If we want better healthcare, we need to make big changes
PART ONE
I recently attended an online Residents’ Forum where people from North West London discussed our draft health and care strategy. What struck me most was how many residents wanted to understand the detail of what will be different within what timescale. This has been a constant theme of discussions with our communities – and our own integrated care partnership – over the last twelve months. I found myself nodding in agreement with many of the comments residents made.
There can be a tendency in the NHS to fall back on what one attendee described as a ‘motherhood and apple pie’ plan – our strategies set out aspirations few people could disagree with, but don’t always spell out why and how things need to change in a tangible way.
In our board and committee meetings, we are pushing for detailed plans, milestones and timescales from all of our programmes of work. While we recognise the challenges in getting there, there is no reason why we can’t be much clearer with local people what changes they can expect to see and when.
I want to start this conversation by setting out more clearly the sort of healthcare system we need our strategy to deliver. I will also be asking senior leaders across North West London to contribute more detail under these headings.
First, I think we all recognise that health services in NW London – and across the country – are not where we want them to be.
There is not enough emphasis on prevention and we have growing numbers of people in poor health leading to a range of conditions, from diabetes, to heart disease to cancer. We do not do enough to support people with long term conditions to manage their health; we do not always diagnose serious conditions like cancer or heart disease early enough; and we have considerable variations in healthcare outcomes, access and experience between different populations.
Too many people end up in hospital when they could have been cared for at home or in another community setting and often spend much longer in hospital than they needed to - with the result that they lose independence. Patients face lengthy waits and delays for treatment; people with mental health problems struggle to access the skilled staff they need; some of our services are delivered from unsuitable buildings.
And while we are making good progress on bringing new treatments and innovations into day to day care they are not as widely adopted as they could be. Similarly, we are enabling digital healthcare in some settings, but we are not doing enough to really capitalise on the benefits new technologies can bring.
All of these are known and recurring challenges; the pandemic may have exacerbated some of them, but it is not their root cause – we have been talking about them for at least ten years.
Doing more of the same won’t work. We need to be planning for a different kind of healthcare system – and that is the conversation we want to have with our residents. If we are to truly improve outcomes, we need root and branch reform of all areas, with a determined focus on improving outcomes and tackling inequalities.
We can expect big changes in three broad areas; how we care for residents in local communities; much greater use of technology; and more efficient hospital care. I will say more about each of these areas in part two of this blog.
PART TWO
In part one of this blog, I set out the case for significant changes in all parts of the healthcare system – and the need to be honest about them. In part two , I am setting out a more detailed vision for change in three broad areas.
Integrated care in local communities
In our communities, GPs are increasingly working with professionals from primary care, mental health, social care, community services, community pharmacy and nursing to meet the needs of their population. These multi-disciplinary teams support GPs, who continue to take overall responsibility for their population’s overall healthcare. Bringing together a range of skills and capabilities means that GPs can focus on ensuring continuity of care for their residents and patients and making sure people can access appropriate care more quickly. This inevitably means larger GP surgeries supporting more people and continuity of care resting with teams of health and care workers led by GPs.
For residents, it should mean not having to keep telling the same story to different people and quicker referral to the right professional to meet their needs. It should also mean a far clearer leadership team with one person/group of people in charge, and responsible for ensuring access to high quality, integrated local services. That team will also increasingly take responsibility for continually reviewing the local populations’ health needs, ensuring a greater focus on prevention and tailoring services accordingly. Some of these needs may be met through enhanced care at home; some will be met in local practices or community settings; some of course will be met through virtual appointments.
By working in this way, we know we can deliver far more and we can provide far greater continuity of care. We can schedule staff to ensure the most appropriate staff member is caring for people – one small example is one of our senior GPs spending time removing a patient’s stitches. This is not a good use of their time and expertise but happened because they work in a single practice with a limited number of practice nurses. If they worked as part of a much bigger team, there would always be a nurse available, always be a pharmacist available and so on. Opening times could be much longer, for example 8am-8pm six or seven days a week. And a wider range of diagnostic services would be available locally.
In many parts of NW London we have some fantastic high quality GP premises but they are typically only used for patient care for around 40 hours a week. Bringing more staff together in these facilities provides both a wider range of skills and capabilities, and allows us to open for longer hours and to provide services out of far better quality buildings.
We are fortunate in London that consolidating services in this way does not mean long distances to receive care. We are planning on the vast majority of the population still being within a kilometre of a GP practice facility (increasingly called hubs)
More and better use of technology
In 2023, we no longer need to deliver all care in person. The pandemic saw a significant rise in online and telephone appointments, and in people accessing information from the internet, sometimes meaning they didn’t need any appointment at all.
There are many examples of how technology can fundamentally change the delivery of health care. Skin lesions can be diagnosed automatically, blood pressure measurements can be automatically updated with alerts set if measurements are abnormal; advice on keeping well can be shared without having to see a healthcare professional. Where appropriate, we want to expand these offers, while ensuring residents who do not have digital access or capability are not left behind. Virtual appointments mean clinicians can see more people more quickly, freeing up time for face to face appointments with those who need them or who are unable to access virtual appointments.
We can also use technology to support far more efficient services, resulting in easier access to care. Historically all GP practices have had their own receptionist and their own phone line. We can now use modern telephony technology to root calls to an overflow service, meaning people don’t have to hold on interminably or not get through. We could expand this further to provide advice to people on a 24/7 basis, to be able to book appointments on the phone 24/7 and so on.
Similarly, we are in the process of automating our booking systems for imaging tests – x rays, MRIs, CT scans, ultrasounds. This will allow anyone referred for a test across NW London to book into a centre anywhere in our patch at a time which suits them. We can also use technology to tailor appointment durations – at the moment, everyone gets the same amount of time – whether you are a fit and healthy 20 year old able to jump onto a couch for a MRI on your knee, or a rather more frail 90 year old having a MRI of your creaking hip. Combining these two approaches, along with reducing no-shows for appointments, will increase our capacity for imaging tests by around 10% or more. That’s a significant increase in appointments.
Over 68% of the UK population has registered with the dedicated NHS app, with the government expected to reach its target of 75% by 2024. certificate. The app can now do much more and will soon do even more. It can now be used to ask questions of GPs and their colleagues, to send in photos of skin lesions, to book appointments (in some cases), to get repeat prescriptions and to see blood test results. Again, these are significant savings in time for pressured clinical staff but are only scratching the surface of what the app could do. Over time the app could be used to hold all health information so that you don’t have to keep repeating your symptoms and past medical history, to automatically review your medication and spot where drugs need to be reviewed, to advise on contraception and fertility, to monitor movement in a frail older person and alert carers if something looks wrong and so on.
Contrast these examples with our too frequent traditional outpatient booking systems –done by mail at a considerable cost to the NHS and deeply inflexible. The patient can’t easily change the time and nor can the consultant should their schedule change. We waste (literally) millions of pounds in stamps and staff time having to change appointments, not to mention the inconvenience to patients and the wasted appointments when the letter didn’t get through or got lost. And when the outpatient appointment finally happens, considerable time is spent asking about symptoms, past medical history and so on – when it could have been there ready to go. All when 90% of people are able to use email. Other services in our lives offer us a choice of how we communicate with them – phone, email or post. Other services capture information in advance and save it for future use. Why don’t we do the same?
More effective and efficient hospital care
Too much care is currently delivered in a hospital setting. We spend proportionately more on hospitals than similar countries internationally, and in NW London we spend more than the best performing systems in the NHS. Within NW London, we have significant differences in how we manage patients – the best GP practices/systems look after people far better at home or in the community and use far less hospital care. Part of the reason is that our primary, community and social care services are not as consistently well organised as they could be. Another part is we are trapped in a vicious circle of not investing more in community care, so people go to hospital and we spend more on hospital services. Repeated studies show that, once we manage our long waiting lists for inpatient surgery, we need at least 20% fewer hospital beds.
At the same time, we currently have around 270,000 people in NW London waiting for care. Of these, around 250,000 are waiting for an outpatient appointment. But we know that our outpatient services are not fit for purpose. Around 2/3 of the 500,000 outpatient appointments we carry out each year are follow up appointments where, again, repeated studies have shown that a number could be replaced with an email or phone call to check up on how the patient is doing and provide advice or hand care back to a GP or primary care team.
Of the new appointments, many could be carried out without long trips to hospital, either by a specialist providing advice to a GP and patient together, or by a phone/video consultation or, increasingly, through a digital consultation. Dermatology and ophthalmology are a very good examples. Modern cameras can take an excellent picture and allow a specialist to provide a quick opinion without the need to see a patient. If we could adopt these well-established processes, we could rapidly reduce our waiting lists.
The other 20,000 people are waiting for a surgical intervention. And again, we have the scope to do far better. We sadly have far too many incidents of fully staffed theatres lying empty for some of the time because the patient wasn’t fully prepped or because a bed wasn’t available (because of far too many people awaiting discharge from hospital) or because the process of getting the patient to theatre on time isn’t working as well as it could. This is crazy and our hospitals are currently focusing considerable time and expertise on trying to improve. We are already one of the better performing parts of the NHS in this regard – but we know we can do far better.
There is lots more we can talk about – from better use of the considerable amounts of data that exist in the NHS, ways to significantly reduce length of stay in our acute hospitals and community & mental health inpatient units, to how we need to support our workforce better with more flexible and responsive working arrangements to how we can free up considerable money from better use of our estates.
There are big questions about how we achieve parity of esteem between physical and mental healthcare, how we can most effectively work with our communities and how we achieve our key objective of tackling health inequalities. In this series of articles, other system leaders in North West London will cover some of these areas and more.
We have been talking about these shifts in the way care is delivered for many years. If we do not adapt our model to take account of changing needs, new technology and integrated ways of working, we will continue to face the challenges in access, quality of care and outcomes that our strategy is designed to address. We need to be bolder in our conversations about the scale of change required to truly deliver the healthcare our residents need.