National Clinical Networks Part One: Why Do We Need them?

This is the first in a series of three blogs describing why and how we decided to reform existing Clinical Networks in NHS Wales. They are personal reflections on the process I undertook with a number of colleagues, listed as authors in our final paper. I am also grateful to Professor Sally Lewis, former National Clinical Director for Value Based Healthcare (VBHC) in Wales for several years’-worth of idea sharing and formative conversation which informed this work.

What is the problem we are trying to solve?

Always the best question to start with, but often overlooked.

The narrative arc for all of this began with the OECD report into the Health Systems of the four UK Nations in 2016 (Fig 1). In relation to Wales, it was complimentary about moves towards an integrated approach for primary and secondary care, as delivered by 7 geographically based Health Boards (and three Trusts). It liked the degree of autonomy afforded to Health Boards but noted the need for a stronger ‘central guiding hand’. For readers in Wales, this report bears a re-read. It is encouraging in the sense that it suggests our approach in VBHC is the right one. It is a bit more sobering in that so many of the issues highlighted remain little changed.

Fig 1. The prolonged gestation of the NCF

The OECD review led to a Parliamentary Review, which accepted and consolidated the recommendations. This in turn led to the Welsh Government Health Strategy document ‘A Healthier Wales’ (AHW). Much of the focus of both was on eliminating unwarranted variation. Delayed by the Covid pandemic, The National Clinical Framework (NCF) emerged from the AHW describing an operating model for the systemic implementation the 40 actions of that document. The NCF described the role and position of National Clinical Networks in a Learning Health and Care System.

I think this is best considered as two related problems: unwarranted variation, and the causes of unwarranted variation. “Down with unwarranted variation, down with the causes of unwarranted variation” as no politician actually said.

Unwarranted variation

Unwarranted variation of what? Unwarranted variation in outcomes.

This is where Value Based Healthcare comes in. Assessing Value requires that we measure outcomes. Unfortunately, much of the focus can fall on variations in process. Process is part of the analysis, but not for its own sake. Much of the conversation in Wales appeared to focus on differences in process, with relatively little on outcomes. Process is relatively easy to measure, outcomes far more challenging.

The outcomes required to assess value are:

• Technical outcomes – what are the outcomes of the clinical process, the ‘quality’

  • Are we achieving what we set out to do compare to a standard or to peers – measured by disease registries, national audits and similar initiatives?

  • Are we achieving those outcomes without causing harm – measured in incident reporting and other forms of patient safety data?
    

• Personal outcomes– the outcomes that matter most to patients, Patient Reported Outcome Measures (PROMs) and Patient Reported Experience Measures (PREMS). This provides an ability to assess not just that we are ‘doing things right’ (technical outcomes) but that we are ‘doing the right things’.
  

• Allocative outcomes– ensuring that resources are distributed equitably and being used to best effect.

*I have left out a fourth category, societal outcomes to keep it simpler at this stage

These outcomes are then ‘divided’ by cost (not just economic, but costs to the individual, societal and environmental costs) to determine value (Fig 2). This is where process comes back into the analysis. If outcomes are equally good in Health Board A and Health Board B (compared to a gold standard), it doesn’t really matter if the processes are different, provided the costs are the same – because then the value is equal. That’s warranted variation. It’s worth remembering that warranted variation is one of the spaces that allows innovation to develop. If the process in Health Board A has greater cost, however, then there is an issue to address.

Fig 2. The Value equation

The bad news (and the reason why I put ‘divided’ in quotation marks) is that much of this is much more complicated than putting numbers into an equation and recording the output. A spreadsheet approach may work for some instances and at a detailed level, and form part of the VBHC toolkit, but for the most part this value equation is conceptual.

The good news is that there are many intelligent human beings working in the health system (I still rate their real intelligence over the artificial variety). They can deal with concepts, nuance and qualitative as well as quantitative assessments. If we let them. And if we enable them.

The roots of unwarranted variation

The greatest frustration over unwarranted variation was expressed by policy colleagues. The root cause – the lack of a strong central guiding hand. Don’t take my word for it – it was the OECD’s analysis too.

The guiding hand’s absence is felt in setting direction for the service and in understanding its outcomes.

Root one: Inconsistency in Setting Direction

Present a policy directive to 7 different, and largely autonomous Health Boards, it can surely be no surprise that there will be 7 different interpretations and 7 different implementation plans (Fig 3).

Fig 3. Legacy arrangement - schematic

A further result of this, given that the Health Boards are primarily responsible for services provided to the population within their geographical footprint, is that services which might deliver better value on a larger regional footprint may not develop in a strategic and planned way. Some ‘specialist’ services are commissioned by a separate entity, but many such services have evolved in a more ad hoc way with individual service-specific arrangements between health boards. There can be a perception that ‘regionalisation’ of services is driven by organisational priorities, often financial, and less so by clinical priorities. This isn’t so much a can of worms as a barrel of snakes and will be a topic of a future piece. But there is an opportunity for these service configurations to be shaped more strategically by National Clinical Networks using a VBHC lens.

Root 2: Not Understanding Outcomes

Because many of the things we measure are ‘process’, that tends to be the main lens through which the system’s success or failure is judged.

Where we do collect more meaningful outcome data, it is often fragmented, difficult to access, and difficult to interpret or compare if information standards have not been developed. We are left trying to compare apples, pears and oranges and somehow make sense of it all.

We need data scientists, analysts, epidemiologists and statisticians at the table to help us understand the data we already have, even if imperfect. Those same tribes will help clinicians and managers develop mechanisms to collect the correct data more easily in future – continually iterating and providing the basis for a Learning health and Care System. The data scientists help clinicians answer questions like ‘is there variation?’, clinicians will help analysts with questions such as ‘is the variation warranted?’ and ‘what is causing the variation?’.

It is this data-to-knowledge (D2K) element of the NCF operating model that provided the early focus of formative conversations for National Clinical Networks involving data science and analytic colleagues. Another topic for a future piece.

Solving the problem: Throw your hands in the air say yeah.

Okay – so massive apologies to Chris Brown, (but also note how down with the kids I am).

It is very tempting for us all to throw our hands in the air and say this is all just too hard. But if we have committed to a VBHC approach, then we can’t do that. We must instead throw our arms in the air and resolve to build the infrastructure we need. We need to embrace the opportunities digital systems provide for capturing meaningful outcome data more readily, and (eventually) employ the statistical learning techniques, machine learning, and yes – AI to understand those data. We also need to determine how to turn that learning into redesigned health and care pathways doing the right things, not just doing things right.

But I meant what I said about preferring the real intelligence of human beings over AI. This is where National Clinical Networks come in. By creating, developing and maturing networks of health system professionals, they can apply themselves to the ‘setting direction’ and ‘understanding outcomes’. The Networks will draw professionals from Health Boards, but because they are National Networks, this enables them to be ‘agnostic’ of their own organisations – with the right leadership and the right support.

This requires high quality clinical leadership, supported from the top. Those clinical leaders need to be able to trust there is a real political and Political will to actually transform the system to VBHC at scale. Speeches and policy documents cut little ice with clinicians delivering day-to-day care, but an ability to participate in National Clinical Networks will start to build that trust.

Clinical Networks and the Central Guiding Hand

So, at this point, it’s clear that we need a system architecture that can enable us to determine what outcomes we should measure, how we should measure them, how we understand the data generated.

Situating the National Clinical Networks within the Central Guiding Hand function are the mechanism that allow that process to be clinically informed and clinically designed at scale (Fig 4). It enables more clinical consistency across the Health Boards in turning policy into practice. That architecture does not yet fully exist – it needs to be built, and Clinical Networks must be part of that process. In their early years, in fact, most of the work to National Clinical Networks will probably involve such construction for the future.

Fig 4. Clinical Networks in the Central Guiding Hand - schematic

It is also clear that those same National Clinical Networks could provide the clinical ‘Direction’ for the planning and delivery organisations and inform the understanding and iterative learning and redesign process (Fig 5).

The National Clinical Networks therefore become the substance of the Central Guiding Hand function. Although it has had a very prolonged gestation since becoming Government policy in 2018, the NHS Wales Executive provides the Central Guiding Hand Function, and the Clinical Networks are established as part of the NHS Executive.

Fig 5. An early schematic representation of what the Learning Health and Care System looks like in Wales. This is a representation of the system diagrams in the NCF. How fully it becomes implemented remains to be seen. The 'Accoutability' word remains challenging - as noted in the OECD report of 2016.

Next time

In the next blog, I will describe what the legacy landscape of Clinical Networks looked like in Wales, and how we set about repurposing it within existing resource.