Professional Documents
Culture Documents
THE HUMAN
FACTOR
How transforming healthcare to involve
the public can save money and save lives
FOREWORD
O
ur public services face an immense challenge over the
next few years. They will have less money but will be
asked to do more in response to seemingly intractable
social problems.
Yet a proper recognition of the scale of this challenge shouldn’t
induce despondency. Rather, it can be used to spur a powerful
combination of creativity and commitment – that we can find
bold new solutions that reform our public services to save
money and improve lives.
This report examines the challenges faced by the National
Health Service. It shows how radical new ways of innovating
that give genuine power to frontline staff, patients and the
public can reduce spending at the same time as increasing
health and wellbeing.
We call this ‘people–powered public services’. This is one of
a series of papers that will show how this approach can be
applied to public services so that they are better placed to
cope with the immediate demands of the current crisis, and
better able to respond to the long–term challenges of the
future.
We welcome your input and views.
Jonathan Kestenbaum
Chief Executive, NESTA
November 2009
EXECUTIVE SUMMARY 3
EXECUTIVE
SUMMARY
T
he National Health Service (NHS) needs to save £15
billion to £20 billion over the next few years. This paper
argues that these savings could be achieved through
radical patient–centred service redesign and more effective
approaches to public behaviour change. However, these
approaches are difficult to develop within the existing health
service. NESTA’s experience of working with leading companies
and developing projects in healthcare demonstrates that radical
new ways of innovating that give genuine power to frontline
staff, patients and the public are necessary to make these
approaches widespread. This would unlock the savings we need
and improve the nation’s health.
new services suggests that all too often the realities of NHS
management structure stand in the way.
NESTA’s experience of supporting projects in healthcare and
other public services offers a better approach to both service
redesign and behaviour change. For example, NeuroResponse,
an innovative Multiple Sclerosis service, shows how genuinely
empowering patients and clinicians can unleash innovative
and cost–effective ways of doing things. Our work on people–
powered behaviour change has shown that an approach that
takes advantage of the ingenuity and strength of existing
communities is cheaper and more effective than many larger
and more expensive public health programmes.
These ways of innovating depend on giving genuine power to
frontline staff, patients and the public, for example, through
creating social enterprises to deliver new services and
supporting community groups to drive behaviour change
campaigns.
The NHS does not have to choose between saving money
and saving lives, or between cost reduction and reform. It is
possible to develop cheaper, more effective patient–centred
services and approaches to public behaviour change – but only
by adopting radical new ways of innovating within the NHS.
Ultimately, the answer relies on frontline NHS staff, the patients
and public that they serve, and policies that enable these ways
of innovating.
We call this approach to reform ‘people–powered public
services’. This is one of a series of papers that will show how
this approach can be applied to public services and the benefits
that can result – so that our public services are better placed
to cope with the immediate demands of the current crisis,
and better able to respond to the long–term challenges of the
future.
CONTENTS 6
CONTENTS
Conclusion 37
Endnotes 40
PART 1: THE NEW CONTEXT FOR THE NHS 7
PART 1:
THE NEW CONTEXT
FOR THE NHS
Why doing the same things only more
cheaply won’t solve the problem
T
he financial crisis means a very different context for
public services – including for the NHS. The health
service has been geared for growth, but this is about
to change. While the main political parties have promised to
maintain NHS spending, making real savings in the order of
£15 billion to £20 billion over the next few years will be critical
to meet rising demand. The current debate has focused on
cuts and efficiencies, but in isolation these are unlikely to be
sufficient. The real savings are to be achieved by devising
efficient, effective ways to tackle long–term conditions and
change behaviours to prevent future ill health. The NHS has
long recognised this need, but has only partially transformed
itself to meet it. Rather than a constraint, tighter budgets
should be a spur for radical change to meet the challenge.
of debt. This is less than the 1.1 per cent rise that was predicted
last year.
For the NHS, the world’s largest publicly funded health service,
this context is distinctly challenging. The NHS in England alone
employs more than 1.3 million people and currently operates
with a budget of over £100 billion – ten times its original budget.
Since the 1940s, spending on health services has seen a ten–
fold increase. After the 1997 election, the Government made
a concerted effort to increase NHS spending as a percentage
of overall GDP so that it compared more favourably with the
OECD average.2 Today, it takes up 17 per cent of total UK public
spending, having risen 5 per cent per year in real terms over the
last decade. In many ways, the NHS has been geared for growth.
11
10
9
8
7
6
Real change as 5
a percentage of
existing budget 4
3
2
1
0
-1
-2
-3
1997-98
1998-99
1999-00
2000-01
2001-02
2002-03
2003-04
2004-05
2005-06
2006-07
2007-08
2008-09
2009-10
2010-11
2011-12
2012-13
2013-14
2014-15
2015-16
2016-17
Historic
PART 1: THE NEW CONTEXT FOR THE NHS 9
PART 2:
CHANGING CARE
Why patient–centred redesign and
prevention generate sustainable savings and
improve outcomes
T
he twin challenges of managing long–term conditions
and encouraging behaviour change cannot be addressed
through centralised efficiency measures. The examples
of both the UK’s most innovative private businesses and
its most ambitious health projects show that user and staff
engagement and involvement is the way to achieve the kinds
of innovation needed to meet these challenges. There are many
excellent examples of patient–centred and preventative health
within and beyond the NHS, which show how these approaches
can save money and save lives.
It is clear that the challenges of managing long–term conditions
and achieving behaviour change are difficult and pressing.
However, there is evidence that approaches that engage users
and frontline staff effectively can achieve remarkable success
in making these happen. NESTA has seen examples of this in its
work with the UK healthcare system, also reflected in its work
with innovative UK businesses in the private sector.
costs, they are doing more innovation now than before. But it
is the way they are doing this that is of particular relevance to
the NHS: they are placing greater reliance on ‘user’ and ‘open’
innovation, relying on customers, partners and staff to provide
innovative ideas and testing grounds.
Firms that NESTA works with have argued that this approach is
cheaper and more effective than traditional, centrally controlled
methods of innovation, particularly since users possess
important tacit knowledge about how companies’ products are
consumed that can be harnessed to create value.
50
40
Percentage 30
of firms
20
10
0
Far less Less About the More Far
same more
Amount used
PART 3:
TRANSFORMING
INNOVATION
How the NHS needs to transform its
approach to innovation to realise the
benefits of patient–centred and
preventative health
P
atient–centred service redesign and effective prevention
initiatives are difficult to develop within the existing
health service, despite the significant savings and
improvements in outcomes that can result. NESTA’s experience
of developing projects in healthcare demonstrates that
radical new ways of innovating are necessary to make these
approaches much more widespread, and so realise the full
benefits of patient–centred and preventative health. These ways
of innovating depend on giving genuine power to frontline staff,
patients and the public, for example, through creating social
enterprises to deliver new services and supporting community
groups to drive behaviour change campaigns.
approach.
NeuroResponse will enable patients to receive treatment
at home rather than having to travel to a clinic or hospital.
This is especially important with a condition such as MS,
where movement can be difficult. NeuroResponse will use
existing telecommunications technology to deliver a more
patient–centred and accessible service, one that improves the
effectiveness of care for patients and enhances their quality
of life. It will comprise a direct telephone/triage advice line, an
email advice service, and teleconferencing.
Supported by NESTA and the Young Foundation’s Health
Launchpad programme, NeuroResponse is being developed
as a social enterprise. As well as benefiting patients,
NeuroResponse will increase productivity, as a greater volume
of care needs can be covered by highly qualified nursing teams.
In effect, it shifts provision from the acute to community care
sector, as supported by World Class Commissioning priorities.
Although NeuroResponse is still at a fairly early stage of
development, the potential impact is significant. A recent study
by the Multiple Sclerosis Society revealed the cost of being
diagnosed with MS to be £17,000 per person. With over 85,000
people in the UK living with MS, the condition costs the NHS
over £400 million (£1.4 billion for the economy as a whole).49
Part of this cost is the high demand for hospital–based clinical
appointments and inpatient stays which can range from
hundreds to thousands of pounds. By conducting clinics over
the telephone and facilitating increased self–management and
community–based care, NeuroResponse has the potential to
dramatically reduce costs per patient. If this type of service
becomes widespread, the potential savings could be in the tens
of millions – not to mention the benefits for the wellbeing of
patients.
sets the terms for this engagement. In short, moving the focus
of resourcing from the centre, with its expensive ad campaigns
and marketing materials, to the local, with its community
groups and networks that can actually change behaviours,
might be more productive.
Further, when government does seek to engage with local
communities in order to encourage local action, it can use
models that still reflect an essentially top–down philosophy.
For example, as part of the Healthy Weight, Healthy Lives
strategy, the Government announced the Healthy Community
Challenge Fund (HCCF), giving money to localities (actually,
local authorities and PCTs, who must be joint bidders) to
test and evaluate ideas that make activity and healthier food
choices easier. Nine areas were awarded ‘Healthy Towns’ prizes,
sharing a £30 million investment that has to be match–funded
by local partners. A further £425,000 was awarded in seed
funding to 14 other towns, to support some of their proposed
work.
The HCCF attracted 160 expressions of interest, despite the
high level of funding available. Some of the winning proposals
focus on improving conventional local infrastructure (for
example, parks and cycle lanes), others on new but expensive
approaches (for example, a project costing up to £15 million for
a ‘loyalty card’ scheme to take part in healthy activities).
Because of the requirements of the application process,
genuine grassroots activity from this programme seems very
limited compared to the Big Green Challenge.
The total cost of the HCCF is £35.95 million – ten times
the investment made in the Big Green Challenge. NESTA’s
experience running a community–based challenge
demonstrates that for far less than £5 million – a fraction of
current spending on a single advertising campaign – a prize
process could be run to leverage community–level ideas that go
further in effecting behaviour change.
Through such an approach, even a 10 per cent reduction in
the occurrence of Type 2 diabetes and obesity would result in
savings to the health service (not counting the wider economy
and society) of £1.5 billion a year.
PART 3: TRANSFORMING INNOVATION 34
CONCLUSION
T
he NHS does not have to choose between saving money
and saving lives, or between cutting costs and reforming
itself. It is possible to develop cheaper, more effective
patient–centred services and approaches to public behaviour
change – but only by adopting radical new ways of innovating
within the NHS.
One response to the financial pressure facing the NHS,
somewhat in evidence at the moment, is to present lists of cuts
and efficiencies in isolation. As we have argued, these do not
in the main represent real reform, but are often only potentially
cheaper ways of doing exactly what we do now. Fundamentally,
the NHS needs a different way of approaching the immense
and humbling challenge of saving money and saving lives.
When resources are scarce, it is doing things differently that
will deliver the kind of transformation we need to ensure that
our public services are fit for the 21st century. In the case of the
NHS, in order to make real savings and to improve health, we
must radically rethink health services and the role of the public
in health.
Across the economy, new processes, tools and technologies
are enabling new ways of innovating between businesses, and
between businesses and the public. These ways of innovating
are more effective and more efficient than traditional, closed
models of innovation – and they are proving their value in the
recession.
The trend towards user and open innovation should also be
CONCLUSION 38
ENDNOTES
1. Economic and Social Research Council (2009) ‘Recession Britain.’ Swindon: ESRC.
2. Mean OECD spending on healthcare was 8.6 per cent of GDP in 1997. From 1997 to
2006, total health spending increased from 6.8 per cent to 8.4 per cent of national
income; see Institute for Fiscal Studies (2005) ‘Public Spending: Election Briefing.’
London: IFS.
3. Institute for Fiscal Studies (2008) ‘Public Finances: Two Parliaments of Pain.’ London:
IFS.
4. The King’s Fund/Institute for Fiscal Studies (2009) ‘How Cold Will It Be? Prospects for
NHS Funding: 2011–17.’ London: The King’s Fund/IFS.
5. Government policies as summarised by The King’s Fund (2009) ‘Budget 2009: Key
Points.’ London: The King’s Fund.
6. Source: Mike O’Brien, Minister of State (Health Services), in a Westminster Hall debate
on 14 July 2009. Available at: http://www.theyworkforyou.com/whall/?gid=2009–07–
14a.20.2
7. See Bassett, D., Bosanquet, N., Haldenby, A., Nolan, P., Parsons, L., Thraves, L. and Truss,
E. (2009) ‘Back to Black, Budget 2009 Paper.’ London: Reform. Also Gainsbury, S.
(2009) DH is told 137,000 posts must go in next five years. ‘Health Service Journal.’ 3
September.
8. Darzi, A. (2008) ‘High Quality Care for All: NHS Next Stage Review Final Report.’
London: Department of Health.
9. BBC News (2009) ‘Chronically Ill Elderly ‘To Rise’.’ Available at: http://news.bbc.co.uk/1/
hi/health/7824455.stm
10. Department of Health/Ipsos MORI (2009) ‘Long Term Health Conditions 2009.’ London:
Department of Health/Ipsos MORI.
11. The King’s Fund (2009) ‘Long–term Conditions.’ London: The King’s Fund. Available at:
http://www.kingsfund.org.uk/research/topics_longterm_conditions/
ENDNOTES 41
12. Beveridge, W. (1942) ‘Social Insurance and Allied Services.’ London: HMSO.
13. Office for National Statistics (2009) ‘Ageing, Fastest Increase in the ‘Oldest Old’.’
Newport: ONS.
14. In 2008, life expectancy for the UK was 78.0 for men and 81.9 for women; see Office of
Health Economics (2009) ‘Sixty years of the NHS.’ London: OHE.
15. The difference between life expectancy and health expectancy can be regarded as
an estimate of the number of years a person can expect to live in poor health or with
a limiting illness or disability. In 1981 the expected time men lived in poor health was
6.5 years. By 2004 this had risen to 8.6 years. From ONS and Parliamentary Office of
Science and Technology data; see Department for Work and Pensions (2009) ‘Building
a Society for All Ages.’ London: DWP.
17. The King’s Fund/Institute for Fiscal Studies (2009) ‘How Cold Will It Be? Prospects for
NHS Funding: 2011–17.’ London: The King’s Fund/IFS.
18. OECD (2009) ‘The Obesity Epidemic: Analysis of Past and Projected Future Trends in
Selected OECD Countries.’ Health Working Papers No. 45. Paris: OECD.
20. Foresight/Government Office for Science (2007) ‘Tackling Obesities: Future Choices –
Modelling Future Trends in Obesity and Their Impact on Health.’ 2nd Edition. London:
Foresight/Government Office for Science.
21. Nursing Times (2009) ‘NHS Spending on Obesity–related Equipment Increases 700 per
cent.’ 9 April.
22. Data from research investigating innovation practices amongst large (FTSE 100 level)
corporates, led by H–I Network for NESTA (2009).
23. For example, see Von Hippel, E. (2005) ‘Democratizing Innovation.’ Cambridge, MA:
The MIT Press; also Flowers, S. (2009) ‘The New Inventors: How Users are Changing the
Rules of Innovation.’ London: NESTA.
24. See for example Cabinet Office (2009) ‘Power in People’s Hands: World Class Public
Services.’ London: MHSO; also Parker, S. and Gallagher, N. (2007) ‘The Collaborative
State.’ London: Demos.
26. To cite one example, the charity Diabetes UK has been looking for delivery partners
for its work on user involvement in local diabetes care and received 31 applications for
three pilot programmes.
ENDNOTES 42
28. The King’s Fund (2009) ‘Long–term Conditions.’ London: The King’s Fund. Available
at: http://www.kingsfund.org.uk/research/topics/longterm_conditions; see also
Department of Health and Technology Strategy Board (2009) ‘Managing Long–term
Conditions – Remote Monitoring.’ London/Swindon: Department of Health and
Technology Strategy Board.
30. Department of Health (2007) ‘Research Evidence on the Effectiveness of Self Care
Support.’ London: Department of Health.
31. Murray, E., Burns, J., See Tai, S., Lai, R. and Nazareth, I. (2009) ‘Interactive Health
Communication Applications for People with Chronic Disease.’ London: The Cochrane
Collaboration.
32. Birmingham East and North Primary Care Trust (2008) ‘Birmingham East and North
Strategic Plan 2008–11.’ Birmingham: Birmingham East and North Primary Care Trust.
33. GovNet (2009) ‘Defined by Quality.’ ModernGov conference edition, p.244. To cite one
area, early detection and prevention is recognised as the most effective response to
cardiovascular disease; see for example Department of Health (2000) ‘National Service
Framework for Coronary Heart Disease.’ London: Department of Health.
34. An alternative approach, based on policy interventions that encourage rather than
mandate more sensible or responsible types of behaviour, has been presented in Thaler,
R.H. and Sunstein, C.R. (2008) ‘Nudge: Improving Decisions about Health, Wealth, and
Happiness.’ New Haven, CT: Yale University Press.
35. See for example, Darnton A. (2008) ‘GSR Behaviour Change Knowledge Review,
Overview of Behaviour Change Models and their Uses.’ London: Government Social
Research.
36. “There is also a strong case for the promising approaches of community–based
interventions in other countries to be expanded to one or two regions or cities in the UK
as exemplars.” See Foresight/Government Office for Science (2007) ‘Tackling Obesities:
Future Choices – Modelling Future Trends in Obesity and Their Impact on Health.’ 2nd
Edition. London: Foresight/Government Office for Science.
37. Diabetes UK (2008) ‘Diabetes: Beware the Silent Assassin.’ London: Diabetes UK; also
Improvement and Development Agency (2009) ‘Diabetes and Depravation: The Facts.’
London: I&DeA.
38. Lay health worker programmes have been shown to be effective in encouraging health
checks and prevention; see Lewin, S., Dick, J., Pond, P., Zwarenstein, M., Aja, G.N., Van
Wyk, B.E., Bosch–Capblanch, X. and Patrick, M. (2005) ‘Lay Health Workers in Primary
and Community Health Care.’ London: The Cochrane Collaboration. Also, see evidence
of programme impact at Dr Foster Intelligence, Diabetes. Available at: http://www.
drfosterintelligence.co.uk/services/diabetes.asp
ENDNOTES 43
39. Health England (2009) ‘Prevention and Preventative Spending.’ Oxford: Health England.
40. The Well London Alliance consists of Arts Council London, Central YMCA, Groundwork
London, London Sustainability Exchange, South London and Maudesley Foundation
Trust, and The University of East London.
41. Darzi, A. (2008) ‘High Quality Care for All: NHS Next Stage Review Final Report.’
London: Department of Health.
42. Department of Health (2005) ‘Creating a Patient–led NHS: Delivering the NHS
Improvement Plan.’ London: Department of Health.
43. Richards, N. and Coulter, A. (2007) ‘Is the NHS becoming more patient–centred?’
Oxford: Picker Institute.
44. Wanless, D. (2007) ‘Our Future Health Secured? A Review of NHS Funding and
Performance.’ London: The King’s Fund.
45. Achieving the ‘fully engaged’ scenario set out in the 2002 Wanless report through to
2017–18 saves 13.13 per cent of the NHS budget, broadly equivalent to the £15 billion
baseline of savings that are required by 2014. See Wanless, D. (2002) ‘Securing our
Future Health.’ London: Department of Health.
46. The King’s Fund/Institute for Fiscal Studies (2009) ‘How Cold Will It Be? Prospects for
NHS Funding: 2011–17.’ London: The King’s Fund/IFS.
47. In the Darzi Review, innovation that improved the experience of patients was regarded
as the driving force for quality. Furthermore, Darzi identified innovation as central to
linking the quality and productivity agendas. See Darzi, A. (2008) ‘High Quality Care for
All: NHS Next Stage Review Final Report.’ London: Department of Health.
48. As quoted in Taylor, J. (2009) Health Innovation: The Future’s Bright. ‘Health Service
Journal.’ 28 May.
49. Multiple Sclerosis Society National Centre (2008) ‘The Case for Change: Why England
Needs a New Care and Support System.’ London: Multiple Sclerosis Society.
50. A review of the evidence for the effectiveness of behaviour change campaigns shows
that a deficit model doesn’t work. See Anable, J., Lane, B. and Kelay, T. (2006) ‘A
Review of Public Attitudes to Climate Change and Transport: Summary Report.’ London:
Department for Transport.
51. NHS Health Development Agency (2004) ‘The Effectiveness of Public Health
Campaigns.’ HDA Briefing No.7. London: NHS.
52. See Dixon, A., Boyce, T. and Robertson, R. (2008) ‘Commissioning and Behaviour
Change: Kicking Bad Habits.’ Final Report. London: The Kings Fund.
53. The ten Finalists have one year to begin implementing their plans, with the help of a
£20,000 grant and further support. At the end of the year they are judged against five
criteria: 1) CO2 emissions reduction; 2) innovation; 3) long–term impact; 4) potential for
growth, replication and transferability; and 5) community engagement. The £1 million
will be allocated to the Finalists who prove their approaches are most successful based
on these criteria.
ENDNOTES 44
54. Appleby (2009) ‘Mapping the Big Green Challenge.’ London: NESTA.
56. Department of Health and Department for Children, Schools and Families (2008)
‘Healthy Weight, Healthy Lives: A Cross–government Strategy for England.’ London:
Department of Health and Department for Children, Schools and Families.
THE LAB:
HUMANINNOVATIONS
FACTOR IN HEALTH AND WELLBEING 45
THE LAB:
TITLE OF REPORT
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NESTA
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