The familiar patterns of healthcare are breaking down. As long-term conditions grow in importance – in the UK they now affect 15 million patients and account for 70 per cent of spending – fleeting visits to doctors once or twice a year no longer suffice.
“What we’re seeing is not only an increase in the numbers of people with long-term conditions, but numbers of people with multiple conditions,” says Dr Sarah Wollaston, who chairs the House of Commons Health Select Committee. “There needs to be a much greater sense of urgency in how we’re going to deal with that.”
Her committee last year demanded big changes in the way services are delivered, conclusions that are echoed in the new blueprint for the NHS in England, The Five-Year Forward View. This calls for a radical upgrade in prevention and public health, greater control by patients of their own care, and the breaking down of barriers between GPs and hospitals and between health and social care.
The report has been accepted by the Coalition Government and shares a lot of common ground with Labour Party policy. “We’re reached the very limits of the 20th-century model of care,” Labour shadow health secretary Andy Burnham told a Reform conference in December 2014. “We urgently need to turn it round.”
The test-bed will be Manchester where a groundbreaking deal has been signed to pool budgets and commissioning, and redesign health and social care for 2.8 million people
Mr Burnham wants to see the combination of health and social care under a pooled budget, commissioned by health and wellbeing boards, and with a reformed payment system that does not favour the acute hospital trusts.
The new pattern would call for much greater involvement by patients in planning their own care. But patients with long-term conditions already self-manage. “For every few hours with a doctor, they have hundreds of hours by themselves,” says Professor Paul Corrigan, a former health adviser to 10 Downing Street. In addition, new models of care call for changes of behaviour that in many cases can help prevent the development of ill health.
The test-bed will be Manchester where a groundbreaking deal has been signed by the NHS, the local authorities and NHS England to pool budgets and commissioning, and redesign health and social care for 2.8 million people. It’s a radical vision, the bravest thing that’s been attempted in UK healthcare for a long time. In addition to the Manchester scheme, NHS England is supporting 29 “vanguard geographies” across the country where new care models will be developed under a £200-million pump-priming fund.
Much depends on the personal choices people make. Polls show the NHS has a huge approval rating, but affection for the system is called into question by the poor lifestyle choices of many – smoking, binge drinking, unhealthy diets. Do people really care about health or just about being able to see a doctor for free?
There is a big job to be done in prevention, not only to improve outcomes, but to narrow inequalities. Earlier diagnosis of many conditions, particularly cancer, would also help. Integration Manchester-style could give a stronger voice to Public Health England, which is a part of local government. It is active in promoting healthier lifestyles and urging people to act sooner on symptoms of cancer or stroke.
Professor Kevin Fenton, national director of health and wellbeing at Public Health England, says: “The earlier cancer is diagnosed, the higher the chance of survival. If we’re to improve early-diagnosis rates, we need to encourage people with symptoms to go to their doctor.”
The long-awaited impact of new technology, including social media – health apps, remote monitoring, data-sharing – could be important. Switched-on patients given the right of access to their medical records are far less likely to be the passive recipients of care, and more likely to become sharers and shapers of that care.
This should improve adherence and ramp up pressure for other changes, such as more convenient appointments, telephone and e-mail access to healthcare professionals, and supported networking with other patients online.
Getting from here to there will not be easy. A positive factor is that all the major parties now seem to agree on the direction of travel, if not the precise details. Health Secretary Jeremy Hunt is on record as hoping that it may be possible to move into “a slightly less partisan phase”.
Transforming the shape of care won’t save money, at least in the short term, and The Five-Year Forward View calls for £2 billion a year annual budget increases, a figure large enough to calm public anxiety about the future of the NHS and small enough to keep the Treasury relatively happy. But this figure does not include any provision for incorporating social care, which unlike the NHS has not enjoyed ring-fenced budgets and needs new money to sustain it.