Who is responsible for transforming the NHS?

Cel­e­bra­tion of a coro­n­avirus all-clear will still be echo­ing around the nation as the NHS turns to face its next chal­lenge.

Per­fect storm after per­fect storm is rolling over the hori­zon: a moun­tain­ous back­log in surgery and can­cer treat­ments, an age­ing pop­u­la­tion and an obe­si­ty epi­dem­ic, recog­nised as a con­trib­u­to­ry fac­tor to the UK’s COVID death toll, seem­ing­ly tat­tooed onto the nation­al iden­ti­ty.

How then to nav­i­gate yet more Trea­sury jeop­ardy? How to recal­i­brate the com­plex and arcane NHS struc­tures pop­u­lat­ed by more than 1.1 mil­lion staff, 1,250 hos­pi­tals and 7,454 GP prac­tices that deal with a mil­lion patients every 36 hours?

These ques­tions are absorb­ing the ener­gy and inge­nu­ity of politi­cians, NHS exec­u­tives, social care experts and the pri­vate health­care sec­tor.

The bright lights are tech­no­log­i­cal advances, super­charged out of neces­si­ty through the pan­dem­ic, that are con­nect­ing patients to treat­ments through com­put­ers and smart­phones. The dig­i­tal rev­o­lu­tion is also reshap­ing the poten­tial for more care to switch from expen­sive clin­ic and hos­pi­tal set­tings to the home.

Chris Hop­son, chief exec­u­tive of NHS Providers, the mem­ber­ship organ­i­sa­tion for the NHS hos­pi­tal, men­tal health, com­mu­ni­ty and ambu­lance ser­vices, believes the nation is fac­ing sig­nif­i­cant threats from an age­ing pop­u­la­tion liv­ing longer with mul­ti­ple co-mor­bidi­ties and the result­ing extra pres­sure on NHS finances, as well as acute staff short­ages.

“Demand for NHS ser­vices is ris­ing by around 4 per cent a year, but we’ve just been through a decade of the longest and deep­est finan­cial squeeze in NHS his­to­ry, when fund­ing went up by around 1.5 per cent annu­al­ly,” he says.

“We will also have to live with COVID for some years to come, but the under­ly­ing, long-term chal­lenge is that you might argue we have a ‘Nation­al Ill­ness Ser­vice’ geared around treat­ing peo­ple when we know we will have to get much bet­ter at look­ing after our­selves and sup­port cit­i­zens to do that.”

Smartphones managing health

The Office for Nation­al Sta­tis­tics fore­casts that by 2030 one in five peo­ple in the UK will be aged 65 or over, while the num­ber of peo­ple aged 85 and over will dou­ble from 1.6 mil­lion in 2016 to 3.2 mil­lion in 2041. Yet 84 per cent of the pop­u­la­tion has a smart­phone and access to a bliz­zard of diag­nos­tic, treat­ment advice and sup­port apps.

“There’s a real oppor­tu­ni­ty here,” says Hop­son. “The vast major­i­ty of the nation has smart­phones that enable them to track their weight and get access to advice around fit­ness which gives us scope to, if we can con­fig­ure our health ser­vices, use smart­phones to help peo­ple man­age their health.”

He believes a new class of health­care pro­fes­sion­als could also be devel­oped to sup­port and school the pub­lic towards health­i­er lifestyles and less reliance on care. But all new ini­tia­tives and struc­tures are freight­ed with the bur­den of social depri­va­tion, employ­ment pop­u­la­tion den­si­ties, the envi­ron­ment and health inequal­i­ties.

“It is clear that to keep pace with care demands, the NHS is going to have to do things dif­fer­ent­ly,” says Hop­son. “The NHS will go as fast as it can. For exam­ple, it moved to online GP con­sul­ta­tions dur­ing the pan­dem­ic at real speed, which gives con­fi­dence that it can change pace and direc­tion.

“But we will have to think quite care­ful­ly how we go for­ward and how we deal with the things that anchor us to the cur­rent mod­el, such as the way build­ings are con­fig­ured and jobs are struc­tured.”

Health sec­re­tary Matt Han­cock laid out a white paper of reforms in Feb­ru­ary designed to strip away bureau­cra­cy, mod­ernise sys­tems and boost local inte­gra­tion of ser­vices so they can with­stand long-term demands. 

Power of transformation

NHS Trans­for­ma­tion Unit, which focus­es on ser­vice redesign to aid recov­ery from the pan­dem­ic and improve care long-term, is devis­ing fresh approach­es to tack­le issues such as surgery wait­ing lists and con­nect­ing the pub­lic more effi­cient­ly and rapid­ly to diag­no­sis, treat­ment and care.

It is mak­ing the best of NHS resources and sees gains in cre­at­ing hubs for spe­cialisms and the use of dig­i­tal tech­nolo­gies to sup­port care in vir­tu­al wards away from hos­pi­tals.

“There also needs to be a big­ger agen­da in terms of health pre­ven­tion and how we do health man­age­ment to reduce demand,” says Janet Budd, the unit’s chief exec­u­tive. “There is a lot of col­lab­o­ra­tion through the NHS and an absolute will to recov­er and then build to cope with future demands.”

Andrew Cor­bett-Nolan, chief exec­u­tive of the Good Gov­er­nance Insti­tute, a con­sul­tan­cy that advis­es NHS exec­u­tives, health author­i­ties and com­mer­cial clients, believes restruc­tur­ing pro­grammes need to have the mechan­ics to func­tion in con­cert or reach the entire pop­u­la­tion.

“The trick to pull off will be to cre­ate a rev­o­lu­tion where some parts remain exact­ly the same,” he says. “By that, I mean a com­mit­ment to the core prin­ci­ples of being free at the point of deliv­ery. But there also needs to be a very grown-up con­ver­sa­tion with the gen­er­al pub­lic about play­ing their part, how they look after them­selves, how they use health ser­vices and how they plan for old age. We also need more research to help under­stand what influ­ences per­son­al choic­es and behav­iour; social research is as impor­tant as clin­i­cal research.”

Rear­rang­ing health­care fur­ni­ture in terms of respon­si­bil­i­ties and demar­ca­tions seems a nation­al pas­time, but it can under­val­ue the impor­tance of human behav­iour.

“Dis­ease pre­ven­tion has always been the Cin­derel­la of our health­care sys­tem, attract­ing less than a tenth of the fund­ing devot­ed to treat­ment,” says Dr Robert West, pro­fes­sor of health psy­chol­o­gy at Uni­ver­si­ty Col­lege London’s Health Behav­iour Research Cen­tre. “Although it is under­stand­able in that we can’t ignore it when peo­ple have heart attacks or devel­op can­cer, yet we can all too eas­i­ly ignore it when peo­ple are build­ing up health prob­lems in the future.

“It is also irra­tional because dis­ease pre­ven­tion more than pays for itself. It has the ben­e­fit of help­ing peo­ple live longer and health­i­er lives, and reduc­ing demands on our treat­ment ser­vices.”

Public behavioural change

Chang­ing behav­iour takes time and is unlike­ly to suc­ceed with­in the time­frame of the gov­ern­ment while the food, alco­hol and tobac­co indus­tries have a pow­er­ful lob­by­ing force and deep pock­ets.

“In the UK, most peo­ple already have a high lev­el of moti­va­tion to improve their health. What we need to do is to har­ness that moti­va­tion by enhanc­ing their capa­bil­i­ty and oppor­tu­ni­ty,” says West. “This has the added ben­e­fit of feed­ing back into moti­va­tion; we are more like­ly to want to do things if we think we will suc­ceed.”

Deal­ing with the pan­dem­ic is a Her­culean task; cop­ing with what comes next will need plan­ning, col­lab­o­ra­tion, inno­va­tion and invest­ment across health and social care. The Depart­ment of Health and Social Care points to a £52-bil­lion invest­ment in the NHS this year on top of a £9.4‑billion cap­i­tal pro­gramme to build and upgrade hos­pi­tals to frame the government’s com­mit­ment.

“I’m always very opti­mistic when it comes to the NHS because of its amaz­ing staff, who are the rock­et fuel of progress, the good­will of the pub­lic, com­bined with advances in research, life sci­ence and biotech­nol­o­gy exper­tise in the UK,” NHS Providers’ Hop­son con­cludes. “We have the capac­i­ty to change health­care to take advan­tage of these trends.”