The Long-Term Plan emphasises the move of care upstream and away from hospital settings, through prevention, better use of technology, alternatives to face-to-face appointments, and better integration of providers.
On the face of this, this sounds great for patients. Fewer patients getting ill, more care delivered closer to home, fewer unnecessary trips to the hospital where parking costs a fortune, and consultations and follow-ups happening, based on need, rather than an arbitrary follow-up schedule.
However, whilst this sounds great for patients, this is not a one-way street. For any of these initiatives, and indeed the wider plan to work, patients will need to give something too. Most tellingly that give is a change in both behaviours and expectations in order to take greater ownership of their role in supporting their own health and the wider health system.
What needs to change?
In particular, it will require the following changes from patients:
- A reduced reliance on doctors as the default expert and accepting the advice of other healthcare professionals.
- An increased recognition of the role individuals can take in their own care and the obligations they have to manage this, even when it may be inconvenient or feel like worse customer service.
- A willingness to engage with new technologies and the use of apps to manage personal data.
All of these fundamentally change the role of the individual in their health, however, these changes are not simply behavioural – ie doing things differently, they fundamentally require patients to think differently. This is hard in the NHS for two reasons:
- Healthcare is a market with asymmetric information, in which the individual with the health need does not know the true diagnosis until told so by an expert. This fosters deference towards the expert and an inherent sense of anxiety and impatience created by these uncertainties -especially when any given symptom may offer a terrible prognosis.
- Free care at the point of need creates some interesting psychological incentives. Managing need now becomes someone else’s problem (commissioners and providers) rather than the individual’s own problem. When I have a need it will be met, it is your problem how to provide it.
The consequence of this is a healthcare system in which individuals are incentivised to want care now, want that care to come from the most qualified professional (ie a doctor) and view the job of the system as immediately treating the symptoms as they arise.
How to change patient’s behaviour
So, given that none of these factors is changing (information is asymmetric and care is free at the point of use), how can we drive behavioural and attitudinal change into patients? There is no silver bullet that will address this for all patients, and the carrot of education and selling the benefits of behaving differently will not be sufficient. Patients will need some stick too. In particular, there are three sticks that the system can use:
- changing access to consultants,
- changing the entitlement to care in the Emergency Department, and
- nudge behaviours that drive the right outcomes.
Changing access to consultants
As highlighted above, the information asymmetry in healthcare means that patients often want a consultant and can get referred to them through primary care. The key change in how care is being delivered, in Integrated Care Systems and in new consultant-led, community-delivered service models, is that referrals are into a service rather than an individual. This means that patients get referred to a Multi-Disciplinary Team (MDT) in which the consultant may be the ultimate clinical decision-maker. But this decision is made as part of a multi-skilled team of experts, working together, with the patient interventions being led by other professionals often in the community or local settings. By breaking the referral connection from individual GPs to individual consultants and making them a referral to a service where the consultant is rationed, patients will adapt to having less access to the individuals they want to see but do not need to.
Changing entitlement to care in the Emergency Department
One of the other sure-fire ways an anxious patient can get guaranteed care today from a senior clinician is by turning up at an Emergency Department, knowing that the hospital will do everything it can to meet the target of seeing them in four hours. The proposed changes to the four-hour target have the potential to transform this entitlement. Moving to much more rapid and urgent targets for genuine emergencies (eg the one hour standard for patients with the most severe emergency needs such as heart attacks and strokes) has the potential to change the paradigm of ED. No longer is there a guaranteed clinician only four hours away. Indeed if the target really pushes the boundaries, they may consider having no backstop time at all.
There are numerous nudges that can be made, either implicitly or explicitly. Explicitly, patients need to be told (by a clinician they defer to) when they have gone to the wrong place. This requires clinicians to stand firm and inform patients when they are unnecessarily attending hospital. Implicitly, there are numerous interventions that can make significant nudges in behaviour. For example, making patients walk further to their appointments as part of a healthier lifestyle can play a big role in helping to reverse type II diabetes in pre-diabetic patients, and reduce the onset of the disease. As indicated by the National Diabetes Prevention Programme pre-diabetes is reversible even over a relatively short time frame, but this only happens if patients are forced to change.
Whilst the Long-Term Plan bodes well for patients in terms of the care they receive and the convenience and effectiveness of that care, it will also involve patients swallowing some tough pills as they see their behaviours and expectations change.