A conversation with the public: could different be better?

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Part of The public and the NHS

As part of our work on the NHS and the public, we are publishing a series of blogs providing different perspectives on the relationship between the NHS and the public, and how it has changed over time. Here, Professor Keith Willett, Medical Director for Acute Care, NHS England, 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.

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.

Comments

Belle M

Position
Patient,
Comment date
06 December 2017

I’m heavily reliant on the health service due to complex needs because of complications arising from Spinal disease and damage caused by surgery, which then required surgery and surgery etc!
Whilst I agree that where possible treatment should be homebased for some; there also needs to be adequate support at home and when this is provided by local authorities, unfortunately it has been my experience that the additional help comes too late, or is not the right help. There is a huge gap between being an acute patient to discharge.
Patient flow and bed pressures caused by an aging population has a massive impact on what is available for the younger patient like myself.
Continuity of care is patchy untimely and causes stress on patients especially when one is told they are lucky to have minimal support in place as some have none.
When we become unwell because of the rush to discharge without the correct care package in place, after 14 days of hospital continued support in the community, more often than not a follow on care package from adult social care is not in place.
So back through the system the patient must go, a life full of appointments and waiting in outpatients. Leaves no life outside of appointments and is exhausting leaving no time to recover.
Ultimately this for me and many others I have met along the way Leads back to inpatient care and more life wasted.

What you see as progress I experience as a substandard ridged service, that puts a bandaid on but never gets around to treating the injury.

The real problem is not the young it is the elderly who’s needs are as complex as my own. Who too deserve better treatment but are left to cope alone or spend months in hospital waiting for support at home or in a home.

The more I experience the service, the more I realise that Domacilary care needs to be taken back by the NHS and not private companies who fall below the standard, who fail to provide on a regular basis and add to the problem by taking on staff who are not trained to the same standards as the NHS some of whom should not be in the job because they are uncaring and dishonest and not vetted enough, appraised enough and the companies they represent are in it for money and profit and put this over service delivery.

If you really want to cure the health service as a whole entity the simple solution is take the monetary market out of the NHS full stop.

Don’t outsource keep everything in house and this keeps it cheap because it costs the cost price!

Sure offer community services but take over ALL health and Social care.
This is a conversation that needs to be had, instead of talking about funding talk about killing the market within healthcare as a whole and in turn we will have a strong unified well led and run organisation, who can get back to doing what it should be doing instead of making it look good on paper and leaving us patients to struggle to cope with the aftermath of inadequate care and support.

After my recent experience I am beginning to believe in assisted suicide more and more!!!

pamela ellis

Position
retired,
Comment date
07 December 2017

In the olden days! we had convalescent homes. People who had had an operation, but recovering, would leave hospital and go for that extra care in to these homes and then discharged to their home.

STUART WOOD

Position
Patient,
Organisation
PPI member
Comment date
09 December 2017

A patient's observation.
Communication, even in this digital age, continues to be an issue with the NHS. The issues are within hospital departments, between primary and secondary care, between hospital and GP, between hospital and patient. The NHS is composed of many excellent people working in small bubbles and as a patient with a chronic illness, I would like to see those bubbles joined up into an integrated care system.

Emily Oliver

Position
Senior Editor,
Organisation
International Journal of First Aid Education
Comment date
10 December 2017

Prevent and prepare, recognition of when an illness or injury requires urgent care, provision of care and recovery are all implicit to Keith Willett's arguement. They are also the explicit domains of the Chain of Survival Behaviour (IFRC, 2016). Yet first aid education, which spans these domains and builds tbe resilience of communities and individuals continues to be ignored as a tool by the NHS and public health. It's not mentioned in 5 Year Forward or in any Health and Wellbeing Board Strategies. Of course it might only be part of the solution, but does that render it worth ignoring to such an extent?

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