Three versions of the NHS

In the past week I’ve observed two very different versions of the NHS. I’ve also glimpsed a potential third version, and very much hope that it’s within reach.

Version one is an NHS under severe and growing pressure. Confirmation came in last week’s performance figures which showed the NHS continuing to miss key targets for patient care, in some cases by a wide margin. It was also illustrated by the Care Quality Commission’s reports of hospitals failing to provide adequate care, and by a survey of health leaders by the Nuffield Trust highlighting concerns about workforce shortages and staff morale.

Version two is an NHS developing new models of care better suited to the changing needs of the population. Our conference last Tuesday showcased examples from around England, reinforced by presentations at our follow-up meeting with primary and acute care systems (PACS), multi-specialty community providers (MCPs) and care home vanguards. The energy and innovation on these two occasions were palpable, as clinical and managerial leaders described how they are beginning to make a reality of the NHS five year forward view.

The challenge for leaders is to see version two as a major part of the solution to version one. The pressures facing the NHS will not be solved by staff working harder or through ‘sticking plaster’ repairs to outmoded models of care. Something different is needed, and the promise in the most advanced of the new care models is of transformational change that will bring benefits to patients and populations while at the same time improving the working lives of hard-pressed staff.

This is already happening in the MCPs, where the Modality super-partnership in Birmingham shows the benefits of practices working at scale and embracing new technologies that can transform the experience of patients. It is happening in the PACS, where areas as diverse as Northumbria, Morecambe Bay, Salford and Somerset are developing accountable care organisations and systems to join up services. And it is happening in the care home vanguards, through use of technology and workforce changes to overcome the fragmentation that often results in poor patient outcomes.

While it is important not to exaggerate what the new care models have achieved, there are real grounds for optimism that the work they are doing will contribute to resolving the problems facing the NHS. All the more important, therefore, that they receive the funding and support needed to extend progress made to date, and to share and spread learning to other areas. They also need time to demonstrate results in a context where there is growing impatience in government at declining levels of performance and frustration at the apparent inability of the NHS and its leaders to turn this around.

The risk this creates is that version one will trump version two as old-style performance management takes precedence over change being led from within the NHS. There are already signs of this happening, as in the funding provided to the vanguards in 2016/17 being released only when providers have agreed control totals with NHS Improvement. Further moves of this kind will dampen the enthusiasm that has been the hallmark of innovative partnerships in the new care models programme on which future progress depends.

The future I’d like to see is one in which national NHS leaders work thoughtfully to calibrate the respective priority to be given to versions one and two. To be sure, they must redouble efforts to stabilise and ultimately improve performance, but this should not be at the expense of a continuing commitment to support work under way in many parts of England to transform care. National leadership must go hand in hand with freedom for local leaders and staff to implement and spread new care models to secure the long-term sustainability of the NHS.

It’s this kind of future that we have argued for in our agenda for action for the NHS. As leaders across the country gather for the annual NHS Confederation conference in Manchester, it’s the future we need to create together. Let’s call it version three.

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#547752 Dr Malcolm Rigler
NHS GP Locum / Health Policy Adviser @ Partners in Health
Partners in Health ( Midland ) Ltd.

It is difficult to remain optimistic about the future of the NHS but as Chris Ham can see there are some "green shoots" and creative ideas that deserve to be nurtured . Another hopeful development lies in the fact that Dr John Middleton has recently been appointed as President of The Faculty of Public Health. In his inaugural speech he made it clear to the 500 delegates at the Brighton Conference that the work of The Health Centre cannot and should not be separated in any way from the work of The Public Library. This chimes well with the statement in Occasional Paper No 64 from RCGP by Dr John Macdonald that " if patients are to be fully involved in their own treatment and care then there needs to be a huge and sustained educational programme linked to the work of the GP and the Primary Care Team" . So the "green shoots of creative change" within the NHS need to be well co-ordinated with the creative change beginning to emerge within the Public Library Service. Let us hope that The Faculty of Public Health working with
The Kings Fund will be able to bring together the change agents within the NHS and the change agents within The Public Library Service concerned with "Health and Wellbeing" to further develop and support the work of the NHS GP and the Primary Care Team .

#547753 Guy Eades
Manager Healing Arts
Isle of Wight NHS Trust

Malcom - Please could you briefly summarise your ideas and proposals for the 'Public Library' so this is better known and understood and how this will inter- act with health centres, GP's etc. Is there a role for artists (and others) working on the delivery of healthcare objectives and haw will their contribution be financed - services paid for. With thanks Guy Eades.

#547759 Dr Malcolm Rigler
NHS GP Locum / Health Policy Adviser @ Partners in Health (Midland) Ltd.
PiH (Midland) Ltd.

In response to your note Guy I find that almost every patient that I see as a GP will now "Google" the medication prescribed , the diagnosis , possible treatments etc. In doing this they are trying to access archived information i.e a library. Patients and carers are then faced with an ocean of information with no guide to what is reliable. Librarians with training in "Guided websurfing" such as those now working within Maggies Cancer Care centres are already helping patients with cancer to find reliable information on-line. They offer this service within artist designed venues - MAGGIES CENTRES - where conversation is the key to their effectiveness and success - as we know conversation is a great art . Arts and Health projects around cancer care are numerous and helpful to many patients. As a GP I now feel that we must all learn from places like Maggies Cancer Care Centres because every patient with a so called "long term condition" could and should benefit from similar venues - maybe converted retail spaces on the High Street . Spaces and places currently boarded up and appearing to be derelict ! Senior people within the retail sector have published fascinating documents under the title of "Beyond Retail" indicating that The High Street must now diversify into both "Health" and "Education". The artist / architect / town planner must be central to this re-invention of The High Street. With regard to funding and sustainability Dr John Middleton our new President at The Faculty of Public Health should be encouraged to bring people together from The Retail Sector /The Kings Fund / The Nuffield Foundation / Public Health/ The Arts and Health Community/ The Public Library Service / The Society of Town Clerks / The Voluntary Sector to explore these issues and find new and creative ways for us as GPs to better support our patients with Long Term Conditions - now over 50% of our workload. Patients and carers with conditions that are not "long term" would also benefit from High Street places where reliable information within a re-invented library service can be found.

#547774 Kate Little
GP moving into population health through community engagement

Hi Malcolm,
I am also very interested in and excited to hear about the "Public Library" concept.
I am taking a career break from general practice and have a number of projects on the go, relating to engaging communities in their health & well-being. One idea I have started is to set up a reliable signposting resource for the community. Like you say many people are searching the internet for information before they come but often come for reassurance that their diagnosis and information is correct. Therefore creating a validated hub that they can access which contains very many of the resources we use, may reduce the need to appointments or at least make patients more empowered when they come in and know who they might be best placed to see. It could include useful apps / IOT. It worries me that there are so many devices out there being marketed to those that are more vulnerable.
I'd really love to hear more information about this project and see is there is a way of linking up / getting involved. Kate

#547791 Dr Malcolm Rigler
NHS GP and Health Ambassador @ The Patients Association
Partners in Health ( Midland ) Ltd.

Kate thank you for your contribution. Our website is at : . You will find the "Quotes" section to be of interest. Contact details are on the website. I shall look forward to hearing from you . Malcolm

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