How can we transform how care looks and feels like for patients?

NHS Commissioning Assembly logoThe opportunities listed below, describing how we can transform how care looks and feels for patients, have been co-designed and developed by NHS England’s clinical directors and local commissioners, who are members of the Quality Working Group and tasked with leading the development of the Quality agenda for the NHS Commissioning Assembly.

For the NHS to secure high quality care, centred around the individual and their needs, commissioners and providers will need to design and deliver models ensuring:

Alongside this, commissioners and providers need to ensure that care provision is equitable across the whole of society, and that positive mental well-being is recognised as being a central part of an individual’s good health and care

Care that supports you to keep healthy and spot any problems at an early stage

The NHS in England should support everyone to live as healthy a life as possible for as long as possible. As those who are less affluent people and those who are vulnerable tend to live more unhealthy lives than the average, it is vital that both prevention activity and diagnostic tests are equally accessible and effective for all.

Primary care services – GPs, pharmacists, dentists and opticians – are all at the front line of improving health outcomes and encouraging healthy behaviours and lifestyle choices. They are the gateway to NHS services for patients and can have a major impact in choices people make about their lifestyles and health.  Primary care professionals should be making every contact with their communities count, encouraging people to live healthier lives by stopping smoking, eating well and taking physical exercise.  GPs should be supporting people to be healthier in delivering Health Checks, and screening services.  They should also be proactively seeking to diagnose people’s conditions earlier, encouraging them to come for a consultation and using the cutting edge scientific and technological advances available in the NHS.

Care and treatment that is organised around you as a person

The NHS should ensure that care – regardless of where it is delivered – is coordinated around the individual’s needs whether that is for urgent care, scheduled treatment, or part of planned care.  Improved care planning and co-ordination between different providers can have a significant effect on the quality of life of older people with frailty and people with long term conditions – their experiences of care are more positive, they are better able to manage their conditions with independence, and reduce the need to be admitted to hospital for complications.  Health and social services need to join up to ensure that people are supported to live independently as far as possible.

General Practices have a vital role in coordinating care from across the system for individuals.  GPs are the person that people with long term conditions for example will see on a regular basis and who will be the most up to date with their needs.    General practice should be acting as a ‘medical home’ for people and giving them a named contact to support them and co-ordinate their care.  They should be seeking to prevent people from needing to go into hospital but also ensuring they are referred to specialist care when needed.

GPs should be able to benefit from same day specialist advice in management of patients with complex specialist needs. Similarly, General Practices and community teams should be engaged whilst patients are in hospital to provide advice and collaboration in a patient’s on-going management in the community, so that clear goals and care plans are established prior to discharge

Care that ensures you feel in control of managing your own condition(s)

The NHS should support individuals to take control of their own condition(s) and by being active participants in the design of their care. There are significant opportunities to design services that enable patients with their family, friends and professionals to decide how their care should be designed and delivered. Scientific advancements in digital health (including telehealth) services now allow patients

and carers to quickly and easily seek clinical advice within the comfort of their own home and at a time convenient to the patient. Personal health budgets allow patients to purchase the items and services that best help them meet their health and wellbeing goals.

A single patient care record, owned by the patient with the power to enable any care provider to access this information, presents a massive opportunity to improve the quality of care people receive. It remains, rightly, incomprehensible to patients that healthcare records are not available as they move through different parts of the NHS and social care. The development of accessible electronic patient records will provide a key driver to promote integration and coordination of care, empower patients to manage their own conditions, and ensure more effective care in hospital.

NHS services should enable a patient’s own network of friends and family to take a more active role in their care. The unlocking of this often hidden wealth of willing support within our communities has the potential to greatly enhance patient experiences, especially where services can be designed to encourage greater mutual and reciprocal care (‘people helping people’) within our communities

Care that gives you the best possible treatment in the most appropriate setting, and fully supports you to recover

The NHS should help people recover as quickly and as fully as possible from ill health or injury. The appropriate NHS response to an episode of illness or injury ranges from providing advice to support self-help in person or on the telephone; to on-scene, in- home care or local community facility treatment; to care in hospital. The creation of a comprehensive and coherent urgent and emergency care system which is capable of dealing with patients’ needs in a timely manner, in the most appropriate location, is central to ensuring that communities can access high quality and convenient care.

The focus of treatment for ill health and injury should be on timely and efficient treatment and support to help the patient recover as quickly as possible, whether this is in hospital or at home.  A patient’s rehabilitation should always be designed around their needs and provided in the most appropriate setting, which could be closer to home than a hospital.  This requires hospitals, community teams and social care to work in partnership and to review together how best they can organise their services around the needs of the patient.

Medicines play a crucial role in maintaining health, managing chronic conditions, and curing disease. In the NHS we invest approximately £13 billion on medicines each year. To date medicines have been managed in relative isolation in the various sectors in the NHS. This has resulted in fragmented services and relatively poor outcomes for patients, in relation to their medicines. Medicines optimisation (making sure people get the right medicines and use them as prescribed) offers a step change in the way that we support patients to take their medicines and will  focus on engaging with patients and the public around what services and support are needed to ensure they get optimal benefits form the medicines they take.

Care that ensures you will always be treated with compassion, dignity and respect

The NHS should ensure that all people have a positive experience of care.  It must promote care that is centred around the patient, so that individuals are supported to manage their own health and services, that put patients in control, are coordinated and achieve the outcomes people want.

Patients expect and deserve better standards of consumer care but also have a range of responsibilities as described in the NHS Constitution.  Patients have vital insights into their care and many are experts in managing their own conditions.  Genuine partnerships give patients an equal say with their health professionals.

We have an opportunity to create a ‘Patient Revolution’ – creating a consumer service culture that serves patients, and is committed to fulfilling the rights and commitments set out in the NHS Constitution: putting patients at the heart of everything the NHS does; delivering timely access to services; and providing treatment and care that is compassionate, dignified and respectful wherever it is provided.  There is strong evidence about what drives a positive patient experience  and good practice does exist in many NHS Trusts. New methods of measurement – such as the Friends and Family test – will now provide a much stronger focus on patient experience.

Care that ensures your safety is everyone’s paramount concern and that staff are open and honest with you if things do go wrong

It is the responsibility of everybody who works within the NHS to seek to minimise harm to patients and to ensure that patients are treated in an environment where their safety is the paramount concern. The NHS is full of caring, compassionate, talented people. No-one comes into work to care for people and wanting patients to be harmed. Despite this, most people in the NHS will be involved in, or witness, an incident that put patients at risk at some point. We need to recognise this and support our staff to deal with these incidents and to reduce the numbers that occur.

Everyone in the NHS, including patients and their families and carers, should feel able to actively identify and challenge services that could put patients’ safety at risk.  People delivering services should then feel empowered to be able to take steps to remove the risks they’ve identified and prevent the harm that might otherwise occur. This requires everyone to be looking out for risks, recognising them when they see them and then, crucially, talking about them, pointing them out, and doing something about them.  It also means professionals being open and honest with patients when things do go wrong

We are not starting from scratch. The past decade has seen a huge growth in the awareness of patient safety in the NHS, growth in the knowledge that we have about why things go wrong and how to prevent them going wrong, and growth in our experience of the approaches that can be effective in driving improvements in patient safety. This increase in awareness must continue, and be embedded across every part of our NHS.

Care that reflects your preferences and where the feedback you provide is acted upon

The NHS is a learning system and all organisations should be striving to continually improve the quality of care everyone receives. At its best, the NHS and the care it provides is cutting edge and constantly evolving – it learns from the past rather than stays in it; it learns from, and builds on new innovations and technologies that are being developed around the world.

At the heart of high quality care though is people, not institutions or processes. Continuous improvements in the quality of care is dependent on the capacity, capability and well-being of those that run and deliver care services.  Staff wellbeing must be of paramount concern to the leadership of NHS organisations.  Similarly, providers and commissioners must have the capacity and capability to act on patient feedback.  They should be analysing different sources of feedback, identifying key issues that need to be addressed and then putting in place improvement plans that deliver an improved experience.

The better use of already available data, in all parts of health and social care (i.e. Care.Data) along with the expansion of clinical audits and Patient Reported Outcomes Measures (PROMs) across the NHS can drive improvements in performance. This transparency enables commissioners and citizens to make informed choices about quality. The Equality Delivery System provides transparency as to outcomes and quality of care Across disadvantaged groups, and should be used to target improvement so that we can reduce health inequalities.

Our goal of tackling health inequalities and promoting equality

Reducing health inequalities and advancing equality are at the heart of the NHS, ensuring that NHS organisations exercise fairness, social justice and an equitable approach across their range of activities and that no community or group is left behind. The NHS Constitution sets out the key values that will guide the NHS. Central to these values is the need to improve lives and make sure that everyone counts.

Reducing health inequalities and promoting equality are essential in achieving this, as well as being underpinned by legislative requirements. These agendas bring into sharp focus how characteristics such as your age, ethnicity, where you live, how much you earn, your sexual orientation and whether or not you have a disability can affect access to, and experiences of, health care services, health outcomes and careers.

Health inequalities are the unjust differences in health, illness and life expectancy.  Sir Michael Marmot’s review of health inequalities in England illustrates the link between social deprivation and avoidable premature mortality.  As life expectancy has grown, so has the gap in life expectancy, with the richest men and women now living an average of 9 and 7 years respectively longer than the poorest.

Up to 2.5 million extra years of life could be enjoyed by those who die prematurely and an additional 2.8 million extra years of life could be free from limiting illness or disability if health inequalities were more effectively tackled.

Under current conditions, less than 25% of the population will enjoy disability-free life expectancy at future retirement age (68 years), and the financial costs to the economy and NHS are substantial at approximately £65bn and £5.5bn annually respectively.

The NHS cannot address all the inequalities in health, which are also significantly impacted by wider social determinants – factors including housing, income, educational attainment and access to green space. This is important to understand when setting challenging but realistic targets within a context where it is estimated that only 15-20% of inequalities in mortality rates can be directly influenced by health interventions that prevent or reduce risk.

It is clear that many of the NHS’ health promotion and prevention services have done well with some people, but less well with others.  The  NHS must do better for those who are disadvantaged.

The NHS’s increasing understanding of the social determinants of health as part of ‘health capability’ – the conditions that affect health and an individual’s ability to make health choices – is exposing the need to fundamentally rethink future healthcare planning.  We will need to ensure that resources, commissioning and services respond to levels of health capability so that the NHS can live up to its aspiration of equitable outcomes.

Our goal to put mental health on a par with physical health

The NHS is here to provide high quality care for people with mental health problems, as well as physical health problems. Nearly everybody in England will know someone who has experienced mental health issues – one in four of us will experience a mental health problem in our lifetime and 700,000 people in England suffer from dementia.

Now we are seeing historic social stigmas around illnesses such as depression or anxiety disorders, relative to physical health, being broken down. Advancements in the both medical and psychological support over the past twenty years – ranging from new talking therapies to more effective medication – should mean that anybody with a mental health issue has the same confidence about their care as those who are treated for a broken leg.

Mental health problems also interact closely with physical health and can trigger or severely exacerbate other conditions. There are huge opportunities – both in terms of improved outcomes and saved costs – for a health service that assesses and treats people’s health problems holistically, rather than providing separate services for physical and mental disorders.

People needing support for both physical and mental health issues should be able to access appropriate care services early, proactively and without stigma. We know this has the potential to reduce some physical health inequalities experienced by people with severe and enduring mental ill health including premature mortality