Wilmington Healthcare – Written evidence (NHS0155)
1.1) It’s our view that the key levers available to be used to achieve a sustainable NHS are joint working, funding and innovation. These lever are reflected in our evidence, which is based on extensive knowledge of working with the NHS and healthcare more generally. We have also conducted exclusive research among over 2,000 healthcare professionals to support this submission.
Use of data
1.2) It’s our opinion that the NHS should unify primary, secondary and social care data sources with controlled access for care teams, working with a common diagnostic language. The NHS should also utilise unified longitudinal anonymised real world data as this will support evidence based therapy development and service refinement
Engaging the workforce and patients
1.3) There is an opportunity for the NHS to engage patients at multiple levels, increasingly through digital media, on issues including:
1.3.1) Their own wellbeing – tax unhealthy food and charge minimum price for alcohol
1.3.2) Service engagement – manage appropriate access e.g. when to see a pharmacist instead of a GP, or a GP instead of A&E
1.3.3) Treatment engagement - 30-50% of pharmaceuticals are not taken as directed.
Long term conditions and re-balancing of focus from secondary to primary care
1.4) A lot of treatments are expensive, but the cost of long term care and supporting people in the community has to be balanced. We have to keep people independent for longer. To achieve this, we need to optimise self-care through education and easy access to advice. There is a need to manage social care integration (aka Devo Manc) to prevent bed blocking which has been increasing as social services are overstretched
1.5) Constant organisational change within the NHS has the potential to diminish innovation and workforce morale. See the workforce’s views in our bespoke NHS workforce survey supporting this submission in section 3.
1.6) We need truly integrated services within STPs, so that providers are encouraged to build the most cost effective models of care not empires. Only then will rapid decommissioning occur effectively.
1.7) Early detection and intervention in disease through harnessing genetics will have the biggest improvement in quality of life and ROI for individuals and the wider tax funded system.
2.2) The perception is that the NHS is free at the point of delivery and a key ‘jewel in the crown’ of UK public services. A primary care co-payment (similar to NZ) is probably the most sensible solution, but politically would be hard to swallow.
2.3) Taxes on goods, such as cigarettes and alcohol, will encourage people to adopt healthier lifestyles. However, in order to reduce the burden on the NHS, we also need to change mindsets and motivate the public collectively through employers, schools and colleges.
2.4) To achieve this, there should be more incentives for employers to run workplace schemes that promote healthy lifestyles and reduce absenteeism and ‘presenteeism’.
2.5) The ‘One You’ programme, which is aimed at 40-50 year olds, is a good example. However, there needs to be a greater level of engagement with employers/HR departments and NHS England/Public Health England/DWP/treasury/DTI to join up thinking
Year | Management | Total Employees | Percentage |
2012 | 10,304 | 975,616 | 1.06% |
2013 | 10,322 | 963,515 | 1.07% |
2014 | 13,716 | 985,878 | 1.39% |
2015 | 13,354 | 1,002,549 | 1.33% |
2016 | 14,348 | 1,027,271 | 1.40% |
3.3) Employee numbers have steadily increased within NHS England over the past few years, with an increasing proportion of those people holding management roles. Given the level of management grade personnel within the NHS, it is surprising that the results of an exclusive survey that we conducted especially for this Committee in September 2016 reveal huge issues managing the organisation and maintaining morale. The survey involved more than 2,000 GPs, secondary care doctors and nurses in the UK.
The key findings of our research for this Committee were as follows:
3.4) The overwhelming majority of respondents (92%) said that low morale was a key issue affecting NHS staff retention. When asked why this was the case, seventy-two percent cited poor pay and rewards; while 64 percent said continued national changes in NHS workforce planning since 2000 and 63 percent said unsociable/long working hours.
3.5) The majority of respondents (85%) said that access to training and development was the key requirement of the future NHS workforce, closely followed by pay & rewards (84%) and flexible working and career progression (both 78%).
3.6) Asked what effect the UK’s departure from the EU would have on the continued supply of healthcare workers from overseas, a large proportion of respondents (48%) said it would be more difficult to recruit and retain staff. Just under half (45%) said it would make no difference and only seven percent said it would be easier to recruit and retain staff. When asked whether scrapping NHS bursaries, in favour of the same student loans system used by other students, would help the Government to achieve its ambition to train more nurses, midwives and allied health professionals for the NHS, the majority of respondents (88%) said no. Only three percent said yes and nine percent did not know.
3.7) A shortage of GPs has been identified as one of the current critical workforce constraints in England. When we asked respondents how the supply of GPs can be optimised for the NHS, better integration with other health service services/ integrated team working was the preferred option chosen by 72% of respondents. This was followed by the provision of financial incentives for doctors to practise in underserved areas (52%) and the promotion of innovations in health service delivery and telemedicine (49%).
3.8) The global strategy on human resources for health, adopted by the UK and all other WHO member states in May 2016, says that 'by 2030, all countries will have made progress towards halving their dependency on foreign-trained health professionals.' However, the recent trend in England, for nurses at least, is for growing rather than reducing dependency. When we asked our respondents what needs to happen within the NHS to reverse this trend, the majority of respondents (85%) cited ‘improve pay and rewards’. This was followed by create more career progression opportunities (60%) and improve unsociable/long working hours (55%).
4.1) Some parts of the NHS workforce are already widening out in terms of the services that they provide e.g. pharmacists, physiotherapists and occupational therapists are taking on some of the roles previously assumed by nurses. This is really important to help the NHS manage demand and to provide more care outside hospitals.
4.2) NHS Vanguards are leading the way in showing how support can be better provided within the community. For example, with many emergency departments in acute hospitals overwhelmed by patients (who often use them inappropriately for non-acute issues) and consequently struggling to meet waiting time targets, one GP super-practice has placed senior primary care clinicians in emergency departments to provide a triage system that redirects non-emergency patients to appropriate services – e.g. pharmacies or GPs.
4.3) This has cut down average waiting times to an hour and is minimising the number of breaches. Standard operating protocols are vital to cover all eventualities, so that everyone involved in the process understands what is expected and can refer patients to the appropriate responsible team member or care pathway. Children and elderly people are the biggest drivers of attendance at emergency departments; new pathways have meant they can be offered a community- or home-based care package rather than being admitted. In another organisation, clear structured pathways for stroke patients have led to significant reductions in length of stay.
Education in schools
4.4) We should not forget the importance of educating children and encouraging them to adopt healthy lifestyle behaviours and beliefs, both for their own wellbeing and also to remind/educate their parents and wider families. For example, Manchester is training children and young adults to be ‘dementia friendly’ and to take on voluntary roles at school to support people with dementia. This should foster better understanding of the problems faced by people with dementia and help youngsters grow up with understanding of these people's needs.
Educating stakeholders
4.5) We also need to educate all stakeholders in how the health and care system works – including patients. Currently workforce training is professionally focused on a single discipline. There needs to be a focus on how decisions on funding are made, and on ‘business’ and ‘leadership’ skills as part of the professional training for all HCPs, both whilst in training to qualify, and as continuing professional development once full qualified. Clinical Leadership is much talked about, but in short supply due to a lack of training.
Radical change
5.1) The NHS and Social Care Planning guidance and financial settlement window is currently two years and we recommend this needs to become a minimum of three years. It’s essential to put in place formal links between the budgets of health, social care, public health, housing, police, criminal justice system, and any other agencies that are interlinked (including Department of Work and Pensions) which enables the Treasury to recognise the benefits of an investment in one area (e.g. NHS, such as investing in a treatment). This can have a positive financial impact on another Government department, and enable a claw back/rebate from the other’s budget. It is essential in order to accelerate innovation and transformation of inter-linked public services.
Integration
5.2) Integration can mean different things to different people. For some people it means integrating budgets and organisations; for others it may involve smaller, but equally powerful changes, such as integrating IT systems. Work currently being undertaken by the East Midlands Radiology Consortium (EMRAD) Vanguard is an excellent example of the latter - www.emrad.org.
5.3) Not understanding what integration is and failing to get clinicians on board are significant barriers to doing things differently. Experience shows that small changes can make a big difference and making changes from the bottom up rather than the top down can be a more effective way of getting clinicians on board and making them part of making change happen. For example, a new best practice pathway for the use of non-oral treatments in Parkinson’s was recently devised by clinicians to make the referral process for these therapies more explicit. See: https://www.parkinsons.org.uk/nonoralpathway
5.4) Developing new patient pathways is key to improving healthcare. However, rather than looking at certain aspects of a condition, we need to manage patients across the whole pathway of that condition from diagnosis to death. We need to define what care is required for each patient, map their needs in line with NICE guidelines and provide an end to end service.
5.5) The Health Management Organisation (HMO) style management is particularly useful for the management of individual conditions and should be considered for the future with patient identification - pre symptom identification and early detection. Once identified, the condition should be managed proactively by an HMO. However, in addition to HMOs, the NHS also needs to consider - and potentially provide more specially trained staff - to tackle co-morbidity issues and the complex health needs of the nation’s ageing population.
5.6) True service integration has to be the long term objective. The 5YFV recognises this, and the fact that success will look different in different localities. Key factors are:
5.6.1) Leadership managing the vision and strategy, through inevitable political policy changes, both at a local and national level. At a local level this leadership currently occurs in individual organisations acute FTs/Community Trust/CCG/GP federation. The vision must move from the individual local organisation to the whole health economy. Empowered leadership teams that can make decisions that affect all the encompassed organisations are essential. This is not yet the case within STPs where some organisations have strong unit identity although they see the need to federate, there is parochial resistance.
Providing this level of leadership and motivating talented directors means encouraging training and development in NHS management skills. The private sector does not always understand the complexities of the NHS or have all the answers, but can bring cross fertilisation to help the move from an institutionalised thinking and strategy to a more flexible, lean approach.
5.6.2) Integrated data is essential for the operation of any accountable care model which can only really operate with patient care/cost and outcome tracking throughout the whole patient pathway.
Where this aggregated data is continuously testing current practice and innovation in terms of intervention whether pharmaceutical, clinical or social. It is imperative that his data is supplied in a useable form to support service redesign.
5.6.3) Public engagement with change is essential, we should utilise existing bodies such as the Academic Health Science Networks, some of whom have set up expert patient senates (such as in the East Midlands), to lead the public debate locally, then pool this across the 15 AHSN areas, to drive a full national public debate on the future of the Health and Care system. Democratic debate has to be seen to have been engaged in, as previous processes, such as the Lansley reform, and again the STP programme, are seen as top down and tokenistic at best in terms of bringing the public along in the change debate.
6.1) It is important to understand the local drivers of burden on health and social care services. Devo Manc has said alcohol, homelessness and drugs are their most pressing drivers on use. This scenario may be true for many other areas; hence in the future it may be increasingly important to provide this type of service earlier as opposed to treating ill health
6.2) NHS Vanguards are already aiming to take this approach. For example, in order to tackle the burden of alcohol on the healthcare system, one Vanguard has instituted a system for rapid assessment, identification and diversion/transfer of patients presenting to hospital who want to stop drinking and require detoxification, and who would otherwise have been admitted to an acute bed.
6.3) In this system, patients from acute hospitals across Greater Manchester have rapid access to medically managed detoxification at a specialist facility 24 hours a day. This has involved closer working with alcohol nurse specialists within acute hospitals, who provide gate keeping and referrals, a 5–7-day admission multi-disciplinary team, 24-hour hospital services, and medical support for specialist individual and group psychosocial interventions, with an emphasis on supporting engagement in aftercare and recovery communities.
6.4) Although the money invested has not yet been recouped, the programme is expected to result in savings to the local health economy of about £2 million over a 12-month period.
Public Engagement
6.5) NHiS, which is part of Wilmington Healthcare, has facilitated what it calls ‘Big Conversations’ with the public as part of patient and public engagement (PPE), asking them what they want from the health service and also enabling them to make the difficult choices on where limited funding should go. This was conducted in Worcestershire and York.
6.6) Many patients want more information and the ability to self-care rather than expensive support. Organisations like Age Concern and the MS Society have done a great deal to provide services in partnership with local authorities to meet identified need.
6.7) The Government could for example set up a Prime Minister’s Great Health and Care Challenge - a national debate in schools, colleges, universities, workplaces, pubs, community organisations, online and via written response, accessible in libraries, in multiple languages, where the Government makes these key questions available for comment, alongside an opportunity for those involved to see what others have already contributed. This will then provide the biggest democratic opportunity for the widest possible engagement before the next Government makes a decision about the future structure and funding of the successor system for health and care.
Technology
6.8) A recent report by NHiS Commissioning Excellence and helps the NHS to plan and commission patient services, shows that the NHS must invest in new technology if innovative models of care being trialled by its Vanguards are to be rolled out. The report, which is based on a recent advisory panel discussion involving eight Vanguards, found that technologies that enable risk stratification, early detection, appropriate intervention and remote monitoring are key.
6.9) Entitled ‘The Role of Vanguards in the Development of New NHS Commissioning Structures’, the report says risk stratification (the process of identifying the potential care requirements of patients by analysing their medical history, to improve the type and quality of care delivered) is important in primary care to help identify patients with complex needs and to determine onward specialist referral. For example, clinicians in one GP super-practice Vanguard have access to the entire electronic patient record, including primary and secondary care notes and results of imaging and laboratory tests, so they can make fully informed decisions about patients.
6.10) Turning to early intervention, which is crucial for many cancer patients, decision support software can be invaluable in helping to identify at-risk individuals early and thereby improve outcomes. A unique cancer Vanguard, which was involved in the discussions, plans to install decision support software in GP surgeries to help them identify the disease in patients who have symptoms that appear vague. This software is designed to raise awareness of symptoms, and to encourage clinicians to ‘think cancer’. Features can include symptom checkers, risk calculators and information to identify ‘low risk but not no risk’ patients.
6.11) Echoing the recent announcement from NHS England CEO Simon Stevens, that there would be an NHS payment system overhaul that will help technology companies gain fast-track approval, Vanguard representatives also agreed that the NHS services must use modern technologies to provide alternatives to traditional face-to-face consultations and remove barriers to communication between different services.
6.12) Many Vanguards already provide telephone triage in primary care and others are offering call-in consultant services that allow GPs to talk directly to consultants and obtain advice without having to send the patient to the hospital.
6.13) Simplifying the NHS is important as many areas run the same services with different standards and practices, and best practice is rarely shared. New strategies are needed to facilitate sharing and collaboration, and these could involve the use of new technologies for cross-organisational discussion and sharing best practice.
6.14) As healthcare and social care serve the same population, there is an appetite for the two to work together to commission and deliver services jointly for their patients and the local population. Technology and innovation could be key enablers and the creation of a new tariff offering an incentive to hospitals to make better use of these is likely to support wider spread adoption.
7.1) The connected person is generating more data than ever before and in the retail world, companies are capturing and integrating as much of this data as they can in order to understand each customer better with every interaction. In Wilmington Healthcare’s survey, and given the wealth of personal information held digitally, we asked HCPs if they believed patients’ data is being protected at the expense of their own health. More than a quarter of respondents (29%) thought this was true; while 35% didn’t know and 37% said ‘no’.
7.2) Advances have been enabled by the advent and integration of ‘big data’, such as information gathered about customers’ online browsing and social media activities, and information generated via smart devices in the home, which have dramatically enhanced insights from traditional sales, loyalty and retail data.
7.3) Indeed, it is thanks to the sophisticated use of big data that, for example, Tesco can send each one of its 15m Clubcard customers in the UK 12 vouchers that have been personally tailored to their needs. Interestingly even this data could be used to support healthy eating options providing gradual changes in diet through menu/recipe suggestions and offers.
7.4) The success of fitness apps such as My Fitness Pal and Fitbits, shows there is already a real appetite for people to share data on their physical activity and this could, in turn, be used to help patients take more control of their health. But applying the retail customer model to NHS users, many of whom may not have access to technologies such as Skype, is hugely challenging. However, it is well recognised that big data brings data overload. Key development is the utilisation of smart algorithms to ensure that clinicians are presented with relevant trends and changes only.
7.5) Initiatives such as the data sharing social enterprise ‘Patients Know Best’, which aims to solve a problem faced by healthcare organisations worldwide: how to get data moving between silos and eradicate incomplete and inaccurate data that can lead to fragmented, expensive and dangerous care – are showing how things can be done differently.
7.6) We should encourage patients to be genetically screened for serious life-limiting illnesses that are known to be preventable/curable with known interventions. Potentially by taking DNA samples at birth of all new-borns and databasing the population’s DNA profiles, we can identify risk factors in the population and opportunities every time a new treatment for a genetically mediated condition is licensed. We could then pro-actively plan the interventions for all people for whom such a treatment could be applicable, follow them up, and identify if they are a candidate for that treatment now or in the future. This would also require a national ID scheme linked to the NHS number or some other tracking system. This would ensure that potentially life limiting or quality of life affecting conditions were prevented or treated at very early stages, reducing healthcare burden and improving quality of life. Given the great expense up front of such systems, an insurance-based approach would probably be required, looking actuarially at short term cost/investment versus long term savings.
23 September 2016