Lessons from Valencia for the NHS

I recently had the privilege of accompanying a team from the NHS in Morecambe Bay to IMG_3208Valencia on a study tour about other models of healthcare. Spain has a NHS, inspired by and designed on the British version – it is held very dear in the hearts of the Spanish people. Spain is in a far deeper economic crisis than the UK and so it is asking some tough questions about the future of the NHS there. We need to do that here too. I was challenged in my thinking and learnt absolutely loads.

Here in the UK, I believe we need to do some brave experiments in order to create together a health system which continues to be free and accessible for all, excellent in its practice, and sustainable for the future. What I saw in Valencia could not simply be transported into the UK, but there is much to be inspired by.

1) We need a paradigm shift in our thinking about health. The Valencians are not shy in talking about the need to engage their community in health care. There is a huge investment of time and resource made in partnering with schools, teaching children and young people about healthy eating, how to cook and having healthy lifestyles. Health promoters in the community work in all kinds of settings from toddlers to diabetes cooking classes. They have embraced the Bechampian philosophy that if we promote health, disease will remain far away and they are therefore able to have less hospital beds and shorter hospital stays. This is in great contrast to the Anglo-American view ala Pasteur, that we can live how we want, but immunise ourselves to the max and kill off disease when it comes. The Valencians are also further ahead in their thinking about where people should be cared for. Their home care teams and investment in community nursing enables people to be cared for at home more efficiently.

images2) Breaking down silos and integrating the care. In the model we studied, there are no separate trusts – it is all one. This allows a full integration of the clinical teams to be able to work in a variety of settings, breaks down communication barriers and causes a wonderful sense of togetherness and collaboration. Staff morale is extremely high (it’s not just the tapas and siestas) as is patient satisfaction. Image from jarche.com

3) Breaking free of centralised power structures. The Valencian system has a unique funding model, which allows them to be free of centralised government. There is still a good system of accountability in place, but a single payment per patient, adjusted according to levels of deprivation and a few other factors allows greater flexibility in care. Interestingly, this model costs less to the government than other models in Spain and is still managing to run at a 26% saving! It would be made far more complicated if the silos were still in place.

4) Using smarter IT. They have a completed integrated IT system across the health sector. So, for example, if I want to refer a patent with complicated renal failure to a nephrologist, I would include this in my consultation and link the consultants name to my consultation via an email. The consultant would then be able to access my notes and email, decide what further tests are necessary, sort them out, see the patient and then any notes she makes and changes to medication would automatically appear in my medical notes also!

5) Investing in diagnostics. For a population of around 300k, they had 17 consultant radiologists! They believe patients want early diagnosis so that clinic appointments can then be arranged according to clinical need. GPs also have far greater access to scans, which cuts down on waiting times hugely and because there is far greater relational team working, a GP can email the radiologist to ask for a certain scan, they have a discussion, work out if a different type of imaging might be better and sort it out for the patient. We have similar possibilities here, but they are far more clunky and more time-consuming.

6) Better team working. There is a lovely relationship between the hospitals and the community settings. Consultants come out into the community to do clinics in a way that really works, they discuss complex cases with the GPs and talk through management options.

7) Smarter training. Nurses are trained to be able to work across the board in the community and so develop skills needed for practice nursing, district nursing, long-term condition, health visiting, etc. This enables far greater flexibility within the workforce and higher levels of job satisfaction. Also because it is all one system, clinicians can work inside and outside the hospital setting and medical students are trained to be more flexible in how and where they work.

8) Investing in community health care. Valencians do General Practice differently to us….Within this model, there are no privately owned partnerships. Rather, GPs are employees, just as with hospital doctors. This means less HR and management responsibility and perhaps less risk. Within that, they all maintain personal patient lists to keep a real sense of continuity, but work a different pattern. The day starts early and they do clinics from 7am – 3pm – all pre booked appointments. (the last 2 hours of this is for administration, so the clinics finish just after 1230h). Then at 3pm the walk-in emergency centres (in the same building) open – staffed by the GPs from the practice. Each GP does one or two 3pm – 8am shifts a month with appropriate rest built-in. The facilities are amazing with imaging on site. It’s actually not too dissimilar from the arrangement we have now with out of hours care, but is a bit more streamlined.

9) Harnessing technology. In Valencia, all patients have an app they can access, which tells them the waiting time in the A&E or in the local GP centre. Unsurprisingly this has meant less people turn up at A&E and are dealt with in the community more rapidly and appropriately.

10) Grasping the economic nettle. I went to Valencia, highly suspicious, as the model is built on a PPP (private-public partnership). A private company owns and manages this system, but is completely funded by the government. My personal politics is far to the left and so I found the notion of this nauseating to say the least. However, I was challenged in my thinking by the CEO who talks about his company being private, but with a public heart. Profits are strictly limited to 7.5% and everything else is invested back into the system. They are running on a lower budget, with less cost, higher patient satisfaction and higher staff morale than anywhere else in the region…..these are hard statistics to argue with. However, I don’t believe a PPP is necessary in order to achieve much of what they have done as there are significant risks involved with the private sector and it is an ideological objective I struggle with. Personally I would argue for a completely different type of economics altogether, but my voice is just one in an important conversation that needs to happen. One thing that I continually challenge myself on though is that business does not equal evil and state does not equal good…..this is why for me, regional government and participatory economics is of huge importance as we move forward. With the huge numbers of people who attend conversations about health in the South Lakes and North Lancs areas, I am confident that such things are possible. However, with tools like ‘the art of hosting’, they could be much more fruitful. PPPs are not the only alternative solution to what we have now. I personally love the idea of health cooperatives. Regional funding with supplemented taxation is another possibility. 

The truth is, we have to find new ways of working that are sustainable for the future, excellent for our patients and staff, and free for all to use. I hope we can learn the lessons from Scotland and learn to engage with the issues that matter. It is time for a new politics and there is no place better to start than with the NHS.

Complex Very Complex

A brilliant midwife, whom I hugely respect, posted this link on her Facebook page recently (if you don’t have time to read it, it details how North Wales is going to lose its special care baby units, so babies needing such care will be transferred over to England):


When we lose local services it causes a sense of anger and disempowerment. What about not being able to give birth in your local area, if you have a complex pregnancy? What if a mum’s baby is taken miles away from her for special care, only hours after having a caesarian section and it is a few days before they are reunited? What is the impact of this on the mental health of the mum and child? What about partners who can’t afford to keep travelling 40-50 miles to visit mum and baby and have to look after the other kids? What about the loss of jobs to the local economy and the sense of belonging that having things available in the local community can bring? What about the dangers of being transported to somewhere so far away to receive specialist care? It seems like a dreadful and unloving thing to close local services.

Sadly, it’s not that straightforward…. I thought it was, until I became the lead clinician for maternity for Lancashire North CCG. When looking to provide services for an area we have  a backdrop of three key factors to consider: 1) Safety, 2) Affordability, 3) Accessibility.

1) Safety: Research suggests that survival rates of babies with complex needs are higher in specialist tertiary centres, which deal with such problems far more commonly. Travel times from studies seem comparatively safe. Women, who have complex pregnancies have better outcomes in more specialist environments. The equipment is better, staff are more specifically trained and due to seeing and dealing with very poorly babies and mums more often, the care is better and survival is higher. Currently, the UK has some of the worst maternity and neonatal data in Europe and there is a hope to change this. I am grateful that none of my children needed this kind of care when they were born. I was also grateful, that if they had, I happened to live in Manchester where there is some of the best care available in the UK. But there is a difficult question for those who live more rurally (as I now do). If your pregnancy is complicated and you need more specialist obstetric input, or your baby needs highly specialised care, do you want that care to happen locally with a team who may not have lots of experience in that specific situation, or would you rather be transferred, potentially some distance, but be able to receive more expert care and have better long term health outcomes?

2) Affordability: Currently in the UK, the litigation budget for maternity and neonatal care takes well over 40% of this whole budget area. They are also hugely expensive specialities. We would all love to have highly specialist units on our doorstep or at least fairly local. But we have to face to some difficult facts that we have a lot of hospitals in the UK, which are extremely expensive to run and we can’t afford them all to be specialist centres for everything….We don’t have the staffing levels needed for this and with the way we currently do economics and due to our strong culture of blame and litigation when things go wrong, we don’t have the money. We have also hugely over-medicalised birth as a process. The Midwifery 2020 document implores us to help birth become a more natural process again, to take out too much over involvement and encourage (more affordable) midwifery led units and home births…..We could also train our midwives and health visitors (and even surgeons) to higher levels of expertise, as they have done in Scotland…..Complex cases could then be handled in larger regional centres…..

3) So, when we talk about accessibility (and for me this is especially important for the marginalised poor and for those for whom mobility is a real issue), we have to have that discussion in the light of safety and affordability. We also need to factor into our budgets the need to help those who can’t afford travel and child care…..

This doesn’t stop with maternity and neonates. Only yesterday we have also seen the Health Secretary, Jeremy Hunt, decide to close large parts of Mid Staffordshire Hospital and redistribute services elsewhere, after the recent scandal involving substandard care. We are seeing ED’s closing and will see many more such ‘reorganisations’ happening.

I believe that leadership can be self-emptying and loving and sometimes hard medicine does not always feel like love. Personally, however, I feel that the way Mr Hunt acted was neither self-emptying or loving but rather dictatorial, bullish and driven by a very different ideological objective.

We do have some significant challenges ahead and there are some changes to our systems that are necessary in order to provide the most excellent and loving care. It will take some serious re-imagination and the breaking down of some current mindsets we hold.

Not that my opinion really counts for that much, but for what it’s worth, some of my ideas would be as follows:

I really believe in participatory economics (sounds fun, eh?!). There has been a lot of rhetoric about devolving of budgets and allowing local health boards to make decisions about how money is spent. Firstly this isn’t really happening, as any time a decision is made on something the ‘powers that be’ don’t like, they come and crush the idea and tell the boards what to do instead, with the threat that they will replace the board if they don’t comply! Secondly, it doesn’t go anywhere near far enough and it lacks integrity because there is no joined up thinking. If local people are going to make decisions about their local economy, then it must be the whole and not just a part. Currently we spend an enormous amount of money on treating disease (or preventing it through vaccinations), but nowhere near enough on promoting health in our communities. Isolated budgeting doesn’t work and we waste an enormous amount of time and resource. We know that maternity care and neonatal care are being made so much more complex by our astronomically rising rates of obesity and diabetes, but we’re not putting the money into the places that could help turn this tide. We are also not collaborating between areas like health and education but are rather putting them in competition with one another, which is genuinely crazy. So, if the people of North Wales want an amazing special care baby unit near by, which provides brilliant care, they could decide to do so, but there are cost implications on other services, and cost implications on keeping up the expertise of staff and giving them enough time and exposure to complicated scenarios to know how to handle them efficiently…..So, less learned helplessness, and more engagement…..

Within that, we need to watch out for selfishness and all wanting our own rights. For me there would need to be priority care for children, women, the marginalised poor (especially including destitute asylum seekers), prisoners, the elderly and the mentally ill.

I also believe in gift economics. Towns and cities within a region can gift things to one another. This is already happening in healthcare and could happen more and in many other fields. For example, in North Lancashire, Blackpool has a gift of cardiology and cardiac surgery. It is a regional centre of excellence. There was initial resistance and concern about losing and moving local services but survival outcomes after heart attacks and many other conditions, both in terms of mortality and morbidity (how well you are afterwards) are far better across the region. Preston has a gift of neurology and neurosurgery and again provide excellent care. We don’t all need to have everything. Learning how to work in partnership and collaboration is key.

We need less of a blame culture. We need more compassion and understanding when things go wrong. Even if all the complex care is put into regional specialist centres, things will sadly still go wrong at times, mums and babies will still be poorly and die sometimes and nothing will change this……so some would ask, is all the reorganisation therefore worthwhile?

The redesign of our current systems is necessary and complicated. Sometimes, in the face of the economic beast and within the suffocating nation state environment, we can feel hopeless of change and helpless in our learnt disempowerment. Foucault says that we’re not really disempowered…..we just think we are. Revolution doesn’t have to be violent and bloody. Revolution can occur when enough people chose to engage, to love and to become the change they want to see…..

In the mean time, my plea would be this. Let those who are making tough decisions do so out of love and goodness, and not look to make healthcare profitable for private company share holders. Secondly, let those who don’t make decisions be kind to those who do….