Swindells: They aren't 'your' patients

With the grand drama and mayhem that is currently consuming every news cycle, the fact that the NHS is struggling to make ends meet after 10 years of austerity, has for the first time in memory not really bounced back from the previous winter’s performance dip and, 18 months into its delivery, is due to produce a set of system plans to deliver the first five years of the long-term plan has been forgotten by the nation and its media. That is not a luxury that the NHS leadership can afford from the lofty centre to the front-line.

Fighting the alligators

The temptation for any hard pressed manager is always to fight the alligators – Brexit, money, winter, staffing – and delay draining the swamp for calmer times, but these calmer times never come. Political campaign rhetoric may turn into the reality of more revenue or capital for the NHS and maybe there will even be more money for local authorities to address the desperate needs of the most vulnerable in society and reinstate decimated public health campaigns, which as a by-product will relieve some pressure on the NHS, but the underlying challenge for health and care will remain.

The NHS has a reasonable claim to be the most efficiency healthcare system in the world. The latest OECD data, which incorporates in health a chunk of what we would think of as social care spending, places health spending in the UK at £3121 per head, France at 3930€ (£3471), Australia A$7170 (£3892), Germany 4593€ (£4057) and Sweden 52249 kr (£4877) – these are more informative benchmarks than the astonishing $10586 (£8489) per head that the USA spends.

That means that if the NHS and social care in England, serving 50 million people, was funded at French levels they would receive another £17.5bn per year or £46.8bn at German funding levels. Yet, all these countries are also struggling to meet the demographic and technological challenges. So, even if one of the parties was to take a leaf out of Tony Blair’s 2000 playbook and this time commit to match our peer group European Union countries funding per head, the NHS would still need to take the next radical step in health and care delivery – one that countries from Sweden to Saudi Arabia are waiting to watch and learn from – and deliver integrated population health at a system level.

As Sustainability and Transformation Partnerships and Integrated Care Systems draw up their joint plans to meet the challenges of the long-term plan, they will need to take bold steps to achieve three things.

If STPs and ICSs plans don’t face these existential challenges to the NHS and grasp exciting opportunities to reinvent our models of care delivery using technology across whole systems, they will miss the chance to enable the world’s most efficient health system to be higher quality and even more efficient in the future

Firstly, they will need to start by looking at the real needs of the people in their populations. You can quibble about the numbers but something like 30 per cent of patients in hospital beds could be being cared for somewhere else, giving them more liberty and quality of life, and up to half of these people have dementia and need constant support. At least a third of hospital outpatients could be eliminated by either dispensing with unnecessary appointments altogether through better referral triage and follow-up management, through appropriate community based services or by moving to digital consultations. And at least a quarter, and perhaps a half, of GP appointments could be avoided through better access to non-medical services and online, telephone and video based consultations. None of these changes will close beds or reduce the need for GPs in the long run, but they will create the capacity to manage growing demand and provide access and more time for the people who really need to be admitted to hospital or sit with a GP who knows them and their history.

Secondly, the NHS will need to the time released for GPs and hospital specialists by these changes and use them to wrap care management around the people who need it most, to keep them out of hospital and living fulfilling lives. As the number of people over 100 increases from 15,000 to 150,000 over the next 20 years and more people live with multiple chronic conditions, the demands on nursing homes, palliative care, social care and families will increase dramatically. The NHS of the future needs to be able to provide support to people with health risks to stay healthy, whole life care to patients managing conditions to stay as well as possible and daily help to their carers trying to support loved ones.

Where will this huge shift to proactive, integrated community care come from? – primary care networks linking health, social care and the voluntary sector.

How will it be funded? – by utilising our hospital capacity more effectively and shifting the balance of investment to community based services so we don’t spend more on outpatient appointments than we do on the whole of primary care or commit the LTP growth money to more hospital beds.

In that way the NHS can proactively provide care management people throughout their lives – not offering a token year’s worth of support to a family living with dementia and hoping they will cope on their own after that.

And thirdly, to make this possible the NHS will have to think outside our traditional boxes in designing services. Patients don’t belong to institutions and nor does the funding associated with them. The NHS isn’t made up of state owned assets and people on the government payroll – ask the 50 per cent of patients who go to a self employed GP and the 20 per cent of patients who go to Boots to fill their NHS prescription whether they think these are NHS services – they are sure they are. The LTP delivery plans must embrace all of the assets available to a population including the voluntary sector, independent sector providers and high street chemists and grocers. They need to champion the adoption of digital primary care, home and care-home monitoring and video consultations, not as challenges to our clinical professionals, but as the next set of tools that will make dedicated professionals able to provide more care to more people, more of the time, whilst creating great jobs that people want to do.

If STPs and ICSs plans don’t face these existential challenges to the NHS and grasp exciting opportunities to reinvent our models of care delivery using technology across whole systems, they will miss the chance to enable the world’s most efficient health system to be higher quality and even more efficient in the future – they may as well focus on fighting the endless stream of alligators.