Sir Muir Grayis an internationally renowned authority on healthcare systems, and has advised governments from Australia and New Zealand to Spain and Germany. Angela Sharda asks how he would tackle the crisis in the UK health service
What inspired you to go into medicine?
I started off doing veterinary medicine.
Sir Muir Grayis an internationally renowned authority on healthcare systems, and has advised governments from Australia and New Zealand to Spain and Germany. Angela Sharda asks how he would tackle the crisis in the UK health service
What inspired you to go into medicine?
I started off doing veterinary medicine.
My family is from a farming background and I can still milk 100 cows in a sitting. For no very good reason I changed to human medicine, then surgery, but realised I don’t have the attention span. I am fascinated by what we mean by ‘normal’ and ‘disease’, so I went into public health.
What have you learned in your 45 years in the NHS?
Oscar Wilde said experience is the name you give to your mistakes. I think I have made every mistake. What’s impressed me strongly is how unimportant structural organisation is. We have changed the structure 22 times, but by doing this you develop systems and end up with culture.
The NHS must have changed hugely over that time?
Yes and no. By and large the way in which GPs refer to specialists across geographical areas is unchanged. Many of these habits are long established. I don’t believe that more is always better. I have tried to shift the debate to value. Do we allocate the money appropriately? Do we use the money for the people who might benefit?
How would you describe the state of the NHS?
Under pressure. Many good things are happening but morale is an issue. In some areas we are doing are the right things [but] we are oversold the benefits of medicine. All healthcare does harm.
Some does more good than harm. Imaging uses radiation; drugs have side-effects. When you do an operation, you only do it if people are really badly affected. If you start treating people who are less severely affected, they still have the same risk and magnitude of harm.
Instead of making a decision about taking a gall bladder out in a 20-minute consultation, when people are too anxious to understand everything we are saying, we need to use the phone to follow up.
Staff morale is at extremely low levels. How can it be lifted?
This is the issue of leadership. We need to say to the public as well as the professionals, we can’t do everything.
We have to be more honest. In the last year of life there is a lot done to people who would like to die quietly at home. We need a more realistic debate with the public about their responsibilities and ours.
Leadership comes from the top. What measures could NHS England chief executive Simon Stevens put in place to improve the NHS?
We need a complete transformation of health services. Mr Stevens is making a good move to try to achieve that. What we have now is two-dimensional healthcare. One dimension is the bureaucracy, health centres, sustainability and transformation partnerships (STPs), clinical commissioning groups (CCGs). The second dimension is levels of care, self-care, formal care, primary, secondary, tertiary. My interest has been in getting people to focus on what they are trying to achieve with health.
We should manage health services more like a supermarket. If you work for Sainsbury’s you’d be much more focused on what you develop personally – meat, fish, children’s clothing, alcohol. You would be focused on that, not on how all the stores are doing, or how much frontage you have. There won’t be CCGs and STPs in five years’ time, never mind 50. We need to focus on the eternal verities of the health service – people with headaches, people with epilepsy, people in the last years of life.
In the Budget the Chancellor earmarked an extra £2.8bn for healthcare. How much more do we need in order to get the NHS into a fit and strong state?
I debate whether we should put more money into healthcare at all. If we spend £700m more on a new anticoagulant, where does that come from? We are spending about £1bn a year on people dying in hospital. If we help people die well at home we reduce spending considerably.
I am in no doubt that district nurses are high value, going to see old people in their own homes. We are not thinking right about what high value is. How do we get the money allocated properly? Are there people who are not being treated who should be?
What should a 21st century NHS look like?
What I would like is for the NHS to be able to answer some questions, such as whether care for people with epilepsy is better in Liverpool or Manchester. Or how many services there are for people at the end of life in London and which the best one is. Whether care for people with asthma is better for people in Somerset or
Devon. Who is responsible for headache in Kent or Doncaster. When I ask how many asthma services we have got, I am told we have 211 CCGs. We have to be clear who is responsible. Then we could find out if the care for people with Parkinson’s is better in East Essex or in Barking or Redbridge and Havering.
How can we move away from institutional-based healthcare towards population-based health systems?
In Oxford University at the Nuffield Department of Surgical Sciences and at the Department of Health (DH) Quality Innovation Productivity and Prevention (QIPP) Right Care programme, we developed the concept of population healthcare, which focuses on people with a common problem. Think of people with a symptom, like headache or breathlessness, or with a common condition like rheumatoid arthritis, or people with a characteristic – in the last year of life, or with multiple conditions. There is a defined number of services. We started looking at that and then started to measure what the outcomes were and see how much we were spending depending on the outcomes.
So what do you think needs to change to meet the health and social care challenges of the future?
We need to change the emphasis from this obsession with the [idea that] there is a right structure. So we need another reorganisation, to systems and then issues of culture. There are two aspects that need to be developed. One is a collaborative culture – we don’t want GPs criticising specialists; we are all in it together.
I am very interested in the culture of stewardship. We are the stewards of the NHS. We have to take responsibility if we are just ordering tests and not thinking about resources. I don’t like the word manager; it is one of the words I would ban.
Do you think the culture of the NHS can change?
Yes. I set up The Centre for Greening the NHS, which is now the Centre for Sustainable Healthcare, a charity. When we go onto the wards, often the front-line staff are more motivated if you speak about the carbon footprint. That is an example of stewardship. People really feel responsible for the resources that are being used.
We have started a campaign called Cut The Crap, focusing on the jargon words in healthcare. Which do you think are the worst offenders, and do you use them?
I am sure I do. I think that language creates reality. I don’t like ‘manager’. People who manage include the clinicians. We are all managing resources. I don’t like the term outpatient – what does it mean? People come in, some for a diagnosis, some for support, some for medicolegal reasons. We need to think, why have they come here?
I don’t like the term ‘savings’. Mr Stevens says we need to save £22bn. People started talking about that as if it is real money, so in one part of the country your share of that is £2bn which means you need to make £2bn savings. They are not making savings, they are trying to do the same work with less resource. Savings then become cuts. It is a very dangerous word. ‘Value improvement’ is a better term. I don’t like the word ‘patient’. These are people with problems. I don’t like the word ‘consent’. I think the principal, the person we formally call the patient, should ‘make a request’.
There’s lot of talk at the moment about accountable care organisations (ACOs). What would you prefer to call them?
I don’t like the word ‘care’. It means doing things for people. I like the idea of systems. I think there are accountable systems or systems accountable to the local population. I think that is entirely a sensible move. Everyone working together, instead of the providers not speaking to the commissioners, hospitals not speaking to GPs or even worse, badmouthing them.
What is your biggest achievement?
I’m hoping it is still to come. I’ve been involved in developing a national activity therapy service. [This signposts patients to physical activity and advice on how to be more active in every contact between care professionals and patients, and also puts exercise professionals in GP surgeries.] Ageing by itself is not a problem.
If you reach your 90s and are only affected by ageing you’ll be like Sir David Attenborough or the Queen. I think we can reduce the need for social care by 25% if everyone with a long-term condition was getting activity prescriptions as well as drug prescriptions. We need to think in a completely different way. We can reduce dementia by about 25% with physical activity, keeping your blood vessels open, but also keeping engaged and preventing isolation. Every morning I do 10 minutes of upper body strength exercises and press-ups – I do two batches of 40.
Suppleness, strength, skill and stamina are vital.
What advice would you give the next generation of doctors?
We look to the people who pay for and manage healthcare, the doctors, to be the leaders; not to the people at the top of the organisation. All of them need to feel responsible for the use of resources. That means we need to change the way we relate to the people we call patients. The most important information is to find out what is really bothering someone. Someone came to see a chap I know in
Oxford and he said ‘what can I do for you’ and she said ‘I need a knee replacement’.
He said ‘what’s bothering you’ and she said ‘I can’t do the gardening, I can’t bend so well’. He explained: ‘do you realise that if I replace you knee, you won’t be able to kneel at all?’ She said thank you very much and went out. Finding out what is really bothering people is a combination of looking at things as a whole, managing resources and listening to a patient.
Angela Sharda is deputy editor of Healthcare Leader
