The Conversation Around the Changing Nature of Care

Professor Keith Willett, Medical Director for Acute Care, NHS England, writing for the King’s Fund: Considers the conversation around the changing nature of care. 

Medicine has changed enormously since the foundation of the NHS; GPs and paramedics can now do in the home or ambulance what I did 10 years ago as an emergency surgeon in an A&E. In specialist centres we can now manage emergency illnesses and injuries that were previously untreatable or unsurvivable.

Equally, as a population our expectations have changed. In the wider world, we are ‘right now’ consumers, technology savvy with high expectations of access, personalisation and control. We can access information 24:7, make informed choices, and expect rapid delivery in a time and place convenient to us. We desire a similar service from health care.

It’s not only expectations that have changed. From a medical perspective the people using health services have changed: they are older, many have multiple age-related diseases, they survive more episodes of illness, and frailty and dementia are common.

Healthcare

While the changing environment and expectations elicit different responses from different groups – health commissioners and hospitals see population need and cost-efficient pathways of care; politicians reduce the complexity to simple strap lines, targets and soundbites; and patients and the public personalise any episode to their life, family and occupation – there is one common theme: the vast majority of the population absolutely support the NHS and its values.

However, much of the NHS is still based on its 1948 footprints. The public is sometimes emotionally resistant to change and wedded to old practices and local institutions, often unfounded on clinical benefit. Many people are suspicious of service redesign as a covert method of reducing the scope or quality of provision. Institutional cultures are ingrained and transmitted across the generations, and often value the status quo, viewing any challenges to this as threats. But every industry needs to adapt, and the NHS, at the forefront of innovation and technology, is no different. Then there is the reality – 70 years into the NHS’s existence – that across the country, GPs, community services, the NHS 111 call-line, ambulance services, A&E departments and hospital services are under intense, growing and unsustainable pressure.

Our health and care needs grow as we live longer, accumulating ageing disorders that affect our independence as much as our wellness and meaning that, as a population, our health and care needs are increasing. However, the current NHS model has an in-built default that when care needs can’t be met in our homes our care is moved, usually to a hospital setting at higher cost to the taxpayer. That’s not good for patients or for the NHS. It is not that the NHS has not modernised, indeed, the hospital service has become very efficient, but only within the same, dated model.

But what if the NHS could meet people’s needs in a different way, that shifted care out of acute hospitals? The current reality is that many of the millions of patients who receive help for their urgent care needs in hospital could have been helped much closer to home. The opportunities for bringing about a shift from hospital to home are enormous, but the NHS needs to convince the public of the advantages of its new vision of care. For example, frail older people will be particularly advantaged through receiving more care at home; hospitalisation disorientates them physically, socially and mentally, and the hospital routine puts them at risk of delirium, loss of muscle strength and loss of self-confidence to care for themselves.

In the past the NHS has often told patients what was right for them sometimes without reference to those who deliver care, or the experience of patients or carers. The NHS expected passivity. In this past, an illness meant that patients must be removed from their home and treated in bed to fit in with the hospital’s set-up and routine, and that they must accept this unquestioningly; ‘the doctor knows best’. Now the NHS understands that patients are best served mentally and physically, when they own their care by maximising their autonomy and making every effort to support them to maintain as much function and normality as they are able to while treating their acute illness. But has the public’s understanding shifted at the same rate as the NHS’s?

NHS England’s Urgent and Emergency Care Review revealed that patients are pretty good at judging how quickly they need help or advice. They understand what a GP does, how 999 and 111 work and what an A&E is for. So, any future design of urgent care should build on this awareness, and consistently guide patients to the correct level of care to meet their needs most appropriately and in the fewest steps.

Often patients say they recognise the pressures on the system and they don’t want to ‘bother’ the NHS, but alternatives aren’t in place. In response, it is incumbent on the system to reward the respect with which these patients treat the NHS by providing alternative options to deal with less critical complaints outside the acute hospital setting.

As patients respect the demands on the system, the system should respect patients’ time in return, such as the ability to direct book through NHS 111 an appointment with a GP or urgent care facility to reduce ‘turning up and waiting’. The NHS needs to improve its self-help options for patients by moving NHS 111 on to a digital platform so patients have more options.

And with better information gathering and sharing the NHS is able to tailor care to the individual – for example, through advanced care planning, clinicians can be made aware of a patient’s preferred response in a crisis. With this type of patient-centred approach individuals will be able to speak directly to a nurse, doctor or other health care professional and personalise the support they receive, rather than being transplanted into a one-size-fits-all hospital routine.

People need to understand that now – and increasingly in the future – the health care team is much wider than doctors and nurses, and using all of the team’s skills is key to future health care provision and sustainability. Pharmacists can provide emergency prescriptions, and have a wealth of knowledge and advice to offer about minor ailments, medications and vaccinations. The extension of paramedic skills changes our ambulances into mobile urgent community treatment services and avoids unnecessary journeys to hospital. Nurse practitioners and physicians’ associates play vital and ever-extending roles. It is crucial to recognise doctors and hospitals as pieces of a much bigger picture.

The relationship between patients and clinicians is rightly evolving from a paternalistic and prescriptive system in which doctors’ orders were handed down to be obeyed, to a process of shared decision-making in which patient autonomy is a priority. This has brought with it challenges for health care professionals – clear communication, evidence-based medicine, flexibility of approach, and the ability to accept an individual’s wishes and decisions regardless of the clinician’s own views. There is, of course, more progress to be made. But this approach will be just as necessary as the NHS tries to establish a new understanding with the public about the changing nature of care – whether that is location in which care takes place or individuals involved in care giving.

The progress of the past 70 years has brought the NHS many great benefits, and with them ever-evolving challenges. It faces these with the dedication and strength of its staff and the great support and commitment of the public. Medicine, society and patients are changing – so must the NHS.

Source: The King’s Fund

Hospital bed numbers – can the downward trend continue?

Since sustainability and transformation partnerships (STPs) published their plans late last year, the issue of the number of NHS hospital beds has been rising up the health care agenda. Alongside integrating health and social care and boosting primary and community services, some STPs – for example Dorset, Derbyshire and some STPs in London – have included proposals to reduce the number of hospital beds in their plans.

Subsequently, some stakeholder groups have voiced concern: for example, the Royal College of Emergency Medicine thinks that the NHS needs more beds, not fewer, if it is to meet performance targets. So we decided to look into the number of hospital beds, explore trends and ask if it’s realistic to reduce numbers further in the coming years.

Hospital Beds

The NHS has been reducing the number of beds for decades: since 1987/8, the total number has more than halved from around 299,000 to 142,000. Within that, the numbers of beds for people with learning disabilities and mental health problems have fallen more substantially – by 96 and 72 per cent respectively. Several changes in the way that care is provided have made these reductions possible. For example, care for people with mental health problems and learning disabilities has gradually shifted from institutional settings into the community; technical improvements in surgery have meant more patients undergo day surgery – in cataract surgery almost all operations are now day cases; and average length of stay for hospital patients has fallen from eight to five days over the past 15 years thanks to developments in clinical practice and how patients are managed.

But can this downward trend in number of beds continue?

On the one hand, there are clearly opportunities to use hospital beds more productively. As the Getting It Right First Time initiative has highlighted, there are substantial variations in average length of stay for some procedures across different hospitals. Variations in how complex older patients are managed means these patients spend more days in hospital in some areas of the country than in others. And many patients experience delays in the discharge process meaning they spend time in hospital when they are no longer benefiting from being there. In July this year, more than 5,860 beds were occupied by patients whose discharge was delayed. Progress in these areas would help to make more productive use of existing hospital beds. While national NHS leaders are keen to make such progress, it is unlikely to be straightforward, as recent tensions between NHS England and local government over efforts to cut delayed transfers of care exemplify.

On the other hand, however, today there are a number of factors that make the wisdom of reducing the number of hospital beds far more uncertain than it may have been in the past. England’s population is growing and ageing: by 2030 one in five people in England will be aged over 65, and therefore more likely to need health care. Demand for hospital care is rising with increases in A&E attendances, emergency admissions, and elective admissions. In turn, bed-occupancy levels in hospitals have risen to new highs in the past few years; in 2016/17 overnight general and acute bed occupancy averaged 90.3 per cent. Reductions in average length of stay have slowed in recent years, and may well slow further in the years ahead. Out-of-hospital services – particularly intermediate care and social care – which play a key role in supporting people as they leave hospital are under real strain with access to publicly funded social care becoming more difficult. Finally, the simple fact that the vast majority of beds for those with mental health problems or learning disabilities and beds for the long-term care of older people have already been closed means there is very little scope to reduce numbers further. Instead, future reductions in the number of hospital beds would mean reducing the number of acute beds, which historically has been more difficult. These factors help to explain why the pace of reduction in the total number of hospital beds has slowed in recent years – falling only around 4 per cent between 2012/13 and 2016/17 – and why bed-occupancy levels have risen.

The NHS’s record over the past 30 years is one of success. Adopting new ways of providing care has allowed the service to provide higher-quality care to increasing numbers of patients while reducing the number of hospital beds. But it doesn’t follow that the number of beds can be reduced indefinitely. Today circumstances make it less clear how patient needs are going to be met effectively if more beds are closed – particularly in light of the lack of money to develop alternative out-of-hospital services. So, while some areas may be able to safely reduce the number of beds, substantial reductions in the total number of NHS hospital beds in the next few years seem neither achievable or desirable.

Source: Leo-Ewbank at the King’s Fund