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Fixing the broken system

NHS performance has improved greatly over the past decade.

NHS performance has improved greatly over the past decade. Despite this, like healthcare systems in other countries, it is struggling to meet the needs of an ageing population and the increasing prevalence of long term conditions. Urgent action is needed to change how health and social care are delivered to make them fit for the future.

This is the bold claim of a new paper, Transforming Health and Care, from The King’s Fund, which makes the case for fundamentally reforming how care is provided to patients and users. Evidence summarised in the paper highlights weaknesses in all areas of the current system. For example, international surveys show the NHS often performs poorly compared with other countries on patient experience.

The Care Quality Commission has demonstrated shortcomings in the care of older people, including failures to maintain appropriate standards of dignity and nutrition. Too many older people are treated in hospitals and care homes because of the lack of suitable alternatives, including at the end of life. Our analysis highlights the need to strengthen prevention, provide more consistent standards of primary care, and concentrate some specialist services to deliver better outcomes.

Several well-known drivers of change will profoundly increase demand for care and accentuate the current system’s weaknesses. First, the ageing population - especially the growing number of people aged 85 and over - will place increasing demands on services that are already struggling to cope with the needs of this age group.

Second, the changing burden of disease, most notably the increased prevalence of long term conditions, will underline the challenges of providing high-quality care in the currenty fragmented system. This applies above all to people with more than one long term condition, as evidence shows that multiple morbidities are now the rule, rather than the exception.

Third, ever rising patient and public expectations mean that users will not tolerate care that is unresponsive to their needs. The retiring baby boomer generation, as well as younger people, will demand rapid access to services that treat them as individuals and matches experience in other sectors.

Incremental improvements to existing service models will not be sufficient to address these weaknesses. A much bolder response is required, involving fundamental changes to how health and social care are delivered.

Although these arguments have been advanced before, they have not been heeded and time is running out to make the changes that are urgently needed.

Models of care that were established to meet the needs of the post-war population should be superseded by new approaches with the following characteristics. Patients and service users should be part of the care team and involved in the co-design and co-production of care, and health and social care staff should work flexibly in teams, making full use of the range of skills available.

Care needs to be provided in the right place at the right time with less reliance on hospitals and care homes, and with much greater integration around the needs of patients and users.

In addition, information and communication technologies, such as smartphones, email and the internet, need to be harnessed as they have the ability to transform patients’ and users’ experiences.

Breakthroughs in medical technologies have the potential to bring benefits to patients where these are supported by evidence of cost-effectiveness, and data and information must be used to support patients and health professionals to deliver high-quality care every time.

The argument for fundamental change is based on long-standing weaknesses in current service models, but is reinforced by the prospect of a decade of austerity in public services. These services sit on a burning financial platform and this provides an opportunity to make overdue changes to how care is delivered.

If this opportunity is to be seized, national and local leaders must move beyond the distraction of the Health and Social Care Act, and the massive organisational changes precipitated by it, and focus on improving services. They should give priority to decommissioning outmoded models of care, supporting innovation, and opening up the market to new entrants where appropriate. Politicians must play their part by supporting risk taking to enable change to happen at the scale and pace now needed.

The King’s Fund’s new programme of work is designed to stimulate fresh thinking on the models of care required in the future and what needs to happen to put them in place. We hope HSJ readers will join us in debating these ideas and taking action to redesign services for the communities they serve.

Chris Ham is chief executive and Anna Dixon is director of policy at The King’s Fund.

Readers' comments (3)

  • I have just read the book online and it is well worth reading even if I disagreed with significant parts of it

    However it is more than a little surprising that there is no mention whatsoever in the article of workforce, management and leadership issues.

    The bookitself does briefly refer to these but surely these are central challenges if staff and their managers are not to sink under further poorly-led, top down reorganisations in which staff (rightly) feel they are pawns ?

    The Kings Fund has publiushed some good review of the research and literature highlighting how a bullying culture that pays token acknowledgement to staff engagement is counter productive for patients.

    Well treated staff with safe workloads, good support and training provide better care. I'm disappointed that the article does not reflect some of the good work the Kings Fuind has published elsewhere.

    The Kings Fund's own web site rightly states in prefacing this book that "another important ingredient is to harness the creativity and skills of staff working in health and social care."

    Trust Chief Executives and Boards reading your article would not know this view underpinned the book. Nor would they have necessarily read other Kings Fund publications stressing the importance of openness and transparency and its benefits for patient care.

    Maybe they will have to wait for Francis Report in November to forcefully remind them of this.

    Without staff engagement and comprehensive openness and transparency there is no realistic chance of the book's vision being effectively and safely delivered

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  • If you are on a burning financial platform the first thing to do is - put the fire out.
    Massive pressure is being applied to force efficiency savings with inevitable consequences on quality of care, staff relations and co-operation with positive reform.
    The NHS benefits from centralised pay bargaining. Better by far to use this to do the fire extinguishing. National negotiations with the suppliers should do the rest.
    Then when all around you are losing their heads the next thing to do is- avoid throwing petrol on the flames.
    That means not making things worse by squandering billions on unproven strategies designed to kill the NHS as we know it on the basis that something better might replace it.
    If you really want to improve primary care nationalise GP's, but putting them in charge of commissioning and encouraging them to withdraw funds from A&E services and hospitals will - lead to the inevitable results.
    Other pitfalls to avoid:
    1. Do not expect to benefit the UK by copying the US- Surely we all know that it is more expensive and delivers both overconsumption for many and underconsumption for those without access.
    2. Innovation cannot be assumed by demonstration in theory alone. Learn from the failures of the NHS to innovate- why has the NHS Pathology modernisation strategy been a failure?
    As i understand it most of the supposed benefits of reconfigurations and out of hospital care are unproven in the uk in practice. Only proceed in general as controlled experiments demonstrate success in practice.
    3. Avoid using nhs capital to fund risky ventures. if the private sector are unwilling to invest hundreds of millions into innovations the nhs should avoid doing so. That means the NHs shouldn't also underwrite or provide guarantees.
    4. Only invest NHS capital if there is a cast iron business case showing investment provides a return ,is affordable and deliverable.
    5. Do not believe everything that expensive management consultants or the Kings Fund say. Learn to think for yourselves.
    Follow that advice and this may avoid the premature death of the NHS.

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  • As usual used the word 'system' with no knowledge of 100 years of scientific, operational and philosophical development in systems.

    Transformation is the same as implementation, strategy, plan, pathway, project and process it is the medieval two dimensional paradigm that gave us religion, mechanics, industry and leadership. All one in the same.

    We've moved on learned systems and do useful work in real time. Drop the old polished turd!

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