As one of a series of blogs for the King’s Fund project exploring the relationship between the NHS and the public and how it has changed, NHS England’s Medical Director for Acute Care looks at the conversation that needs to be had with today’s generation of “right now” patients:
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 from which the patient wouldn’t survive.
Equally as a population our expectations have changed. We are ‘right now’ consumers 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; frailty and dementia are common.
While the changing environment and expectations elicit different responses from different groups – 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. Our health and care needs grow as we live longer, accumulating ageing disorders that affect our independence as much as our wellness; 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 ‘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. 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.
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. With this type 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 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 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 last 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.
- A longer version of this blog has been published on the King’s Fund website.