The NHS at 70: blow out the candles and make a wish

Key:

• HM: Helen McKenna

• DB: Don Berwick

• CG: Ceinwen Giles

• SA: Siva Anandaciva

HM:     Hello, welcome to The King's Fund Podcast where we talk about the big issues and ideas in health and care today. To help me deal with these really quite massive questions, I’m joined by three very special and distinguished guests. We’ve got Siva Anandaciva, Don Berwick who’s come all the way from the States to be with us here today, and Ceinwen Giles. So Siva, Don, and Ceinwen, could you please each introduce yourself and continuing on the lines of the birthday theme, tell me what is the best birthday present you’ve ever received. Let’s start with Siva.

SA:     So I’m Siva Anandaciva. I’ve the Chief Analyst here at The Kings Fund, and I am wracking my brain to think of, so I’d go with two things I think. One was when I was very young, my parents bought me a model of Castle Grey Skull which was everything I wanted and made my world complete, and then more recently, I think either the last birthday or the birthday before, my wife said we’ll do whatever you want and it doesn’t have to be anything big. So we spent the day on the couch, eating take away, watching episodes of Columbo. That’s the perfect day for me.

HM:     A dream come true for Siva.

SA:     It is.

HM:     Don?

DB:      I’m Don Berwick, I’m a paediatrician and I’m here as an international visiting fellow to The Kings Fund and I’m the founding CEO of the Institute for Healthcare Improvement, IHI which I ran for 20 years and then ran Medicare and Medicaid for President Obama. Best birthday present? Hmm? Well I turned 70 a year ago and my family organised a surprise party. It was my whole life in review. I showed up at one of my children’s homes in Boston and there were about 50 people from my whole journey. It was amazing. Old college roommates and friends from today and friends from yesterday. It was really wonderful.

HM:     Great, and Ceinwen.

CG:     So I’m Ceinwen Giles. I am a director at Shine Cancer Support which is a charity that supports people in their 20s, 30s and 40s with cancer. I’m also on the general advisory council here at The Kings Fund. I’m really trying to think. Yeah, I can remember coming home once when I think I was about 7 and my parents had a Cindy doll house all set up for me. That was pretty exciting because it was huge and it had an elevator on the outside, but yeah, I turned 40 a couple of years ago and my husband got me a ring, an eternity ring which everyone, says 'oh were you married for ten years or something' and we hadn’t been but actually because I’ve been really ill, I never knew if I would make it to 40, so yeah it was a really lovely present and my daughter had hidden it under her bed so I couldn’t find it, which was very, she was so excited. It was very cute. She also says she wants it when I die. Not for a while hopefully.

HM:      But she's got her eye on it?

CG:     She's got her eye on it, yeah.

HM:      So the NHS reaching its 70th birthday is a real milestone, particularly given that at various points during its history people, many people speculated that it simply wouldn’t survive and yet here we are, the NHS is still here. So, a great time to take stock and think about where the NHS has got to 70 years in, how it’s doing and where it’s headed. So let’s start with the current state of the NHS and Siva, I think you’re the expert here. You run a quarterly survey of NHS finance leads. You look through that to find out how the NHS is doing on finance and performance. So what sort of state is the NHS currently in?

SA:     So I think the NHS is in quite a tense state at the moment, so operationally strategically and politically. Operationally you’ve I think just got this fundamental mismatch between what people expect of the service given the resources it has, so A&E targets of seeing patients quickly are routinely missed now up and down the country.  Targets for seeing people with cancer within two months of diagnosis. Financial performance, you know I remember four or five years ago you could count on one hand the number of NHS providers that were failing their financial targets. Now, it’s overall more honoured in the breach than the observance  So, there’s quite a lot of pressure and tension because you feel like you should be delivering when you fundamentally don’t have the resources. So that’s one piece of tension. The second piece of tension is more strategic, I think, which is over and over again when you look at the survey data, you see finance directors, chief operating officers caught between two stools. The needs of their organisation and the needs of the system and it’s easy for people like me to say, well just prioritise the system, do the right thing for your local area but they’ve got boards, they’ve got staff, they’ve got local politicians who are saying do the right thing for your hospital. So again, that’s a source of tension and the final source of tension is political. You know, we are clearly at a moment as the NHS approaches its 70th birthday. The government has provided some additional funding, or the offer of additional funding for the NHS but again it comes loaded with expectations. So I think the mood is as always cautiously optimistic. Whenever you come to a moment, there’s also quite a lot of tension that needs to be resolved.

HM:     Ceinwen, you do a lot of work looking at patients’ experiences of NHS services, so what’s your take on how patients view the current state of the NHS?

CG:     So I think, you know patients understand this, the tension, the political tension that’s happening. I mean you, but I think we also have to be careful. I think there’s a risk that you can develop almost a tolerance for things that aren’t right because you’re grateful for the service. So people who, you know, go to A&E and wait hours and hours and then say 'but I understand you’re under a lot of pressure', that’s not necessarily right. What I hear from a lot of cancer patients is that there are little things that are being chipped away at. You know, so people who go to the hospital and they find out their chemotherapy drugs aren’t ready because the nurses didn’t have time to pick it up from the pharmacy. You know, from myself, I attended clinic every month to receive an immunoglobulin treatment and you can see in the seven years I’ve been going, anything that was nice to have has been stripped away and we’re getting to the point I think where it’s, you know if we were a factory model before, we’re just, we’re like at the machinery I think, and no fat, exactly. I think that’s really hard as a patient because it means that you are increasingly just treated like a problem.

HM:     And so, just for the benefits of the listeners Ceinwen, would it be helpful to just say what your condition was and is?

CG:     Sure, I mean obviously you know, I've been thinking about the NHS at 70 and for me I am hugely grateful to the NHS because I would be dead without it. I was diagnosed with stage 4B non-Hodgkin lymphoma eight years ago. You know, I was actually really lucky to be in London. I ended up accidentally at a hospital that had a lot of really very well-trained lymphoma specialists. I was put on a clinical trial but I spent six months in the hospital as an inpatient and for me that was really, it was a very, well it was a hugely traumatic experience but it was very transformational and it gave me a lot of food for thought about how the system treats patients.

HM:     And Don, so whenever I listen to you I always hear optimism, so I’m going to look to you now for an optimistic note in terms of current state of the NHS from your perspective.

DB:     Yeah, I think I’m looking at the cup half full part of it. There’s certainly problems, every healthcare system in the world has, not just problems but very serious problems and my career is devoted to trying to help make things better, but when you look at the NHS, I think it’s important to say compared to what, and I continue to regard the NHS as majestic, unique and extremely valuable to preserve and improve, even despite the current stresses. What’s so striking to me about the NHS is what has not changed, which is from its founding, these principals of universality, support for general taxation which means it’s re-distributional as it needs to be and free at the point of need. These are really important principals which your country still seems committed to, Tory or Labour, across the spectrum. The solidarity is very impressive and I don’t think it’s equalled anywhere else in the world. In a way, the fact that we can sit and talk about the problems is a mark of its systemness that there is, it’s possible to have these conversations, as troubling as they feel and to maybe think about how to fix them. That said, of course, the cup is half empty. There are serious problems and they’ve been aggravated in the past few years by choices that probably need to be reconsidered. I think, as Siva said, I think the austerity measures went far, much too far and that’s being, hopefully will be addressed. I think you still have a problem in, and a worse one now in under investment in social determinates of health and working on prevention. Illness doesn’t come from the lack of healthcare, it comes from other causes. I think there is a tendency in this country still to blame people when things go wrong when those of us in the world of quality know that it’s not people it’s generally systems. When things go wrong it’s because good people are trapped in systems that are not well designed. All of that you can deal with, all of that the NHS can deal with and I think it will but I don’t want to understate how difficult it is right now and you have a workforce in distress and I think that’s really clear and again, I’m optimistic you can work your way out of it but not if you don’t recognise first that poor morale and too much stress on the workforce isn’t good for anyone, the workforce or the patients.

HM:     Obviously you’re based in the States normally, what do you see as the big differences between the healthcare in the States and here?

DB:     Well on the positive side, here you, as I said earlier, you can have policy. You can think about the healthcare system of the UK. You can make a decision if you choose to rebalance investments on determinates of illness, work on equity issues for example. We can’t have that conversation in the US. There’s no platform. There’s no consolidated responsibility for what you are holding your government responsible for. In terms of differences in delivery, there are one or two that I do notice which is that the, what I would say the consumerist view of healthcare, the voice of the patient, the importance of patient family care participation and design and redesigning, governance of care is slightly better developed in the US than here. It’s changing fast though, thanks to people like Ceinwen and others. We have very well developed high-tech medicine in the US if you have a very advanced illness you’ll pretty much get proper care. That’s true here also, but I think we’re probably on a par. Your commitment to general practice and primary care is much stronger than in the US though. Here the idea of empanelment that everyone has a GP, that there’s a reference point for your care, you committed to that at the founding and the US still lacks that kind of very, very strong primary care infrastructure and we’re struggling with it.

HM:     And Siva, just continuing on the theme of international comparisons, I know that recently we along with the Health Foundation, the Nuffield Trust and the IFS recently published a report which looked at how the NHS is currently doing a comparison to other countries. What did it say? Is the NHS currently the envy of the world as politicians sometimes say it is?

SA:     So very briefly, it was a mixed picture. So it was mixed depending on what areas you look at and then even some special areas within that. So, overall, if you look at the resources the NHS has it feels like we are under resourced relative to other similar countries. The number of doctors, number of nurses, number of hospital beds, the number of MRI, CT scanners, you know these are all very hospital-based metrics but we’re below average on all of them. So you’re not working with a lot when it comes to resources. The second thing is, we seem to use those resources relatively efficiently. If you look at the rates of prescribing for generic, cheaper forms of medicines. If you look at lengths of stay in hospital, we perform quite well. We seemed to use those resources well, but when it comes to the outcomes, you know part of the main purpose of a healthcare system is to keep the population alive and healthy. That shows the NHS has some room to make up compared to other countries. We do well on outcomes for conditions like diabetes, for some kidney conditions but the big killers, cancer, heart attacks, stroke, we lag behind other Nordic countries. We lag behind other western countries. We lag behind Australia. So, whether it’s screening, whether it’s early treatment, there is a lot you can still learn from other countries.

DB:     What did the data show about the level of investment per capita, expenditure or percentage of gross domestic product here compared to other developed countries? Where are you now?

SA:      So we’re about average. Now we spend about 9.7% of our GDPR national wealth on healthcare which for the basket we worked out, obviously the US was an outlier right at the top but we came out about average but - and it’s a pretty big but - we’ve, the OECD have recently changed how we measure health spend. So a whole host of things that you know I would consider social care, bathing, washing, helping people live their daily lives, that spending is now included in health so we’ve jumped up the league table, we’re about average but for some reason that’s not translating into more tangible resources.

CG:     But there is an incredible fragmentation here too between sort of public health and prevention and the NHS, right and you, I mean the report talks about the cuts to local authority funding for public health and if we want to improve population health you need a whole system approach. I think that’s what one of the dangers that I see as sort of the increasing fragmentation of bits of the system that do support people to live well because where you have growing rates of inequality and people unable to get information or support to live well, well then you’ll see them when they’re sicker and that’s not necessarily what we want.

DB:     To me that’s probably the biggest policy choice I see for NHS at 70. I think in the long run you really need to work on causes and I think that’s a big decision that the government’s going to have to face.

HM:     Let’s move onto how the system is changing right now. Don, I know you have been travelling across the country over the past few years doing a tour of the NHS and looking at what are called vanguards or the new models of care, how the system is changing. So, tell us a little bit about what you’re seeing.

DB:     Again, it’s a half full half empty picture isn’t it? Well the vanguards represented an investment about three or three and a half years of a kind of experiment that your country did through the NHS. You selected fifty Trusts, fifty deliverers of care, some hospitals, some physician groups, some care homes, some A&E departments and you gave them a little more money and a lot more headroom to change the rules and try to reinvent care locally to achieve what we call, the triple aim; better care for individuals, better health for the population and lower cost or at least less waste. My job has been to visit these vanguards. I probably visited I guess forty of them in the three years and it’s thrilling. I mean it’s absolutely thrilling. I wish everyone could kind of come along with me. We go to these small communities or cities and watch these Trusts try to do something completely new, completely new relationships between specialists and GPs. Completely new use of telemedicine. Completely new use of homebased care and resources. I mean you’ve got a catalogue now of breakthroughs distributed around the country that any country could benefit from. Certainly yours and the results are triple A results. In general, they are better for patients, improve health and if not reduce costs at least make better use of resources. So that’s the good news. The vanguard programme is now ended, your transition and you’ve got another enterprise underway now which is integrated care, which means building even more ambitious population-based approaches to care. Right now you’ve got ten integrated care systems and more are coming. They’re fantastic. I am more optimistic about that form of change than almost anything I’ve seen.The half empty part is, it doesn’t spread. You want to find a place that’s revolutionised, that relationships between consultants and GPs, I can tell you where to go to see it but that’s about where you’ll find it and you’re now trying to figure out as a nation, how could we take these great examples and make them useful to everyone and I think that’s kind of the next big challenge.

CG:      And when you’re on this tour, have you seen like in the vanguards or in these integrated care systems, a different approach to working with patients as well, because that’s one of the things that I've heard and I feel like I’m getting sort of negative, but I have heard people say, well we didn’t really have time to engage with the patients so we’re going to bring them in at the end and obviously that’s not ideal. So has that been thought about well?

DB:     Not everywhere but certainly in many places. Really thrilling stuff. I was in Winslow for example which is a, there the, actually the community and the GPs have come together to reinvent care very authentically. They’re absolutely working together. If Wigan is going to become a legend in this country, what’s going on there is, it’s so wholehearted in the combination of community-based resources, patients, carers, families and deliverers of care, so I’d be, you’ve got some great models. The trouble you’re hearing, I’d like to hear more about because I’m sure there are places that haven’t quite done it. I’d say by the ways, coaching the people doing intervention which is, I’ve never seen a place that’s invited patients' families, carers into the picture in governance and improvement work and gone back. It’s always better.

HM:     Absolutely, yeah. And so thinking about how the NHS needs to change, Ceinwen what about the relationship between the NHS and patients?

CG:     So we’ve got good examples. What I would like to see is a commitment to working with patients at all levels. So, Don’s report, Robert Francis’ report, loads of reports have talked about, you know how do we really fundamentally work with patients and that’s not just kind of you know get some volunteers in for a tea trolley service, it’s I think we need to look at what does it mean to have patient care representative at all levels including governance. So on the boards, on the wards, you know right down to the very bottom working with porters so that they understand what it’s like to be a patient. That to me would be a fundamental change but I think it feels really risky to people but there’s a huge opportunity. There is a huge opportunity to save money, to make things better, to have better outcomes and that’s what I would really like to see happen.

HM:     And really exciting if we could make it happen.

CG:     Yeah hugely exciting, and like Don said, people who do this work they don’t go back and you don’t go back because the energy that you get from working with people is amazing. You get to work with people who care.

HM:     How else Siva, do you think the NHS is going to need to change beyond the new models of care, ICSs, the stuff that’s happening now, what else needs to happen?

SA:     I think if you pull off the ICS movement, in all aspects, you know a new approach to thinking about how you plan care, new approach to how you involve patients, I think that tackles quite a lot of the issues but the ICSs if I’m being honest, as great as they are also seem quite insular, still focussed mainly on healthcare provision and maybe pushing the boat a little bit to social care. I don’t see any real appetite, at least with the places I’ve seen to really embrace public health prevention. I see that maybe in the healthy new towns more than the ICSs where they’re thinking we can either work in the best hospital in the world, I can have the best GP surgery in the world, if my kids have to walk past 17 chicken shops and if the logical choice for them for a quick, cheap, easy dinner is to pop into that chicken shop then they’re not going to solve the fundamental root causes of a lot of the health problems we’re seeing. So I think embracing ICS movement, absolutely embrace public health and prevention is serious lots of motherhood and apple pie initiative and then hopefully in twenty years’ time we won’t be saying, as health system leaders, why didn’t we do more to prevent and de-steer diabetes epidemic.

CG:     And also I think that link to social care that you mentioned as well, because we have an aging population and I sometimes feel, I mean maybe it’s people my age and younger, it’s like everyone’s put their hands over their ears and go la, la, la, I’m never going to get old, that’s not going to happen to me, but that’s a huge problem that we need to grapple with and I think we need patient and carer involvement in that too because I’m not sure that we listen to the elderly as well as we could to find out where their priorities are and that is causing a knock on effect on what’s going on in the NHS.

SA:     Absolutely. The two scariest charts I’ve seen the last few years, one of which is what’s happened to nursing and midwife applications from the EU and the second was what people think about social care and it’s just stunning how, I’m broadly generalising, but people don’t understand what social care is. When they understand what it is, they think that the state will pay for it in a very similar way to the NHS. So I think you’re right, there are massive awareness issues to be raised here.

HM:     Okay, so we’ve looked at how the NHS is currently doing, we’ve looked at how it’s changing, now onto the fun bit which is predictions. So, first of all I know the NHS has recently been asked in exchange for additional funding, it’s been asked to write its own ten-year plan or certainly lead the development of a ten-year strategy and I think we’re going to see that over the coming months that will come out. Before we see that, let’s speculate on what the NHS will look like at the end of that period. So, Don, you talked about integrating services, we’ve been talking about integration for a long time, do you think in ten years’ time we’ll finally see integrated care across the country?

DB:     I do. I think Siva’s spot on that right now the authenticity of investment in public health and prevention it’s not really there. I mean people know it’s important but, yeah if you visit these places they’re having a lot of trouble mobilising the resources. I think it will change, I really do. I think there is so much reason to work on community health and wellbeing as the enterprise, not just delivery of care. The other thing we haven’t mentioned at all but I will predict with near certainty is the exciting creative use of digital health mechanisms, telemedicine, telehealth, self-care, artificial intelligence in health care. These are really promising and they’ve been sort over promised for a while you know, but I’m seeing that that will change and it’s changing very fast right now. I think the NHS could lean on that if you invest properly.

CG:     Especially for long-term chronic conditions I guess, where you know you’ve got people going in regularly for appointments and you go in and they go, 'everything looks good' and you go away and you come back. I mean you can do that over the phone in 5 minutes.

DB:     Then there’s the self-care aspect of that because, Ceinwen may disagree, but the people that generally are coming to know the most about the care of an illness are the patients themselves, they have access to so much knowledge and we don’t use it and that’s the biggest workforce you’ve got because they’re there 24/7 you know and I think that’s going to change and telemedicine is going to help people be much better at caring for themselves.

HM:     And on the workforce Siva, we’re currently facing a lot of pressures, where do you think it will be in ten years’ time?

SA:     I think we’ll still be talking about we don’t have enough doctors, we don’t have enough nurses. What I hope we’ll also be talking about is a bit more enjoying work that people feel, ‘do you know what, ten years ago I felt like there was a lot of pressure to do things quickly to turn the handle, to get the next patient in and out, now I feel like I have, first of all that I work more in teams and those teams are wider, that I’m not just doing things that help this patient in the moment to get better, I’m helping them throughout their lives to stay healthy.’ So the way you spend your time, where you spend your emphasis will feel very different. I hope that it’ll feel like your on call is a lot more flexible in their approach to you. I see a lot of junior doctors now, well one in particular who’d said, 'do you know what, I want a portfolio career. I want to work on this tech start up 20% of the time I’m going to be staffed to a rota 80% of the time' and the clinical director’s response was, 'do you want to be a doctor or not?' I think in ten years’ time, it will be if we’re a good employer, how do we work around your lifestyle?

HM:     So this is the even more fun aspect, thinking about in 70 years’ time. So other than very wrinkly, how do we think the NHS is going to look when it’s 140 years old. Don, where do you think most of our care will be delivered? Will we still be focussed on hospitals the way we are now?

DB:     I think hospitals will be intensive care units, that there is obviously there are conditions for which you need to be out of your home, in a safe medical environment but the acuity levels in the hospital will be much higher and of course you’ll be going with an aging tsunami. You’ll have people who are 100 years old or 110 and there’ll be a need to focus on the needs of frailty, more and more. I think home will be the hub and more and more will happen where you live your life.

HM:     And Ceinwen, where do you think we’ll be in terms of self-care which came up already? Do you have any predictions about it? Don’s already talked about most of the care’s going to maybe be happening in the home, by 2088, do you think we’ll all be doing a lot of our care ourselves?

CG:     Yeah, I think we will. I mean I think it’s already moving that way. My one wish I suppose, is that when that happens that we use things like tech to ensure that patients still have a community because I think one of the difficulties with moving care into the family is that people can become more isolated. I guess the other thing that I would, I hope to see in 70 years is that we do have patients integrated into the governance and management systems in a different way. So we have patient directors, and you know that we don’t even think about that. We think about why didn’t we have these guys before? And that actually the skill that is required to work with carers, patients, the public is recognised because I think at the moment we tend to think that anybody can go out and work with patients and the public and they can’t because it is a skilled job and I hope in 70 years that we’ve recognised that and that we have practitioners who have that as a job and patients who were in those kind of important roles and who have those skills as well.

HM:     Great, and so last question which is for you Siva, you’re going to love this one. So, back in 2008 when the NHS was 60, Nico Henke of McKinsey estimated that by 2050 most countries would spend more than 20% of GDP on healthcare and that by 2080 the US would be spending more than half its GDP on healthcare, so a nice easy question for you, thinking ahead to 2088, how much of our GDP do you reckon we’ll be spending on health?

SA:     I reckon we will be spending about 15% of our GDP on health but by health I mean health, I mean public health.

HM:     In its broadest sense.

SA:     In its broader sense including those part of, I’d include everything; education, the portion of education that is, this is how you live a healthy life. I wish somebody had told me at 15 I’d be in a better place now.

CG:     We’re going to come back and check with him right?

HM:     Absolutely yeah, we’ll revisit these predictions in ten years’ time and in another 70 though I probably won’t be here to do it. Thank you so much to all of you for a really interesting discussion as the NHS hits 70, it’s great to reflect on these things. So thanks Don, Siva and Ceinwen for a fantastic discussion. Well that’s it from us. Thanks for listening and if you enjoyed it please subscribe, rate and review us on iTunes and also tell your friends and if you have feedback or ideas for topics you’d like to hear covered in future episodes then please get in touch either on Twitter @thekingsfund or my account @helenamacarena or you can leave feedback on our website which is www.kingsfund.org.uk. Bye for now and hope you can join us next time.