Former NHS chief: Strengthening health systems shouldn't be 'all about doctors'

Sir David Nicholson, former chief executive of the U.K.’s National Health Service, says he would’ve been a better head of the world-renowned health care system if he’d spent more time working in emerging markets. Now retired from the NHS and a chair of Abraaj Group’s impact committee, Nicholson is working to achieve the global investment firm’s goal of setting up 10 health care systems in developing countries by 2020.* If successful, Nicholson says Abraaj will have launched a model for medical service delivery that could revolutionize the drive for universal health care.

“The thing that drives me is, how do you get health care to everybody? We haven’t really found a constructive way yet that the private sector in emerging markets can actually help to do that,” Nicholson told Devex.

Nicholson said his time working with growing health systems in emerging countries has offered a more open and innovative landscape, less mired in bureaucracy, in which to experiment with how the private and public sectors can work together in health systems.

“For the last two and a half years I haven’t worked in the NHS at all, I’ve spent my time in the the growth markets and I’ve learned so much, and in fact I would be a far better chief executive for the NHS if I had done that a few years earlier in my career,” he said.

Nicholson sat down with Devex last week to discuss what he believes are the recurring mistakes made in fledgeling health systems, how he feels the public and private sector can better engage, and why focusing on lower- and midlevel health professionals should be the focus of providing wider access to health care in the developing world. Our conversation, below, is edited for length and clarity.

People are increasingly gaining agency over their own health, through technology and access to information and education. Are donors and stakeholders working on developing health systems that take full advantage of the increasing expectations and independence of patients?

Giving people agency over their healthcare through education, information and technology is absolutely more vital in the emerging markets than it is the rest of the world, because the scale and nature of long-term conditions and the impact it will have on health systems is much greater in those environments.

In London today, 20 percent of our hospital beds are filled with people with complications coming out of Type 2 diabetes, and that’s only on the back of about 12-13 percent of the population having Type 2 diabetes. I was in Hyderabad recently; over 40 percent of the population have been diagnosed with Type 2 diabetes, so in a few years when they start having complications, it will completely swamp any health care system. If you have this disease, even in the best health systems, chances are you will spend 0.00001 percent of your time with a health professional, and the rest of the time you’re on your own. And diet, exercise, making healthy choices — very difficult in circumstances like those in Hyderabad — are going to be vital if we’re going to control it.

Education about secondary and self-care is the most important; in terms of evidence, it’s the most impactful. Developing programs of education for people is going to be critically important for people controlling their own health and health care.

Health systems in developing countries face challenges in educating the workforce in a cost-effective way and then retaining preventing brain drain and doctors seeking better opportunities elsewhere. What’s the solution?

I chair the impact committee for Abraaj and this is a really important issue for us. Investors in health systems in emerging markets, in particular the governments, aid agencies and the private sector need to focus quite a lot of their attention on how we train and educate people, but not to the highest level, because if you invest all of your money in training doctors, many of them will leave your country.

The role of doctors in this era is relatively limited. One thing we’ve seen with diabetes care in the West is that it’s increasingly delivered by nurses, dieticians, nutritionists and exercise experts, not by doctors. So those people that say you need a fully formed general practice, a primary care system, not true. You can do it without doctors, and indeed you can deliver it better without doctors.

If you organize yourself around associate physicians and physician assistants, who you recruit from local communities, you have a much better chance of having a much more stable workforce at the bottom of it. What struck me particularly, for example in India, is that the best and most productive way that young women from poorer backgrounds can get degrees is through a career in nursing. If you think about the population and the way you train and the way it’s organized, there are lots of ways to do it but you have to be sort of creative.

What recurring mistakes do you see in health systems in emerging markets?

I’ve been to Brazil, Colombia, Mexico, China, Pakistan, India and countries in the Middle East, and everywhere I’ve seen, the issue is workforce. The key is the public and private sector working together. Essentially you only have one workforce, and depending on how different organizations work, you can either compete for that workforce or you can use it effectively. [It’s a question of] how you bring the public and private sectors together to pool their resources against a background of mutual suspicion, where they both feel [disadvantaged by the other].

When I talk to hospital directors in emerging markets, they’ve got the same kinds of issues as hospital directors here: if they’re in the private sector they feel like the public sector is given a soft hand, that they are given tax advantages, that they’re not regulated as hard as they are. Whereas the public sector feel the private sector has more access to funds, that they cherry-pick patients, they only pick the easy patients. This is consistent in all the health systems that I’ve seen, and it means government needs to take responsibility for bringing these groups together. One can’t work without the other, because patients move between them, they’re mutually dependent, and the workforce is also relatively fluid between them. You can’t really resolve one without solving this big dilemma. Confidence-building, creating a level playing field, is the kind of answer to all of this to enable both the public and private sector to operate.

We had a massive problem with waiting lists in [the U.K.], and we brought in the private sector to deal with all of that, and the waiting lists went down massively. That’s not just because we brought in the private sector to treat patients; we said we’d only pay the same amount we paid in the public sector. But the public sector had to change the way it worked in order to compete in those circumstances. So it was massively improved and good for productivity.

But how do you prepare a traditionally public sector health institution for private sector engagement? How do you lay the groundwork and change public sector culture?

The first thing you need to do is think really seriously about how you manage your public sector institutions. Traditionally, public sector hospitals have been very bureaucratic, it hasn’t been very clear who’s in charge, the government intervenes quite a lot. You need to give these organizations independence, you need to give them the power to make their own decisions about capital and workforce numbers. A massive issue in China is that you can’t decide how many staff you have or who they are, but that’s the only way you’ll create dynamic organization that’s capable of working with the private sector on equal footing.

You also need to think about how you’re going to organize capital investment for public sector hospitals, so where the investment going to come from. You need to open up the possibility of getting private investment. You need to rethink the way in which you manage your hospital sector completely.

And you need to think about how you can incentivize the private sector to be engaged in those areas in which traditionally they haven’t been. Abraaj are very interested in getting engaged in mental health and in community services. Both of these have been traditionally been government. There must be ways in which government can incentivize the private sector to do that. And if you’re open about that, I think there’s huge possibilities.

The United Nations recently issued a statement admitting it hasn’t done enough on disability and mental health in its interventions, and criticized the U.K.’s poor integration of these health concerns into the NHS. What are the key challenges to prioritizing disability and mental health in primary care?

I spent 10 years working in mental health services when I first joined the NHS in 1971, and I think since then there has been this worldwide shift to understand what we describe here as equality for mental health. If you take for example Type 2 diabetes — a massive problem in emerging markets — about 40 percent of people who have Type 2 diabetes also have depression. Increasingly this connection between the mind and body is important, it’s no longer an either/or. This new understanding is really welcome.

The issue is, who pays for it? I think there’s very little private sector provision in mental health services, there’s very little activity outside of government. Government needs to take the lead to make it work.

You take depression, there’s some really good evidence about what works, and there are some really good things that you can put in place relatively cheaply that will make a big difference. The kind of massive investment in infrastructure people try to put into place in secondary health care isn’t applicable in mental health, it’s much more about the workforce and training.

Many global health organizations — including a few in the U.K., such as VSO and the Tropical Health and Education Trust (THET) — put a strong emphasis on volunteering and institutional exchanges as one way to support workforces in emerging market health systems. What lessons can be learned on both sides, for volunteers coming from both the private and public sectors?

There’s no doubt that both healthcare systems benefit when people move between them. I worked in the NHS for nearly 40 years. I was also a graduate trainee and spent my whole career in the NHS, and was in the end their chief executive. For the last two and a half years I haven’t worked in the NHS at all, I’ve spent my time in the emerging markets, the growth markets, and I’ve learned so much, and in fact I would be a far better chief executive for the NHS if I had done that a few years earlier in my career.

You get perspective, you get to understand the issues in the West more clearly. One of the very impressive things I’ve seen in emerging markets is first of all, how quickly people make decisions. We’ve grown a significant bureaucracy here, and the people there are much more willing to take risks, to innovate and to make change happen.

Secondly, people are much tougher around cost. They’re constantly thinking about how you can reduce the cost, which we tend not to do in the developed world. What we do here is just put the insurance premiums up or ask the government for more money.

One of the organizations I’m involved in is Care in Hyderabad. They know if they can get their price down a little bit, they can give access to more and more people. And that drive to reduce cost and therefore be able to give access to a greater segment of the population is a fantastic driver in the system, and we’ve kind of lost that here.

I think the voluntary exchanges can help quite a lot. If you talk to people who volunteer, part of the deal for them is not operating all day; it’s skills transfer, it’s the prospect of being able to transfer their skills and understanding to other people.

* Update, Nov. 15, 2016: This article has been updated to clarify that Sir David Nicholson is a chair of Abraaj Group’s impact committee.

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