During 2015–16, NHS England's new care models programme, in partnership with NHS Confederation’s EU office, linked up with leading EU care model professionals to share and adapt good practice for the improvement of local care models.
Today, as the programme hosts the Adapting International Care Models Conference, Nigel Edwards reflects on the complex challenges and opportunities that often arise when replicating international good practice.
The NHS has a history of interest in other health systems, although there has been a bias towards English-speaking countries. There have been many visits and case studies and there is often great enthusiasm for what has been found. However, it has frequently proved rather more difficult to replicate the models than might have been hoped, and it is worth reflecting on why this might be the case.
Context and history may be more important than we like to think. We should consider whether these factors have created a specific environment that was fundamental to the foundation or growth of a model. It’s striking that some important elements of context and history can sometimes be taken for granted: for example, the fate of the original private finance initiative (PFI) deal at Alzira, or the origins and history of Kaiser Permanente and its medical group model.
Starting points matter. For example, moving from a system of fee for service with little primary care to a capitation model centered around a medical home is likely to have a much more significant impact on admissions and costs than moving from a traditional GP contract to a multi-specialty community provider (MCP). Having said that, as Mary Dixon-Woods points out, if your intervention fails, it might not be the context – it could be how you implemented the programme.
Some models have represented a new and significant departure from the existing way of working from day one, whereas others have grown or evolved over time to look quite different. The new creations required some clear space, the exit of previous incumbents or the ability to operate without regulatory or other interference. This involves more than a little double-running, and the inability of the NHS to remove incumbents or create sufficient space has been a major obstacle.
The importance of elapsed time has also often been neglected. The NHS has historically assumed that it can implement changes in half the time and with a quarter of the resource used elsewhere. Although many of the new models have starting points, some have evolved, and all of them seem to have developed and improved their operating models over time.
These models often seem to have different types of relationships, for example, between specialists and GPs (Kaiser Permanente); between payers and providers (Alzira); between intermediaries, physicians and insurers (Gezundes Kinzigtal); and within teams and the wider organisation (Buurtzorg). These take time to develop and it may not be possible to truncate this with programme management and exhortation.
Since the trick to adopting models is to adapt them to the local context, it is important to be able to identify the underlying design principles that are the active ingredients that make the difference. This is not always as easy as it seems, since the models are highly complex. It is even harder in the absence of a good conceptual framework for describing them. A further issue is that it may be that there are a number of these active ingredients and that they all need to be in place together and be reliably executed 99.9% of the time in ways that fit the local context. This is further complicated by the use of terms such as 'care navigator' and 'multi-disciplinary teams' that conceal a vast range of different definitions, philosophies and methodologies.
I would suggest one final hypothesis that adds to the difficulty.
While every report stresses the importance of leadership, I think that this story is incomplete, as well as being insultingly obvious. Firstly, in a number of cases the role of particular individuals is a key and unavoidable part of the story. They often have a strong personal and values-based motivation for creating change and have benefitted from a combination of being in the right place, with the right support, at the right time. This is not a claim for a heroic or charismatic model of leadership, but individuals matter; their contribution can be pivotal and ignoring this can mean that the difficulty of the task may be underestimated.
Secondly, the other part of the leadership story is how far a number of the models rely on the boring, repetitive and unglamorous work of developing a reliable operating model and making sure it runs reliably 24/7.
We should be looking for new models and ways to learn, but a more critical, analytic and realistic approach may be required.
Edwards N (2016) ‘Why is it so hard to copy international best practice?’. Nuffield Trust comment, 11 May 2016. https://www.nuffieldtrust.org.uk/news-item/why-is-it-so-hard-to-copy-international-best-practice