We need to talk: could different be better?

As one of a series of blogs for the Kings Fund project exploring the relationship between the NHS and the public and how it has changed, NHS Englands Medical Director for Acute Care looks at the conversation that needs to be had with todays 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.

Keith Willett

Professor Keith Willett is the Director for Acute Care to NHS England and is the Professor of Orthopaedic Trauma Surgery at the University of Oxford. An NHS consultant surgeon for 24 years he has extensive experience of trauma care, driving service transformation and healthcare management.  He has taught surgery and leadership extensively across the NHS and internationally.

In 2003 he founded the Kadoorie Centre for Critical Care Research and Education focusing on the treatment of critically ill and injured patients. This year IMPS, a children’s safety charity he launched, celebrated 20 years and over 250,000 children trained in risk awareness, first aid and life support.

He was the co-founder of the unique 24-hour consultant-resident Oxford Trauma Service at the John Radcliffe Hospital in Oxford in 1994. Building on that model, in 2009 he was appointed the first National Clinical Director for Trauma Care to the Department of Health and was charged with developing and implementing government policy across the NHS to radically improve the care of older people with fragility hip fractures and to establish Regional Trauma Networks and Major Trauma Centres. By 2012 both re-organisations and care pathways were successfully in place and are now credited with marked improvement in patient care and survival.

In his current role, he has the national medical oversight of acute NHS services ranging from pre-hospital and ambulance services, emergency departments, urgent surgery, acute medicine, children’s and maternity, armed forces, and health and justice services and national major incidents. He is now leading the transformation of the urgent and emergency care services across the NHS in England.

He was awarded a Commander of the Order of the British Empire (CBE) in the New Years Honour’s List in 2016 for services to the NHS.  On receiving this honour he said “I have been exceptionally privileged to build a career as part of the collective commitment of so many dedicated individuals and friends who are our NHS”.

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  1. Alan Bradshaw says:

    My wife just had her second heart attack in 12 years, even though the 999 operator said that ambulance crews are busy
    as it’s 3:00am Saturday and said to call her if situation got worse the ambulance still arrived in
    8 minutes, the 2 paramedics were nothing
    but professional and caring
    They called for any assistance near by, who arrived almost instantly
    The 3rd person travelled
    in the ambulance leaving
    her car at my house, constantly treating my wife
    despite being thrown all over the ambulance going
    over speed bumps
    They even hung around at
    the hospital to see my wife
    I have nothing but praise
    for our Paramedics, Doctors and Nurses and their professional attitude
    and caring for their patient
    My wife is in a good place
    and hopefully back home
    in two or 3 days.

  2. Susan Kerrison says:

    Two matters I would like to question;
    1) Is it time to reintroduce small convalescent hospitals, which could be staffed in the main by retired over 50’s looking for vocational work?
    thereby, releasing main hospital beds quicker for more urgent cases.
    2) Why does it take hours, (in excess of a couple of hrs on occasions), to discharge a patient, which means hospital beds are not vacated quickly enough to accommodate new patients. Can they not be directed to a discharge waiting room or similar, instead of still occupying the bed?

    • NHS England says:

      Hi Susan,

      Thank you for you comment.

      In answer to your questions:

      1) Is it time to reintroduce small convalescent hospitals, which could be staffed in the main by retired over 50’s looking for vocational work? thereby, releasing main hospital beds quicker for more urgent cases.

      Medicine has changed dramatically from the days of convalescent hospitals, keyhole surgery, modern interventions and immediate rehabilitation means we don’t have that same need. Many elderly patients however can benefit from a period of rehabilitation but their needs are quite different; they often have very limited mobility, dementia and require help with basic personal care, toileting, supported walking etc. These are mostly 24 hour activities and require nursing, therapist or healthcare training for both patient and carer safety so we often we undertake this step down care in community hospitals or nursing homes. There is a really important role for volunteers in adding help and Age UK, RVS and other organisations are well set up to support such people particularly when they first arrive home.

      2) Why does it take hours, (in excess of a couple of hrs on occasions), to discharge a patient, which means hospital beds are not vacated quickly enough to accommodate new patients. Can they not be directed to a discharge waiting room or similar, instead of still occupying the bed?

      The vast majority of patients now only stay in hospital between 1 and 3 days and efficient discharging of patients is really important we agree. From the moment of the decision to discharge by the doctor several things need to be put in place such as prescribing and obtaining medicines to take home from the pharmacy, booking a follow-up clinic appointment you can attend, producing a communication to your GP in case there is a problem and for your record, sometimes arranging transport or an ambulance to take you home, and/or agreeing with the care home to accept you. So ‘discharge lounges’ are quite common in hospitals but clearly all the personal knowledge about you has to be handed over to the lounge staff so it’s not without adding more work.

      Kind Regards
      NHS England