Confronting the risks of unintended consequences

21 February 2013

There are moments when you sense that we might be on the edge of some genuine transformation. For me, last week’s Reform conference was one of them.

The theme was the ‘new NHS’ and considered the likely impact of the white paper policies of integration, clinical commissioning and competition as the changes go live this April. While in my experience these topics have, in the past, generated some quite technocratic discussion – focusing on cost reduction, incentives and levers – coming less than a week after the Francis report there seemed to be one thing on everyone’s minds: the patient.

Speaker after speaker concluded that to transform healthcare to meet the challenge of rising demand and constrained resources, patients must be put at the centre of what we are doing. While for some of us this begs the question 'What did you think the health service was about if you weren’t already working on this basis?', now is perhaps not the time to say ‘I told you so’ but rather to welcome this universal acknowledgement.

However, as I listened to the presentations I was struck that, as is often the case in healthcare, good ideas poorly implemented can have unintended consequences. While the unintended consequences of access targets cast a shadow over the Francis report, we shouldn’t forget that these targets were introduced as a response to people suffering outside of hospitals and on trolleys in corridors as they were unable to get access to the right care at the right time.

So, as well as the direct lessons from Francis, I feel there is another one: we must consider now the possible unintended consequences of the current groundswell of change, rather than regret later. Redesigning care around patients is essential but confronting the risks this might present means we can act to mitigate them.

I am sure others will have their own thoughts on this question but based on what I heard last week, two things struck me:

Firstly, in making services more person centred, we must avoid the risk of continuing with a model and philosophy of care that inadvertently encourages dependency. Rather we need to make the shift to a service that supports patients look after their own health and healthcare. The best way to maintain dignity and respect is to enable people to stay in control of their health and healthcare. Where people are seen as equals, it is a lot harder to de-humanise them.

Secondly, an encouraging theme of the conference was the commitment and action to move care from the hospital to the community setting and to people’s own homes. Of course this should be welcomed and needs to be the shape of future services, but if people can be poorly treated in the broad daylight of a hospital ward, what are the potential risks if we don’t have proper assurances of the quality and safety of care provided in people’s homes?

The patient safety agenda has focused largely on acute care, both in terms of measuring harm and implementing safety improvements. As the shape of care changes, we will need to improve our understanding of the safety challenges in community and home settings and the mechanisms for mitigating these.

It feels like we are on the brink of some very real change in healthcare. A debate about the risks of doing the right thing wrongly could be time well spent.

Jo is Director of Strategy at the Health Foundation.

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