The future of the NHS - patient care, sustainable services, preventing illness - depends not on competition, but collaboration and cooperation, argues Peter Carter.
As anyone who keeps up to date with the latest healthcare news knows, there is an exceptionally difficult financial climate in the NHS. Our healthcare service has been set a monumental task, namely to save billions over the next three years, £20 billion in England alone. What we know is that implementing drastic and deep cuts whilst maintaining a good level of care is often an impossible task. Something will have to give, it always does.
What some people may not know is that there are 70 hospital trusts in England that have so far failed to achieve mandatory levels of quality care or financial competency required to become Foundation Trusts. How are these Trusts coping with the “Nicholson Challenge”; that £20 billion saving target?
Without the intelligent reconfiguration of services, many of our NHS organisations will either fail to make the savings required, or adopt the short-sighted and predictable cuts to staffing numbers that always hit patients hardest.
There are, of course, aspects of more radical redesign to the healthcare services in this country that need to be properly and sensitively addressed, not least the number and effectiveness of acute settings in our metropolitan areas. These can often be painful and controversial decisions, but the patients of tomorrow will judge us on our resolution and conviction today.
Reconfiguration, real reconfiguration, needs to be bold: it needs to be meaningful and focused on improving care. We need to resist the inevitable political interference that comes when the services of a hospital or local health provider are re-evaluated – patients depend on it. We know that the NHS can often deliver better, bespoke, and more efficient care away from the hospital ward.
The last government tripled investment in the NHS. Sadly, some of that money was spent in the wrong places. Community care has been treated like the Oliver Twist of healthcare provision: always asking for more and often being ignored. If we really want to ensure our NHS can meet these incredible financial challenges, whilst also delivering appropriate care for patients, we need to make it fit for the future. In short, we need to throw out the rule book.
With demand growing on services, an ageing population, rising expectations, and a dramatic increase in those living with long term conditions, now is the time to do things differently. By 2050, the number of people living with long term conditions is expected to increase by an astonishing 250 per cent. Treating these people in hospital is just not an option. The NHS needs to do many things: dramatically increase investment in localised and innovative practice, harness the power of specialist services, and learn to cooperate rather than compete.
Some services in the NHS currently provide wildly differing patient outcomes depending on where in the country those services are offered. If the NHS is to save money whilst maintaining good standards of care it needs to be radical; it needs to think intelligently and empower innovative practice at a local level.
We need to reconfigure services so that a patient’s contact with the NHS isn’t necessarily in an acute setting when their medical problem is serious, but can be in their own home when the situation is manageable. At the Royal College of Nurses (RCN), we have plenty of examples of when care provided outside of an acute setting is revolutionised by the staff providing it. That’s not to diminish the creativity of staff working on hospital wards, more to highlight that evidence proves locally led services deliver improved results, and often for less money.
Take pressure ulcers, an unnecessary and painful condition for patients, which currently cost the NHS £2.4 billion a year. They are preventable and, for patients being cared for at home or in local community settings, hospital admissions are often entirely avoidable.
One of our members, care home nurse Carole Gill, saw that an “early warning system” involving Healthcare Assistants (HCAs) could lead to better prevention. She set about training and educating HCAs to recognise early signs and symptoms in her care home. Within a year of her implementing the early warning system, incidences of pressure ulcers were reduced by 25 per cent, and fewer patients needed to visit hospital or use “traditional” NHS services.
The point here is a simple one: when a patient is admitted to hospital, the moment has been lost, the cost incurred, and the patient inconvenienced. If we can utilise community care to prevent instead of treat, then the patient experience improves and the cost to the taxpayer is reduced.
What worries me most is the fact that across the country, and indeed even in neighbouring hospital trusts, innovative ways of working like Carole’s are not being shared and best practice models are not being adopted. There is huge disparity in levels of care and patient outcomes. The intelligent reconfiguration of care relies on best practices being shared and healthcare staff being empowered.
Yet when we are shown how effective they can be, the infrastructure of the NHS somehow prevents these models of care from being shared and implemented across the country. Frankly, it’s absurd. It needs to change for everyone’s benefit.
People do not lower their expectations when they use the NHS: they expect as good a service and experience as they receive in any other consumer setting. The onus is on us as healthcare providers to ensure that, when reconfiguring services, the ultimate aim is to achieve the best patient outcomes; the highest quality care. Empowering innovative practice by investing in community care is one way of meeting this requirement; another is the use of specialised services.
Take, for example, the treatment of stroke patients. For nearly a decade, the Royal College of Physicians has undertaken regular audits of stroke services across the county. It has consistently found that specialist stroke centres, those which work to achieve the highest patient outcomes, which innovate, which share best practice, are radically reducing the mortality rate of stroke victims. The North East London stroke survey (2008) showed that stroke patients who were treated in acute settings (which did not adopt innovative best practice models of care) were more than twice as likely to die from having a stroke.
A RCN report, which was conducted into rheumatology specialist nurses, found that by providing telephone support and managing outpatient appointments they freed up hundreds of doctors’ appointments. This increase in efficiency, across the board, would be equal to saving the NHS around £100 million a year.
A report by the British Heart Foundation (2008) revealed that close monitoring of patient symptoms by a nurse specialist reduced readmission rates by 35 per cent, saving Primary Care Trusts (PCTs) £1,826 per patient. In 2009, at a Northamptonshire PCT, a multiple sclerosis specialist nurse saved £65,773 by treating 34 patients in their homes rather than in hospital. Statistics like these are everywhere, proving beyond any doubt that bespoke and specialist services, with nursing at their centre, are the future of care delivery.
The continuity of care delivered by a specialist nurse enhances a patient’s ability to cope, which in turn leads to reduced readmission to hospital and fewer medical complications. They are also able to give unparalleled insight to the most beneficial reconfiguration of services. Why then, when there is such clear evidence of their effectiveness, is the NHS not clamouring to invest more in specialist nursing? Unsurprisingly, the reason is financial; those desperate to make quick savings habitually target services that are seen as more expensive – ignoring their longer term cost benefits.
The RCN knows that innovative and specialist working improves both practice and patient experience; that it’s the key to redesigning services – it’s also one of the most attractive aspects of the Quality, Innovation, Productivity and Prevention (QIPP) programme.
Long term conditions are one of the main work streams of QIPP, and with good reason. Dementia costs the UK economy £23 billion per year, cancer costs £12 billion, and heart disease costs £8 billion. It is right that the NHS prioritises QIPP as innovation is the bedrock of making these targets a reality, yet we must also begin to see evidence of where the QIPP-promised financial reinvestments are being made. Treating patients with a long term condition is a huge challenge for the NHS, and how we deliver care to these patients must change if the NHS is to be financially sustainable. If the NHS continues to care for patients with long term conditions in hospital, it will have failed. It needs to harness local solutions, innovative practice and, yes, specialist nursing.
In the meantime, there are very specific and manageable ways to make the NHS work better with fewer pounds in its purse. NHS Trusts must work in a much more financially collaborative way – they must share surpluses and they must share the burden of debt. They must also listen to their staff and empower them to work innovatively, particularly in our communities and in local health settings.
Trusts must share ideas, best practices, and they must reconfigure services which have been seen and proved to work better elsewhere, like specialised centres. The future of the NHS isn’t going to be in enabling competition, it will be encouraging cooperation and collaboration.
Patients’ lives depend upon us getting this right, and the future of the NHS depends on it also.
This essay appears in The next ten years published by Reform.