There is no shortage of ‘design’ in the NHS. Yet, despite this, the system struggles to keep pace with demand. So why does such a ‘designed’ system struggle, and what are the changes needed for it to become more stable?
Let’s play out how the system is designed to work
You fall ill. Your first port of call is primary care, via a GP surgery, pharmacy, NHS Choices, a specialised institution like an optician, or 111 if you’re unsure. Alternatively, you may seek a more immediate appointment, in an urgent treatment centre (UTC), or a GP offering extended hours appointments. Or, if you are very ill or badly injured, you might call 999 and go to A&E.
Your GP or pharmacist might recommend treatment and send you home immediately or admit you to a hospital for further diagnostics or treatment.
For unscheduled care, you may be treated directly in the hospital at the UTC or A&E and either be discharged or admitted into one of the hospital wards as an ‘inpatient’ (a patient who stays in the hospital). The target for being either admitted or discharged from an A&E is four hours – although new targets are being piloted to focus effort on those patients that need it most.
For planned care, you typically have an appointment for a consultation and potentially treatment scheduled, and then become either an outpatient (going home immediately) or an inpatient. Planned care has a target of 18 weeks between referral and treatment of a condition.
You have, therefore, ended up somewhere in the healthcare system and, when better, will be discharged. You may require community care such as clinics, or social care like supported living or care homes. The idea is that you are then able to stay in your community with access to the right kind of support.
The system follows a logical model with gate-keepers and points of escalation or exit, but it is failing to manage the demand. Let’s go through the system again and explore why.
Why is the system failing to meet demand?
1. A person should not fall ill in the first place. However, so much NHS treatment and time is spent on avoidable illness. This includes the 200-a-day deaths that are related to smoking and 9% of NHS funds spent on treating Type II Diabetes.
2. Even when ill, a patient should only be in a hospital for genuine emergencies or treatment. But the shortage of capacity that primary care providers face often encourages patients to seek faster alternatives.
3. This is because patients may have a sense of urgency that may not reflect their real need. Health is an asymmetric market – the patient doesn’t know what is wrong and they wish to find out immediately, in A&E rather than via primary care.
4. When in A&E, the four-hour target, which hospitals are rigorously held to, means that an over-run A&E is incentivised to admit a patient at 3:59 rather than breach the target regardless of the urgency of your need, and the need of others.
5. Hospitals are often unable to discharge medically well patients because there is no community home or social care package in place to support their living outside of a hospital. These patients become delayed transfers of care (DTOCs), and their health deteriorates. Ten days of immobilisation in a hospital bed can lead to ten years of muscle ageing in the over-75s.
6. When individuals see a specialist in a hospital, the appointment may have been made with little consultation with the patient, which can lead to late cancellations and the possibility of wasted appointments.
7. Patients scheduled for surgery can also face difficulties, as on-the-day demand for emergency surgery and intensive care space will trump elective procedures. An ill patient needing non-urgent surgery but who may require recovery in an intensive care bed could get bumped for a major trauma patient. During the delay, the patient deteriorates more and when they are treated, they are sicker and stay longer.
8. Once patients are discharged and being treated in the community, they are given several follow-up appointments. These appointments are often routine check-ups that do not need to be face-to-face, and use up far more time and resources than needed.
9. When managing their conditions out of hospital, individuals are not always fully equipped to manage and monitor their conditions, resulting in poor self-management and an increased likelihood of future admissions to hospital.
The need for change
The NHS, the government, and the patient community all know that something needs to change. But there is never enough money to fund large-scale change in the NHS whilst maintaining a high standard of care. When money is available, it is thrown at mitigating and lessening the effects of the flaws in the system rather than addressing the system itself: focusing on the ‘catch’ as opposed to the ‘throw’.
The recent NHS Long-Term plan tackles many of these issues head-on, including:
- emphasising greater prevention,
- increasing focus on technology to support self-management and remote treatment, without the need for face to face appointments,
- rethinking the targets in the system and the incentives they create,
- encouraging the join-up of contracts and incentives through Integrated Care Systems,
- supporting greater separation of ‘hot’ (emergency and specialised) services from ‘cold’ (less complex, planned) services, and
- promoting legal and structural changes in the commissioning and regulatory framework to encourage a greater system-wide focus on outcomes.
These changes are all welcome and can address many of the challenges described above. However, we believe that they will only succeed if they are coupled with a fundamental change in mindset from providers, regulators and commissioners.
Our Health team will be exploring what the Long-Term Plan and the associated change in mindset may look like from several perspectives:
- What does it mean for patients and how they view and consume healthcare?
- What does it mean for provider organisations?
- What does it mean for leadership and cultures?