We asked readers what behaviour and process changes do they believe are needed for the NHS to deliver consistent, financially sustainable 24/7 working. These are the most popular ideas regarding communications and managing public expectations

Just enough – just right

As a patient, first of all I want to know where to go if I have a problem. The current system is confusing. So fo me, clear communication is number 1.

I want health professionals to take a personal interest in me and make the effort to coordinate all the care I need in one visit. So clear communication, coordination and understanding between all the care professions and services is number 2.

And I want decent after care and rehabilitation services so I am not simply discharged to my little flat at 3am with no further contact with anyone.

The news stories are bad enough. So I do not want to hear people making excuses for poor services all the way along my journey.

Managing expectations

We need to manage the expectations of the public, patients and the workforce in relation to how the NHS can continue to deliver in the future.

The public and patients need to understand what they can reasonably expect in terms of their care (regardless of duration), treatment and interventions. They need to understand their own role and responsibility in supporting this (lifestyle, not missing appointments, following treatment instructions etc). They also should expect an appropriate explanation when their ‘wish list’ cannot be met and reasons should not be purely fiscal. The workforce also need to understand what is expected of them in relation to delivery treatment and care, and to be appropriately supported to do so (access to resources and training).

Delivery of care should be in partnership and respect the principles of the NHS constitution, but to do so we need to establish a culture of trust. It will take many years for the current environment of distrust and suspicion to be overturned, if indeed it can actually recover from where it is, not just from the public and patients, but also those working in and for the NHS. Healthcare is far too important to be left to the whim of inconsistent electable politicians.

Staff awareness, public awareness and the right incentive and behaviour change

We all know the importance of enabling the public to understand how to make best use of services. Choose well is too broad and confusing. We need something simpler. Then people need to be able to trust it.

This also means consistency of branding and service design (in as far as possible) so people know what to expect say from a minor injuries unit vs an A&E. For example, opening hours vary widely; some have Xray, some don’t etc. Some primary care settings (such as pharmacy) provide good services and privacy when necessary. Some really don’t. All this results in a default to A&E.

Understand people and their motivations – not just the reasons
There has been considerable work done to identify the behaviour profiles of people visiting A&E - it’s not all because they know what the other options are. These should be reviewed. We worked on this across nine PCTs in the South East and little of the learning was implemented then.

Stop patching and start solving
Frequent return visitors to A&E are those with chronic conditions. We have to stop patching them up and ensure they go back in to the system with the right information and support so they don’t end up being “frequent flyers”.

Staff awareness is low – tackle it
In previous studies we found staff awareness of alternative services, where they were, what they did and how they worked was low or they didn’t trust many of the alternatives either. This needs to be addressed as a priority. Show them new services and connect them, make sure they have easy access to information about local alternatives and ensure they respect and trust them too.

Educate all staff and empower them with information as ambassadors
Research also showed 40% of people contacted a friend who worked in health. Whether they were a secretary or a doctor they took their advice on whether to visit. People trust people they know.

Use A&E
While people are sitting staring at the walls we have a big opportunity to educate and engage them - we should use it.

Track the patient

We should be able to track every single patient at every stage on their journey through the system. This will help to identify problems and blockages along the pathway and will enable expecations of patients, relatives and care providers to be managed.

It would actually revolutionise our understanding of the patient journey and should improve productivity.

Invest in communicating how the ‘new” NHS works to the public

Moving services to providers that are best able to deliver 24/7 care requires a fundamental adaptation in how the public interact with services. However, the NHS has failed to communicate to the public why a proliferation of A&E services and general hospitals are putting people at risk and why change is required to deliver safer 24/7 care.

People whose families have suffered as a result of poor care on weekends are the same ones protesting to keep failing A&Es open when they put more families at risk. We need to re-invest in advertising and PR to change how the public come to and move around the NHS and understand how it needs to work to continue to be sustainable.

To get patients using the right services in the right way we need a complete re-education of the British public and this needs to be done urgently in an engaging way.

Sustained, consistent communication

Changing people’s understanding and expectations is a long-term process, so factors for a successful change in understanding and behaviours (eg for presenting at/access to GP practice/out-of-hours service/A&E/111) include:

  • well defined, clear, consistent explanation of roles and access arrangements (nationally and over time - no structural reorganisations);
  • same messages (explanations, illustrations, “maps”) at all locations and patient interfaces;
  • sustained communications using all appropriate “channels” (social media, PR, posters, booklets etc);
  • recognition that establishing new patterns of presentation and public understanding / expectations could take 5+ years.

Being open

Information about our health is one of the only things we don’t have either access to or hold the information ourselves. While people love and moan about the NHS in probably equal measure people have no idea of the value of the healthcare that they receive. By that I clearly mean what things cost. We should tell them. What is wrong with an ad in the middle of Coronation Streetor Emmerdale (I hasten to add I don’t watch either) with pop-ups about the cost of a hip operation or a tonsillectomy etc? Equally we need to help people help themselves - in which case the value would increase.

We talk about empowering patients - one of the first things surely is to be open and transparent about what things cost. I can’t imagine it would hurt to hold our own records and have the cost of the treatment alongside. Surely that is real empowerment?

Right place first time

Where should people go, or who should people contact, when something goes wrong – A&E, Minor Injuries Unit, GP surgery, pharmacist, phone 999 or 111 etc? The ordinary person in the street will either contact their GP if surgery is open or go straight to A&E. There needs to be clear communication as to where you should go to be treated.

Get it right first time

None of the sugggestions made to date address the problem of the first contact being the right contact. The service is set up by layers of triaging where no one has the ability to make an appropraite decision and everyone hands off and refuses to take responsibility. Half a day ( or longer) the right person is seen and the patient says: “Do I have to tell my story all over again?”

The management answer is it should be recorded sequentially at every step of the way so that the decision maker only has to read the dialogue to date to have a complete understanding of what is happenning and will be able to leap into action with the solution.

The reality is somewhat different. Lower levels of triagers rarely ask the right questions and are unable to put answers into context; patients are frequently misdirected to the wrong service as a result, which entails more waste.

It is knowledgeable people who should be doing the initial triage and the directing the patient to where they need to go or delegate activities which need to be performed coupled with a system to ensure that these are fed back in a timely person to the person in charge to make subsequent decisions (this is called continuity of care; one of the consequences of everything that has happenned since 2004 is fragmentary in nature).

So, investment (or incentivisation) of the appropriate people on the front line, who are empowered to tell the time wasters to go home without fear of complaints driven by poltical correctness. We tolerate such appalling behaviour and lack of discipline within the sytem that no one does the obvious in holding time wasters to account. And this again is partly because we have such a fragmented system.

As a GP trying to admit patients to hospital, I frequently have to wade through a marsh of triagers clerk, nurse, nurse specialist, junior doctor… all of whom have tactics to divert the patient to somewhere else with a variety of concoted excuses. It is quite clear they have not listened to, nor understood, the story given to them. This takes time, and of course engenders complaints from the patients in my waiting room about how long they are kept waiting.

As I GP I need to be able to admit a patient to the right unit, where they will be assessed by a team that has the apropriate skills and managed correctly. Having them admitted randomly through A+E delays the process of assessment and clogs up A+E. If they are admitted to the worong service they are frequently not assessed adequately or managed properly and frequently discharged early resulting in re admission…and not always to the right unit.

All this activity is purposeless and costs a lot of money aside from the fact that the patient does not gey what they need.

So think on you managers who love multi layered assessment systems which make sense from the point of view of stocking sheleves but are complete nonsense when dealing with clinial problems.

1. Lower expectations 2. Demand management 3. Harms caused by standard of care treatment

1. Lower expectations. Expectations have soared too high. Eg: expectations of the need for early detection; expectations of better outcomes with early detection; expectations of better outcomes than are achievable; expectations that all diseases can be cured; expectations that all symptoms need or should be treated; expectations that chemotherapy cures solid tumors; expectations that surgery always results in successful outcomes with long duration; expectations that an operation for treatment is always better than no treatment; expectations that screening for cancer results in more cures and better outcomes.

… add your own.

2. Demand management. Focus now is on supply side management of healthcare, eg. workforce, monies, facilities, timeliness. More attention is needed to managing demand for care, eg not all symptoms need treatment; screening for cancer creates risks; limited value of chemotherapy for stage III and IV solid tumors; end of life care interventions consume high resources for limited value AND they deny patients of a better quality of life at end of life.

…add your own.

3. Harm caused by standard of care treatments. We need to better understand that many of the treatments that are standard of care cause considerable harm. More and more we are learning these treatment do not render the value we thought, but they cause harm when none existed.

Computers and technology which is compatible

The right vision and strategy for technology across the NHS is essential – particularly when considering 24/7 working.

Technology is so all encompassing these days that its procurement cannot be left to the small specialist project teams that, history shows, usually make a poor job of this.

Crucially, technology and IT systems must be compatible and we must not end up in situations where technology becomes one of the major barriers to working seamlessly across health and social care.