One of the First Tasks That the Group Tackled Was Constructing a Picture of What a Future

Route Map

1. Introduction:

The first route map event took place on the 27th September 2010. Individuals from a variety of backgrounds attended to contribute in the task of constructing a vision of what a future health system might look like, and what actionmight be needed to get there. It was decided that in talking about the subject, we would need to be candid about the terms that we used, marking the difference between the ‘health service’, ‘health sector’ and ‘health system’. This enabled the group to re-evaluate a traditional, insular perspective of the ‘health service’ and begin to develop a holistic view of a ‘health system’ that might include any organisation or individual with a stake in improving health. The group looked at the way in which the World Business Council had approached the subject, following a presentation by Per Sandberg, and discussed how this approach might be applied to the health system in the UK;the value of Vision 2050 is to provide an optimistic, positive and attractive perspective on the future that helps to avoid being hostage of the present and its barriers. It was clear from the beginning of the event that this task would necessitate a revision of some of the very building blocks of the current health system.

One of the first tasks that the group tackled was constructing a picture of what a future health system might look like in the year 2050. This is the year by which the UK government has agreed to reduce its carbon footprint by 80% on 1990 levels. To aid this discussion, sub-groups were given different ‘future probables’, which represented pressures facing the UK 40 years from now, to guide the conversation towards different aspects of a new health care system.Individual groups explored and discussed a wide range of likely occurrences and factors that would have to be accounted for; these were generally accepted by the group as a whole to be fair and fitting, though not exhaustive and are listed in section 2. The future propables comprised of:

• Population
• Carbon
• Heat
• Money
• Networks

The next task was to look at how we might arrive at a sustainable health system that we were satisfied with. Delegates were once more split into sub-groups to work about out what these steps might be. Whilst this discussion was by no means constructed a linear and operational pathway, it made clear some of the opportunities and challenges that would need to be accounted for and started to look at the order that different actions would need to be taken in, and these themes are discussed in section 3. The themes that were examined were:

• Measures of Success
• Research and Innovation
• Organisational Resilience
• Public Opinion/Societal Debate

2. Health System Vision 2050: Pressures to the System:

1. Population

If we envisage a planet populated by 9 billion comprised of an ageing population, then what might this mean for the health care system? Groups were asked to look at a scenario whereby the population of the UK had increased by 10 million.

2. Carbon

In the health system that we are envisaging for 2050, there could be the need to reduce the carbon that is emitted by 80%. Groups were asked what this might mean for the healthcare system.

3. Heat

In this future scenario the climate is significantly hotter; the country is in a similar state to the heat wave in the summer of 2003, where temperature caused a significant number of deaths in Europe. There is also a greater incidence of other extreme weather events.

4. Money

By 2050 funding for the health system will look very different; due to an ageing population there is a higher dependence on state resources for subsistence and a smaller tax base to provide funding.

6. Networks

The role of networks, communication and technology will likely change significantly in the future health care system. We might arrive at a situation whereby all people and all man made things are online at all times. What might this mean for health care?

3. Themes that emerged:

These are themes and ideas that arose from the first ‘Route Map’ event in September 2010 as well as points raised during the follow on exercise and the NSIG event on 14-15th October.

1. Financial Framework

Finance is closely tied in with sustainability of the NHS; the economic climate makes resource saving a necessary condition. Many discussions that were had during the route map event involved financial levers being used as tools to hasten non-financial aspects of sustainable development. It was proposed that the measurement of carbon could be dealt with using financial mechanisms, either by creating a separate currency for carbon, or else monetising carbon completely, so that a quantity of carbon would have a real financial cost attached. This idea could be extended further by relating these costs to health outcomes to produce and make visible a realistic cost of achieving certain health gains. A financial framework should incorporate measurement of other aspects of sustainability, so that other limited resources such as water are monetised also.We must ensure that the impacts of measures such as this are weighed against timeframes to ensure that outcomes are achieved quick enough.

It was discussed that ‘sustainability should be properly incentivised in others ways too. For instance, we could build sustainability metrics into commissioning arrangements.Agreements regarding sustainability should be as non-negotiable as financial balance. Also, if sustainability measures were built in to a ‘license to operate’ then failure to comply with agreed conditions would have significant financial implications on any organisation. This could work as a regulatory system similarly to the way Monitor currently ‘licenses’ foundation trusts.Assurances similar to the ‘Statement of Internal Control’ used by accountants should be used throughout the health system. Carbon budgeting and accounting should be in audit programmes as a matter of course and should carry an equal weighting as financial factors.Also, the financial system as a whole needs to be flexible to accommodate innovation throughout thesystem-for instance, if telemedicine is to be adopted as standard practice, the PbR tariff will have to be able to ensure that payment for using the new service is realistic and fair.

2. Metrics

To be able to assess our progress towards a sustainable health system we will need suitable metrics, based onboth processes and outcomes.Metrics should be used to publicly benchmark and compare the performance of different organisations.There are already a series of carbon reduction targets that the NHS has to meet, such as working towards a national reduction of 80% by 2050. We should also look at how we measure waste in the system such as through packaging and unused consumables. We could measure how many health professionals are trained and certified in particular aspects of sustainability, how many employees are using public transport and how many providers have solar panels on their roofs. We could also measure outcome measures relating to the effects of a drive for sustainability such as a reduction in respiratory conditions and the growth of the low carbon economy.

As well as hard financial and carbon metrics, we should also consider how we might develop metrics to measure the cultural shift towards a sustainable health system.These might include public perception surveys.We could also measure a range of issues affecting other sectors such as transport, employment, air pollution and education. All these factors have an impact on sustainability and health. It will also be important to look at how we measure indices of poverty and health inequalities. We might also look to introduce a wellness index e.g. using DEFRA wellbeing indicators.

3. Resources

A move should be made away from reporting on performance in terms of the financial bottom line in isolation. Similarly, we should not only think in terms of carbon but in terms of the entire ecological footprint that the system as a whole, or a given organisation is responsible for. We must focus on natural resources efficiency to ensure that waste is not prevalent throughout the system. It is suggested that NICE could play a role in carbon effectiveness, as well as the use of other resources, such as water for instance. By taking a more holistic view of the resources that we that we have and that we use, we can take action to ensure we stay within reasonable limits.

4. Leadership

To move towards a more sustainable health system we must think about where leadership is most likely to come from; will it come from the top or the bottom of the system? If sustainability is to be championed locally then there is a real concern that ‘gated community’ attitudes might develop, whereby the minority feel they are doing more than their fair share, and someother localities may fall behind. To prevent this from happening local action has to be accompanied by national and global frameworks. Top down leadership is required to fully embed sustainability into the health system through mechanisms such as commissioning arrangements and regulation. It would be useful to understand ideas such as systems theory and change theory to understand how best to go about helping organisations to become ‘future proof’. We need to seek a host of answers to questions about what makes a sustainable system, and we need to extract and adopt good practice, both from inside as well as outside of the sector.

5. Innovation and research

Innovation will be transformational and ‘whole system’ focussed. New technology will be embraced and new approaches to service delivery will be sought.It will be needed right from the mundane, e.g. improving building stock efficiency, cutting transport emissions to the fundamental, e.g. delivery of remote care, reform of end of life care. Innovation will be necessary acrossstructures, processes and systems, e.g. care pathways, goods and services, e.g. medicines, as well as thinking and decision-making,e.g. carbon as a performance metric, healthcare staff’s direct involvement in embedding sustainability into operations. In all cases innovation should be directly informed by feasibility on the ground.

Research will be needed to clarify what needs to change and how we can bring about that change. Intuitively plausible suggestions, e.g. care closer to home is greener, need to be confirmed empirically. This is not a reason for inaction, but for the evaluation ofany action that is taken. A clearer sense of how sustainability can be made a core organisational concern will also be needed.Socialisation of research at the moment it is treated as a private good.

6. Engagement

Engagement with a broad range of stakeholders including decision makers and patients will be crucial in delivering a totally sustainable health system. GPs, local authorities, NHS trusts and commissioning boards will have to be fully engaged at each point of change towards sustainability. This can partly be done through means of education; integrating sustainability into curricula and exams, for instance with the RCGP, will ensure that individuals and organisations have the knowledge and skills to make sustainable decisions. It will be important to seek buy in at different levels within these groups and organisations.The current changes to health care system present an opportunity to engage with a new group of commissioners who will be making decisions about services and resource use.

With regards to engaging patients and the public, the media will play a key role. The development of new media presents opportunities to engage patients and public in decisions regarding the future of the health system as an alternative to the popular press. In doing this we will be able to reconnect the system with public opinion. By using the media in the role of external influencer, positive new stories about sustainability can be used to influence public opinion and promote action. Patients should be consulted on broad issues, from which arguments about sustainability can be weaved into. By getting the regulation system for sustainability right, the public and patients will also be able to engage in the discourse concerning the performance of different elements of the health system.

7. Communication/Travel

NHS travel and communication should be reformed to ensure a sustainable service and improve patient experience. The system as a whole needs to be open to new technology, and encouraging of innovation and service redesign. For instance, there should be a greater number of health centres closer to people’s homes to reduce the need to travel. New technology such as telehealth should be embraced and issues such as equal access to new technologies should be addressed. In this regard ‘connectivism’ will be seen as an enabler of sustainability.

8. Resilience

Typically, organisations are poor at reacting to slow burn, major problems. For the health system to become resilient to future demands, measures will have to be taken affecting all aspects of business. For instance, environmental risk assessments should be built into emergency planning and resilience planning. Guidance should be given for strategic planning so that plans may acknowledge and address threats to organisational resilience. Adaptation should be a key part of business planning and should be led at a local level. This includes adaptation of the health system estate. Carbon management could be led by commissioners and involve-cross sector partnership working, ensuring that it is not only healthcare that benefits but education and transport among other sectors.

9. Societal issues

There are many societal issues that must be debated to stimulate a broader cultural shift that favours sustainable healthcare. A compelling narrative is needed to link the health of our population with the health of the plant to illustrate the many ways in which the two are connected. One subject that could be broached is how society will view family size: will 2.4 children be acceptable in a society where people are living longer and less are dying from disease? Attitudes to contraception and migration might influence this. We might also need to look at how families will change, from the nuclear family to a complex web of relationships facilitated by social networking technology.The way that society views death is also important; is it appropriate for healthcare to constantly medicalise dying or could there be a more mature approach? How do we deal with an ageing population and how do we balance quality of life with length of life?

Society should look at how it views consumption and making do with less; could we use education or pricing to influence consumer behaviour? World economic systems have tended to destroy low carbon lifestyles that we could learn from- do we need to look at other societies for inspiration? We could begin to talk about healthcare in terms of quality rather than quantity. There is also question about how the perception of loss that people feel when having to make changes to their behaviour. Society will also need to consider how it views lifestyle choices, especially those that have adverse effects upon the health of others or themselves. It must also be recognised that low carbon actions might have unintended consequences on social and health inequalities, for instance by internalising the cost of carbon, it might make goods and services prohibitively expensive for some social groups. It could also be important to look at social commitments, similarly to the Conservative notion of the ‘Big Society’, and how the expectations placed on individuals to contribute and care for others might change. Another important question to ask is how we balance the health of the individual today with the cost in the future; many modern health interventions are carbon intensive so we may need to come up with the carbon equivalent of the QALY.

The role of the patient in their own healthcare has evolved significantly and this might involve a renewed social contract that exists between the patient and the healthcare system. This might involve people taking far greater responsibility for their own care. Wider determinants of health have a huge impact on health outcomes, due to social and environmental factors, for instance. By creating incentives for people to improve their lifestyles, people might be assisted in influencing their own levels of health. This would in turn assist in preventing patients from entering the expensive and often dangerous healthcare system. This would mark a shift from ideas of sickness to ideas of wellness. For the healthcare system, this might mean involving patients to a greater degree in their decisions about healthcare. Patients could also be empowered by ensuring that they have ownership of their own medical notes, to ensure that they are able to move freely between different parts of the healthcare system.We also need to look at the globalisation of society and healthcare services. For instance, retired people may move to other countries for cheaper/faster/better health care services, or young people from developing countries moving to the UK for better health care. We need to consider what effects this may have on the national and global health system.

10. Models of Care/Systems

In the journey to become a sustainable health system, change will have to be truly transformational, but efficiency gains will also have to be made as well.We should look at remodelling care, such as bringing care closer to home and using technology such as video conferencing to conduct consultations, however these all need to be underpinned by evidence. All NHS organisations will see carbon reduction as falling within their remit. Unnecessary activity should be reduced. This can be done by reducing the supply induced demand that currently exists in the system, by cutting out clinically ineffective treatment and by reducing inappropriate referrals. There could be better integration between healthcare and social care; it would be useful to realise that the distinction is arbitrary and if we move towards a system that values self-care and prevention, then this integration will be vital.

Appendix 1. Follow on Exercise

To explore the matter of what a new healthcare system might look like in greater detail, a follow up exercise was contrived to gather further thoughts and ideas. These were centred around each of the themes highlighted for the ‘building blocks’ exercise at the first route map event. These are detailed below: