The state health service (NHS) in Britain has been a huge success fulfilling the vision of its founders; it has freed the poor from the fear of illness, provided assured careers for its staff, coped with demographic change, an information revolution, the rise of new and professional management and technological innovation. It remains free at the point of use, funded from general taxation, free from market imperatives and part of the fabric of the welfare state.
In 2018 it will have been in existence 70 years, most people in Britain have no pre-NHS experience. It is taken for granted, “We contribute according to our means and receive according to our needs” regardless of age, race, gender or social class.
In 1959 I entered Medical School and retired in 2015. I have worked in the NHS as a hospital doctor, a principal in general practice, a Director of Public Health, an Academic in Social Medicine & Public Health and for some nine years in Africa and Papua New Guinea as a clinician and academic; I have worked for locum agencies and done private practice. I have been a Manager and taught management skills. There has been involvement with NICE, the BMA, the RCGP, the IBS and the Faculty of Public Health. I believe that the NHS, with some reforms and a new model has an even more important role in the future.
The present model of the NHS is outdated, inefficient and often inappropriate- what follows is a personal vision for the future of the service over the next 25 years. This model is sustainable, evidence based, effective, caring and would deliver real health gain for the people of Britain within a reasonable envelope of time and money
50-70% of doctors’ workload should be performed by clinical practitioners/ medical assistants/ nurse practitioners. We need 50% fewer doctors, differently trained.
Clinicians e.g. Nurse practitioners can be trained in three years or less; they are less costly to train and employ, they are more likely to remain attached to a particular work site over time; their clinical care is more conservative and less costly than doctors (use of investigations, prescriptions).Their career aspirations are different, they are often content to remain at this professional grade for a working lifetime, competent and experienced..
Many medical procedures can be performed by non-doctors without impairing the outcome achieved. A clinical practitioner can be taught a complex procedure which is perfected over time e.g. Caesarean section, hernia repair, cataract removal, administration of a general anaesthetic. A good deal of health care is routine and repetitive working on well-designed algorithms. The medical skill is in determining the most appropriate management and care e.g.an operation, an investigation, and in determining a treatment plan on the basis of a presumed if tentative diagnosis.
The doctor-in primary or secondary care does not need to do the procedure him/her self-provided there is the expertise available. The doctor is managing, teaching and supervising a team of10+ others in the ward, the theatre or in primary care, most importantly the doctor is looking critically at workload, effectiveness and outcome, the doctor is auditing the work of the unit. (A platoon in the British Army is 25-30 soldiers; they bond together and work effectively and loyally)
A Salaried Service;
Primary Care in the 21st.century needs to be streamlined into the main health service.
The private contractor status of the GP should end and be replaced by a salaried service with training, refreshers, promotions and a definite career structure. Four or five primary care doctors (equivalent in status and paygrade to Consultants in secondary care) would co-ordinate the work of some 100 people in the care of a patient population of 25-50,000
The polyclinic model ( energy efficient, purpose built and ease of access to its population means demolition, compulsory purchase and capital investment) is best, with on-site physiotherapy, psychology, minor surgery, social work, laboratory, radiology and day beds There must be a single linked medical record, accessible, used by and updated by all the caring agencies and the patient/person. There should be visiting/linked consultation with secondary care e.g. OPD, teleconsultation, domiciliary visits.
A clinic serving 25-50,000 people would be fully staffed from 7.00 to 23.00 with consultations-booked and urgent access through the day, telephone/skype consultations, e-mail and provision of house visits as necessary, mainly performed by clinical practitioners working with a doctor lead.
Staff would work 8 hour shifts which might be staggered two hourly i.e. 7am-9am-11am-1pm-3 pm and the numbers/mix of staff determined by patient flow and workload. The service would operate daily (Sunday to Sunday) and staff would work five, eight hour shifts (40 hours) with 4 of those hours reserved for catch up ,paperwork, audit)
Out of Hours (OOH) from 11pm to 7am the clinic would be open with a small team including a doctor. OOH emergencies would be directed there with ability to perform telephone triage, advice, short term admission for observation and domiciliary visits.
Overtime and additional money for unsocial hours should be abolished. All “on-call” work should be acknowledged and paid at 50%.
All clinical staff would be contracted to be available for all shifts shared equally and a maximum 40 hour week. The overall employment package should take account of the demanding hours (salary, subsidised food, rest facilities-showers, beds, car parking working environment, crèche, and holidays) and the need to nurture the workforce, develop its skills and reward long service financially (study leave, retraining ,seniority awards at 10/15/25 years of service)
.Part-time contracts would take account of shifts offered e.g. a P/Timer available for all shifts but working a 40 hour week would have 50%of the Full/T salary. A P/T unavailable for unsocial hours working 20 hours per week would receive 10-20% less.
These agencies should be taken over and run by the state as part of the health care service;
Presently these companies are competing with one another in the market place, their main concern is to produce profits and reward shareholders. It is proposed that with a single, state agency there would be an agreed tariff of payments appropriate to the skill- type and grade of the employee, the timing and duration of employment and the administrative costs of the agency.
As it would not be a service run for profit, the fees charged would be less and the formal registration/assessment of applicants ensures standardisation and quality of locum work. Arguably with better terms and conditions for health care employees, gaps needing urgent cover and long term vacancies would be less.
An improved contract and conditions would mean that fewer staff would feel impelled to take on extra shifts for financial reasons or disillusion with working in the service.
No fault compensation is the best way of controlling and reducing the increasing sums paid out and the cost of defence premiums for workers while eliminating expensive and prolonged litigation
. The costs to the state health system are a significant part of the whole budget and yet this money is, in one sense, largely wasted.
The accusation, investigation, “trial” can take many months; it can damage the litigator and have grave consequences for the professionals involved-stress, burnout, suicide and inevitable decline in the quality of their clinical work.
A rapid investigation to determine the problem and its remedy should run in parallel with agreed financial payments available once the harm done has been assessed and its impact upon the litigator determined by a neutral arbiter.
If clinical/system error is found this can then be examined, reported and corrected without jeopardy to the clinician.
Professional bodies-GMC, GNC would still be involved and take further action if appropriate.
The Private Sector:
The role and purpose of the Private sector needs re-examination
The private sector and its use is part of the freedom of individuals-as patients or as clinicians. The private sector can set standards for quality and patient care. In this sense it can show the state service what may be accomplished, albeit, with often more resources-staff, buildings, facilities.
However there can be conflicts of interest when health workers work across both sectors. The private sector tends to “cream off” cold, standard, surgical procedures; it provides little data on its work and profit; it does not contribute to the training of staff. Its first priority is for profit and to the shareholder and it can withdraw its service at any time with no consequence to itself
These areas need to be clarified and an agreed code of conduct determined with necessary sanction if failure to comply. A strong, thriving private sector should be limited to 10%of the whole health care of the UK in any year.
A long term and flexible strategy,
The future direction of Information Technology (IT) in health is particularly difficult to predict as its applications multiply, as computing power expands and as human beings learn to use and become safe and comfortable with the digital revolution. Here change will come quickly altering the way people use the service, the response of clinicians, clinical investigation and robotic devices in human care. At the same time the system must have the ability to provide access, confidentiality and safety.
The clinical record needs to available to all clinicians involved with a person. It need to be updated in real time and patient friendly so that the patient can participate in the record and ensure its accuracy
It is suggested that to ensure continued and adequate investment, maintenance and cyber security that 0.25% of the health budget be ring fenced for this purpose.
Need, demand, fairness and transparency
A new model needs to be considered
The most difficult elements of health care to determine are need and outcome, presently the system is often managed on a mixture of demand, new technology, demographics, expediency, pragmatism and politics. There are recurrent funding crises, staff feeling ignored, ill-prepared and with little say while the media often concentrate on failures with a blame culture fuelled by high expectation and expensive, time consuming litigation.
Management decisions and the decision pathways are not transparent. They are difficult to challenge and are rarely revisited.
It is proposed that for every main specialty- i.e.
(Surgery) General Surgery, Cardiac Surgery, Orthopaedics, Obstetrics, ENT, Ophthalmology etc.
(Medicine) Sexually transmitted disease, Nephrology, Neurology, Dermatology etc.
(Mental Health) Psychiatric illness, Learning Disability etc.
(Support services) Radiology, Pathology, Microbiology, Haematology etc.
(Public health) Communicable disease control, Health Promotion etc.
That a group of key individuals (maximum 20 people) be proposed-
Consultants in specialty, Nurses, GP’s, Patient representatives, Managers of the service, Epidemiologists and Health Economists (the epidemiological and health economic methods and models would be standardised across all the groups).
The group would be chaired by an independent manager and would try to determine the real population normative needs in the next 3-5 years taking account of new technologies, evidence from clinical trials, incidence, prevalence, prevention and outcome. The aim is to recommend a “bread and butter” service to meet the needs of a UK population in the first part of the 21st.century.The key factors are ethical awareness, environmental impact and clinical/cost efficiency, effectiveness and measurable benefit e.g. DALY’s, QALY’s, morbidity and mortality
Their recommendations, once agreed could be translated into the requirements for skilled staff, equipment and buildings with the essential logistics and infrastructure to provide. The consensus which emerged would be the best estimate of population need for a population of 500,000 with concessions for age, gender, race and deprivation and the anticipated health gain. The process of discussion and reasoning would be transparent and could be challenged
All the specialties would report and a global sum established. Government would then decide how much of the GDP was available for health care and thus the percentage which could be realistically funded-possibly 60-70% at best. It would mean that every specialty was funded at 70%-cardiac surgery or learning disability. If more or less funding was available then the 70% might be raised to 75% or lowered to 65%.
Funding then in place the group would monitor the effects of this pattern of delivery by auditing agreed outcomes or proxies and to see how their estimates were appropriate.
The group would review their service every three years to reflect changing patterns of disease, socio-demographic change, and new technologies. Over several cycles the whole process would become better informed and better understanding of need and outcome emerge.
The local management responsible for the health care of 500,000people would commission on the basis of these recommendation and the provider networks would have a clear indication of longer term service development. Arguably there should be some flexibility, a leeway of 1-2% in “commissioning/providing” to take account of local factors.
Health Care in the UK needs to be rethought; it needs to be evidence based and affordable. The decisions around health need to be transparent and the reasoning open to scrutiny and challenge. The tools to achieve this are now available.
At present there is uncertainty about the real funding needs and optimal skill mix to best meet the health needs of the UK population.
Up to date information, the changing nature of clinical interaction and accurate, timely health records require a funded, safe system provided through a national, agreed and funded Information strategy.
Every member of staff needs to be developed, nurtured, and reskilled over his/her career; they must be routinely involved in contributing ideas and in planning the service
Shift work (8-12 hours) and a standard 40 hour week for all staff is recommended
The number of doctors should be reduced and new or existing Clinical grades expanded to replicate much of the work doctors do. E.g. Nurse practitioner, Physician’s Assistant.
Primary Care should become a salaried service, the independent contractor status is no longer appropriate. The service would be led by doctors and serve population hubs of 25,000 people based upon a polyclinic model
Locum agencies should be an integral part of the health service
No fault compensation would be less costly, less distressing and more effective in providing early compensation, avoiding a blame culture and learning from errors
The patient voice, interaction and perspective is essential in planning and auditing health care
A different methodology based on the epidemiology of common conditions and their management is suggested which tries to link need with outcome and uses health economics to determine costs The present tools, while not perfect are adequate and over several cycles would be improved.
. This model should be debated, refined and then trialled.
Peter Sims Saturday, 05 August 2017