • Cutting-edge equipment that performs the required task in a streamlined, effective way.
  • Technology that is harmonised, supporting connected facilities for a truly holistic healthcare system, that facilitates easy communication with the population at every level of care.
  • A well-trained and fully supported workforce that understand they are valued, led by an exemplary, strong and focussed leadership base.

Delivering transformation

How healthcare is delivered is moving towards population-based delivery to help the NHS provide more pertinent, tailored services to a region.

Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICS) will work with Local Authorities supported by a single Clinical Commissioning Group.

There has been considerable thought applied to how to move forwards at a macro scale.

The challenge now is to ensure, amongst all this reorganisation, that we have a serious, solid process at the project level, through robust briefing, clear communication and strong leadership.

This must be paired with experienced healthcare designers who understand the complexities and the pitfalls, and clinical modelling that has been piloted and evaluated.

There has been little review of the impact, positive or negative, of the previous intervention predominantly delivered via PFI.

The Nuffield Trust has collected anecdotal data which emphasises the importance of a robust briefing process.

For example, standardised rooms, reconfigurable space, acuity-adaptable single-bed rooms, loose-fit planning to facilitate flexing without major intervention, the ability to isolate part of a ward and to initiate one-way systems have all been shown to be indispensable when managing COVID-19.

Robust briefing

Briefing of healthcare premises has never been more important.

User Group Meetings regularly form a crucial part of this process, yet they often result in unnecessary rounds of design interrogation, exploration, and verification.

Melanie Relf

Stakeholders attending User Group Meetings should be empowered to share information, but also to deal appropriately with wild-card requests that do not sit naturally within the aspirations the department has identified.

To ensure consistency, the same people must attend the stakeholder meetings, to feedback clearly and regularly to their team and relay input back to the user group meetings.

Many people are naturally interested in the process of creating new hospitals, but a large amorphous ever-changing group makes it difficult to identify the key players and the process becomes burdensome.

The smaller the group of key personnel, the better, resulting in dynamic decisions, quick responses, and the ability to maintain a clear focus.

Cross departmental reviews should be integrated into the user group process, so the same decisions are applied across departments for example, with infection control, cleaning regimes and the processing of lab samples.

Clear communication

Some time must be spent identifying a clear process, key personnel, and lines of communication. Defining ‘gates for approval’ i.e. the purpose of each design review or meeting, ensures the purpose of each stage is clear, identifying what is open for discussion, what has already been signed off (and therefore should not be revisited unless absolutely necessary), and what will be explored further along the line.

Strong leadership

It is crucial that key personnel are identified, have the time to devote to the project, and clearly understand their roles, the overriding objective of the team, and the steps to be attained along the way.

While the design process may well be iterative, the briefing should not be. Changes in personnel are unavoidable, given the length of time that major projects take to procure, but handovers of previous decisions taken within individual areas are crucial to maintain consistency.

A social experiment in project procurement has been undertaken over the years, consciously or otherwise, using design firms with no previous healthcare experience, in the hope that this would produce radical designs that healthcare experts overlooked, blinkered by their expertise and knowledge, stifled by unnecessary restrictions that are rarely challenged by the industry.

The inevitable occurred.

Post project evaluation

There has been little review of the impact, positive or negative, of the previous intervention predominantly delivered via PFI.

There is a wealth of information that post-project evaluation can offer to new projects, but we rarely take the time to learn from our mistakes.

Transformation success

When visualising success, we should aim for smart, sustainable and clinically sound facilities, occupied by patients for the shortest viable time, cared for by appropriately skilled, highly valued staff, where the outcomes do not vary, and records of all health events are available as required is the goal.

Furthermore, we should aim to see reductions in avoidable deaths, technological enhancements facilitating real-time results, and a health journey free from delay. We are on the way, and we occupy an unprecedented position, but care and caution will pay dividends.

Melanie Relf is senior consultant in healthcare strategy and planning at ETL.


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