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

Is investment in GP services increasing?

Beccy Baird writing at the Kings Fund: Last year we published a report highlighting the crisis in general practice. There are strong signs that general practice continues to be under increasing strain, including a rise in complaints about GPs, surveys showing patient satisfaction – particularly with access – is declining, and reports of all GPs in an area closing their registered lists as they feel unable to take on more patients.

The government and the national NHS bodies have made attempts to recognise and address the issues facing general practice. In April 2016, NHS England published the General practice forward view, which outlined a range of initiatives and investment for general practice. Among the measures it introduced were a programme to address some of the administrative burdens placed on GPs, initiatives to improve mental health support for GPs and support to deal with rising indemnity costs. Many of the measures focused on recruitment, both through training more GPs and by recruiting from abroad, although figures so far suggest that the government’s target of 5,000 more GPs by 2021 will not be met.

Financial investment in general practice is mind-bogglingly hard to track, and there isn’t any published data that fully profiles promised investments over the period covered by the General practice forward viewNew figures from NHS Digital show that spending in general practice increased in real terms in 2016/17 compared to 2015/16 (though by less than the increase between 2014/15 and 2015/16), but it is still unclear how much of this increased investment is actually reaching frontline services. This is particularly true for the money GPs receive outside their core contract. For example, the overall increase shown in NHS Digital’s figures includes financial flows which don’t reach GP practices directly, particularly payments for information management and technology, which accounted for about 29 per cent of the overall growth in investment.

King's Fund

NHS England has indicated that in future significant additional funds for general practice will have to come from local commissioners, particularly the Sustainability and Transformation Fund. However, it’s highly unlikely that much, if any, of this spend will materialise in the near future as the Sustainability and Transformation Fund is used to offset deficits in other parts of the system, especially acute hospitals. In the past, NHS England has also suggested that as clinical commissioning groups build new care models in line with the NHS five year forward view that investment in general practice would grow even further. However, NHS England’s latest annual accounts show commissioners underspent the budget for primary care and secondary dental care by about 2.3 per cent in 2016/17, suggesting that this increased flow of money to general practice is not happening.

Overall the money does seem to be going up, but by exactly how much and whether it’s in line with the promises made in the General practice forward view (namely to increase spend by 14 per cent in real terms between 2015/16 and 2020/21) is unclear. There’s also no way of knowing whether this money is enough to meet the rising demands placed on GPs. We’ve talked endlessly about the lack of good-quality national data which means it’s hard to know how much extra investment is needed. NHS England is working hard to address this, but it will be a long and complex process to address the lack of national data.

But there is good news. Last week the Care Quality Commission published its first report on the state of general practice. There was much to celebrate in the report, with the majority of general practices found to be providing safe and high-quality care despite the ongoing challenges of rising demand. What particularly struck me was how strongly correlated communication and relationships were with good-quality care. Practices where clinicians were connected to others, within the practice, in their community and in wider professional networks performed better than those that were insular and inward looking. These better practices have been developing innovative ways to deliver care and there are many examples of creative thinking, including the primary care home models, community-based models and new ways of reaching specific population groups. This needs to be the way forward. There could be a focus solely on delivering more of the current model, faster, by finding more GPs, adopting new technologies and improving the understanding and management of patient flow. But the realities of recruitment and retention challenges mean significantly greater numbers of GPs are unlikely and the changing health needs of the population, with growing numbers of people with complex long-term conditions, mean these approaches alone are unlikely to meet patient needs.

The Fund is launching a new project to look at innovative delivery models in general practice from the UK and internationally, seeing if we can distil from these a set of design principles that might guide practices developing new ways of working. We’d love to hear from GPs who are innovating in this way – please get in touch.

Source: The Kings Fund