Built to cure, forced to care
The NHS is a 20th century solution to 21st century problems.
Lord Darzi’s 100-page plus report into the state of the NHS, which came out on Thursday, makes for dire reading.
Life expectancy in the UK is falling.
More people are now dissatisfied with their GP surgery than satisfied: the same story with A&E.
You can now expect to spend about double as much time waiting in a walk-in centre or urgent treatment centre than you would have in 2011.
Your odds of finding a dentist accepting registrations are worse than your odds of getting heads in a coin flip.
About half a million adults and children have spent more than a year waiting for a mental health service.
The number of complaints about the NHS has doubled in the last decade.
The NHS is a symbol of national pride, but lately it is not something to be proud of.
Unless we diagnose the problem and treat it pretty rapidly, things are only going to get worse. And if the NHS starts to lose public love, we open the door to US-style alternatives which would deepen social inequality.
What’s the diagnosis?
The NHS is very good at curing: you can go with an ailment like a broken leg, and come out in a cast. That makes sense, it was built in an industrial age where an injury or illness could either be cured, or it couldn’t (in which case, you’d die).
Things are different today - a quarter of the population now have a long-term, chronic condition. These conditions can’t be cured, but they’re not deadly either. They need ongoing care and support to deliver a quality of life. The NHS is not equipped to deliver long-term care.
It’s set-up like most organisations were in the early 20th century - as the social designer Hilary Cottam writes: “the NHS functions like a factory, managing the distribution of drugs and patients. The latter move through the system like any other industrial unit: they are lined up, placed in beds, and moved along the conveyor belt.” (That’s from her book, Radical Help, a great book that I’ve just finished and which, along with the Darzi report, inspired this post).
The demand on the NHS is growing. We’re an ageing population and we’re getting sicker. More people need more support more often. It’s primarily driven by three things: chronic pain, mental illness, and diabetes. One in four people are living with chronic pain; 8 million people are now taking antidepressants; 4.4 million people have diabetes. All of those numbers are rising.
And all of those are conditions which the NHS is poorly equipped to handle. You can’t put someone with poor mental health in a surgery bed and treat them. You can’t give someone with chronic pain a two-week run of medicine and send them on their way. You need to drive lifestyle changes, which takes lots of time and lots of contact. And all of these ailments would be better off if they were prevented in the first place, and prevention is something the NHS dedicates almost no time to.
The people who need long-term care and support end up churned through a system that is designed to cure; and that doesn’t help them. But it also means those that do need a cure will find there is no capacity to offer it. One in three beds in NHS hospitals is taken up by someone who is fit for discharge, but has nowhere to go to get the right ongoing care: it’s a symptom of this chronic shovelling of money into cure, and almost none into care.
What’s the treatment?
There isn’t an easy one. The whole system is blighted by a horrendously confusing funding and management model. The solution is not just more and more money or more and more doctors.
Take GPs. The Royal College of General Practitioners suggests the problem is that there are not enough GPs. They are calling on the government to commit to training more GPs, in fact a growth of 10% year-on-year. By that projection, in 20 years we’ll need more GPs than we have soldiers and police officers combined.
Clearly, that’s not sustainable.
If I had to make one reform to the NHS, I’d look at reducing the role of GPs, and introducing self-referrals.
If my eyesight is getting blurry or I need a check-up, I contact my nearest optician, book an appointment, and go - usually within a matter of days.
For some reason, if I have a problem with any other part of my body, I have to:
Register with a local GP
Phone the GP at 8am to check for appointments, repeat daily until one becomes available
Attend the GP appointment in person
A referral letter is sent to the specialist, and I am hopefully contacted to book an appointment (if not, repeat steps 1-3)
Book an appointment with the specialist
See the specialist
Why not skip to step 5 and self-refer?
The NHS website explains the reason:
“Your GP also generally understands your health history and treatments better than anyone else.”
But I’m not convinced that’s true. My GP wouldn’t know me from Adam. The only distinction between my GP and a specialist is that the GP has access to my clinical records. But why not broaden that access to specialists? It made sense when medical history was confined to a binder, but now those records are digitised it makes almost none.
In July, almost half a million referrals were made to mental health specialists. If the average GP appointment is 10 minutes long, that means GPs spent 75,000 hours seeing patients they then referred to a mental health specialist. Why don’t we trust these patients to refer themselves, instead of GPs spending 75,000 hours a month writing referrals for them? (And by the way, that’s about £6.5 million of public money).
Of course, opening the gate to self-referrals would carry risk. Specialists could become inundated with cases they shouldn’t be dealing with. Ear Nose and Throat doctors might have queues of patients with stuffy noses or allergies. However, GPs are likely to be just as trigger-happy with referrals as their patients: the number of clinical negligence lawsuits is rising year-on-year. For GPs, failing to refer a case could lead to an expensive trip to court.
There would also no doubt be patients going to the wrong specialist: people booking an appointment to see a neurologist when they need a psychiatrist. This would be costly and burdensome for practitioners and patients alike, and makes a strong argument for GPs as the wayfinders.
But there is a way to resolve both of these issues: tech-enabled triage. 111, for example, is a fantastic service: more than half of calls are answered in under a minute. It’s so effective because it uses a combination of technology and specialists to triage: the call-handler works through a survey to ensure the patient is given the right advice and sent to the right service. 111 is working and proving triage calls can be handled effectively and safely even by non-medical practitioners (50% of calls are taken by a handler who is not a doctor or nurse): let’s make a triage call the gatekeeper and wayfinder to a specialist service, not a GP.
There will, of course, always be a place for GPs. In particular, for those patients with comorbidities. By the age of 74, 40% of people will have two or more long-term health conditions. A patient with multiple ailments and chronic conditions could be seeing 3, 4 or 5 specialists: none of whom will communicate with each other. The GP should be acting as the quarterback, ensuring the specialists are working together to give that patient the optimum quality of life: such as ensuring she has one blood test, rather than one for each specialist; or by limiting the number of medications she needs to take; or by identifying where there’s an underlying cause to her medical conditions.
But GPs aren’t doing an especially good job of that today. They are registering as many patients as they possibly can, because that’s how funding is allocated, and letting A&E pick up the slack from those patients they can’t see. Patients like the one I describe above are left being batted around specialists who rarely get sight of what the other is doing.
GPs need to see far fewer people, and that means scrapping their role as a gatekeeper to services, so they can focus on their role as the primary community caregiver.
But self-referrals would barely touch the sides of the institutional problems that the NHS faces. It’d be a shot of painkillers to a system that needs open-heart surgery.
You need to build a new healthcare system that works to prevent illness as well as treat it, and one that is prepared to care, not just cure. There should be a lot more technology and data. And patients should be empowered to own their care, not as something that is done to them but something they are a part of: particularly when a huge number of conditions now require lifestyle changes to treat, not drugs and surgeries.
These are sweeping, institutional changes - and ones that no government to date has dared to make. Could this one be any different?