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.

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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

New breed of paramedics charged with keeping people out of hospital

Steven Morris for The Guardian 20/01/2016, gives us a viewpoint from Steve Hulks a community paramedic practitioner in Kent, whose job is about advising, reassuring – and easing pressure on A&E

You do get a rush of adrenaline,” says Steve Hulks as he activates the blue lights and siren and speeds to the first 999 call of his shift – an elderly man has fallen in his bedroom and is unable to get back on to his feet.

“But you have to be careful that the rush doesn’t distract you. You need to drive safely and think of what you need to do when you get there – how to get in, where the key may be hidden, what you may need, what may have happened to the patient. You have to stay calm.”

Hulks is one of a new breed of ambulance personnel. When he first signed up a quarter of a century ago the job entailed going to the scene of an emergency and rushing the patient to hospital. “It was about doing some first aid, putting the patient in the back of an ambulance and taking them to A&E. The problem is most people didn’t need to be in hospital – it was no good for them and no good for the hospital.”

Now as a community paramedic practitioner working on a ground-breaking scheme in the seaside town of Whitstable, Kent, the aim is just about the opposite.

He is still there to save lives but his job now is much more about helping an ageing population stay out of hospital and remain independent, advising and reassuring troubled young people, thinking about patients’ mental wellbeing as well as their physical health and working closely with GPs and other primary care providers to create a more joined-up service.

The door of 90-year-old Jack’s flat is open when Hulks arrives. Jack just about missed bashing his head on a chest of drawers when he tumbled. Carefully, Hulks checks him over before using an inflatable cushion to get him back into his wheelchair. “That’s better, that’s heaven,” Jack tells Hulks. “I don’t want to end up in hospital – that would be terrible for me. I like it here, I like my garden.”

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Over the next hour (there is no set limit to the time he spends with patients) Hulks carries out a series of tests on Jack, from his blood pressure to his eyesight. The elderly man appears confused, which could trigger a trip to hospital for head injury tests. But Hulks has visited Jack several times before and so knows he suffers from short-term memory loss. He is happy to leave him sitting in his wheelchair looking out on to his garden, knowing that a carer will arrive soon to give him lunch.

It is a good example of how the scheme works. The idea is to embed teams of highly trained paramedic practitioners into the heart of communities. They have the decision-making skills – plus the local knowledge of regular patients – to know when someone needs to be taken to hospital and when they are better off staying where they are.

Launched in Whitstable last spring and now being rolled out across other areas in Kent, the scheme has already kept scores of people out of hospital. Only a third of 999 calls handled by Hulks and his colleagues have ended in someone going to hospital; across the South East Coast ambulance service’s whole patch, the figure is around 50% – and in some trusts it is up to 70% or 80%. It is good news for patients and good for hospital emergency departments – crucial at this time of year. Other trusts across the country are watching with interest.

Today Hulks, 57, is staffing a 999 car, ready to head to urgent calls like Jack’s fall. His colleague Jess Willetts is in the GP car, carrying out home visits on behalf of the doctors’ surgery where they are based. This helps take the pressure off the hard-pressed GPs – they may be able complete six appointments at the surgery while Willetts does one home visit – and also tethers the paramedic practitioners to the patch they are covering. Meanwhile, other more conventional ambulance crews are ready to head for emergencies more likely to require hospital transfers.

Hulks’ second job of the shift is a reported assault. A young woman has been kicked in the back and had her head slammed against the steering wheel of her car, apparently by her partner. The police head off in search of the attacker while Hulks checks her over. Like Jack, she would have been taken straight to hospital a few years ago but Hulks satisfies himself that she does not need to go to A&E.

It not just her physical state Hulks considers. He talks to her about her fears and concerns. He tells her that social services may be involved. “She was upset, shaken. It’s good to give people a chance to talk. It’s often as much about mental health as physical health. We try to provide more of a holistic service.”

Another vulnerable elderly man, Pete, is the next patient to be visited, this time by Hulks and Willetts together. The 83-year-old fainted face-first into his smoked haddock at lunchtime and needs an ECG to test his heart. It saves him having to be taken to the GP surgery – good for the surgery, good for the patient.

Pete is not happy to see the paramedics. “What’s all this about? I’m fine,” he mutters. Hulks and Willetts chivvy him along. “You do the job to help people, to make a difference,” says Hulks later, “You’re journeying with someone through illness or crisis. You’re there for that moment helping, supporting.”

“Nowadays, the safest ‘pair of hands’ you can be in is most probably a paramedics – strength to all of them”