Pearls and Irritations

The success of the NHS covid-19 vaccination programme shows the benefits of national leadership and local delivery in healthcare. Working at speed and scale, the programme put in place a service delivery model that delivered a standard offer to the public with the aim of achieving equity in vaccine delivery and zero waste. The question now is whether these lessons can be applied in other areas of care as the NHS embarks on restoring non-covid services, arguably the biggest challenge in its history.

National leadership focused on the design of the programme involving hospitals, general practices, mass vaccination centres and pharmacies. This was supported by a well-functioning system for sourcing and distributing vaccines helped by the military. Local delivery drew on the assets of the NHS, local government, volunteers, community and faith leaders and others to ensure the safe and effective provision of vaccines. The private sector played a supporting role in data analytics, and delivery was enabled by access to a comprehensive patient database.

If national leadership and local delivery can work so well for vaccinations, then how can the same principles be applied to other forms of care delivery? We have known for a long time that there are wide and persistent variations in how care is provided even within the framework of a “national” health service. These variations have been documented in the NHS Atlas of Variations and they mirror experiences in many other countries.

While it would be comforting to believe that variations reflecting differences in the characteristics of the populations served, the seminal research of Jack Wennberg and others demonstrates that this is not the case. Far more important are differences in the supply of services and in the practice patterns of the teams delivering care. Fragmentation of NHS services – with many organisations involved in provision – also hinders attempts to provide care in line with the best available evidence.

Integrated care systems across England have begun to tackle fragmentation by planning improvements in services for the populations they serve. These systems played a vital role in some areas in the response to covid-19, facilitating mutual aid between hospitals, enabling closer collaboration between health and social care, and supporting general practices to work together to meet the needs of their patients. Their role will be just as important in work to restore non-covid services and to deal with the huge backlog of need that has built up.

If they are to be effective in delivering consistent standards of care, integrated care systems will need to draw on expert national advice and guidance – as the vaccination programme was able to do through the work of the JCVI. There are precedents in the national service frameworks produced during the Blair government, which were supported by substantial spending increases and the backing of politicians as well as clinicians, and in guidance issued by NICE and others. A good place to start would be elective care in view of the huge increase in the number of people waiting to be treated, including those waiting longer than the 52 weeks maximum.

The argument for greater consistency in care delivery is primarily about what is in the best interests of patients, but also concerns the most effective use of scarce resources. Studies of high performing health care systems show that it is possible to deliver better care at lower cost by reducing overuse, underuse, and misuse of services. The financial pressures facing the NHS underline the importance of improving outcomes and releasing resources by tackling variations and waste.

The NHS covid vaccination programme was successful in part because it was created in response to an exceptional threat. Adaptation of the principles it embodies to other areas of care will be spurred by the challenge the NHS now faces in restoring services at speed and scale. Addressing this challenge is much more difficult than setting up a new service from scratch—as in the vaccination programme—because it entails changing established and sometimes deeply embedded professional practices.

That is why progress depends on alignment between national and local leaders based on a shared vision of what success looks like and how it will be achieved. The “how” needs to draw on Wennberg’s insight that reducing variations requires a science of health care delivery drawing on the experience of health care systems that are in the vanguard of this work. These systems invest in quality improvement methods and ensure that clinicians and managers are supported to improve care

Integrated care systems must learn rapidly from this experience if they are to restore non-covid services and deliver care in line with evidence of what good looks like. National leaders have a role both in providing expert advice and guidance and securing additional resources on the scale of those that enabled the vaccination programme to succeed. Ministers must enable local leaders and clinical teams to lead improvements in care and resist the temptation to reassert control as the next election approaches.

Just imagine an NHS where patients everywhere experience the same high standards of care, where unwarranted variation has been reduced, and where waste has been minimised. If this can be achieved, the enduring legacy of the vaccination programme will be its impact on all areas of care. That feels like a prize worth fighting for.

This article was written by Chris Ham, republished from The BMJ Opinion 7 April 2021. Click here to read the original article.

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