A Critical Moment For Health and Care – Paul Gray
The current health and care system in Scotland is overwhelmed. By health and care system, I mean everything from hospital care to primary and community care to social care; I include everything that is delivered by the NHS, local government, the third sector and the private sector. By overwhelmed, I mean that the current design and resourcing cannot meet the current and emerging challenges and nor are they designed to do so. The current system was going to be overwhelmed regardless of Covid. The virus has simply brought the date of that event forward. The intersection between demography, population health status, funding, and availability of the right skills in the right place, was going to mean that to the system would be unsustainable in the next 2 to 3 years anyway; in Scotland, the Feeley review was tacit acknowledgement of that. Some would argue that it was already unsustainable. Covid has been the tipping point.
For some in Scotland, the chosen battleground is localism versus central control. This will of course attract considerable support from local government, whose role is fundamental. But this particular fight is emblematic of the problem itself. For as long as the delivery of health and care services is split across a range of providers where the incentives, governance, political mandate and accountability mean that the different budget holders can have adverse impacts on their partners, the issue will not turn to the needs of patients and families (or citizens, or clients, or people, or human beings in need of care – call them what you will) or the intractable issues of population health. The issue will be a series of budget and resource challenges where increasing demand will drive increasingly perverse incentives, to the detriment of the people who actually need diagnosis, care and treatment. This will also operate to the further detriment of third sector and private sector providers, who are already under represented in decision making; treating the third sector as a disposable contractor while calling them partners is the worst of all possible worlds.
Another area of contention is the contribution of the private sector to the design and delivery of health and care services. I will return to this later on, but I start from the basis of my own experience as well as my own ideals, and I am very committed to a health and care system in public hands, under public control, accountable to parliament. However, ignoring the private sector or wishing it away is a mistake.
It should go without saying, but in what follows I am making no criticism of citizens who try to access health and care via the range of doors available. It is for health and care providers to make it straightforward to access the right care and advice in the right place, and to help the public understand where they can receive the most appropriate care: the present context makes that more difficult than it should be. I am not ignoring the fact that a few individuals call an ambulance for issues such as a broken finger nail, in the same way that someone calls the police because their parcel hasn’t arrived. But the citizen isn’t the root of the problem.
Primary care is fundamental to the effective functioning of a health and care system; the vast majority of contact with health systems is via primary care. The narrative in relation to primary care was changing before the pandemic, and it needs to continue to develop. Primary care includes general practice but “seeing your GP” is not primary care. It includes many other specialisms such as a wide range of nursing skills including community nursing, phlebotomy, health visiting and psychiatric nursing; it includes pharmacy, dentistry, physiotherapy and paramedics. Some primary care consultations need to be face to face; many do not. Some need to be with a GP; many do not. The effective function of primary care involves the patient having contact with the right person, in the most appropriate setting, at the right time. A general practitioner is a highly skilled clinician, with particular strengths in managing undifferentiated risk – complex cases, often where it’s not necessarily clear what the immediate problem is. But all of the other contributors to primary care are skilled professionals too and patients will get the most appropriate care by going to the right one.
In the very simplest of terms, if primary care is overwhelmed, people will not come into the system until they are acutely unwell, or in response to life events such as pregnancy and childbirth. Primary care is not the place for acutely unwell people; in most cases they either need hospital treatment and if left untreated, will ultimately need community care or palliative care. So a dysfunctional primary care system leads to more pressure on hospitals, which in turn means that people with treatable but less urgent conditions are left untreated until their condition becomes acute and unmanageable. Or, if they are frail, they move instead into the social care system, either requiring care at home or in a care setting, and they do so more quickly than they would otherwise have done if they had had access to functioning primary care. And across the spectrum if people’s acute illness manifests suddenly as a result of under treatment, they pitch up at the emergency department – or they attend in frustration because they cannot access care or treatment anywhere else; or they try to call an ambulance adding further to pressure on the ambulance service. And a dysfunctional hospital system means that people can neither get in, because the emergency department is jammed and there are too few hospital beds to permit a stream of planned admissions, and once patients are in they cannot get out because there is no space in the community care system and no care or treatment at home from primary care; the people who cannot get in revert to primary care which is already overwhelmed, and add to its burdens further. Failure in any one part of the system precipitates failure in all of it.
The social care system is also critical to the success of the whole system, and operates with primary care (ideally in an integrated approach which is seamless for citizens). Further progress with integration is definitely needed, but social care faces other issues as well – not least recruitment and retention. The social care system is under intense pressure and this pressure both contributes to pressure elsewhere in the system (because for example social care does not have the resources to support someone who is ready for discharge from hospital, thus leading to a delayed discharge which in turn slows down admissions), and is increased where the rest of the system is overwhelmed (where for example frail people whose elective treatment in hospital is delayed require additional support from social care providers as a result).
All that said, the health and care system is chock-a-block with highly skilled professionals and amazing techniques for diagnosis, treatment and care. It is at its fundamental best, its inspiring pinnacle of performance, in a crisis. The people within the system are most definitely a crucial part of the answer to the problem we currently face. But the problem will not be solved simply by wishing for more of them, or by a bidding war between the professions and specialisms, not least because there are worldwide shortages of supply in some specialisms and it would take 10 years to train the additional numbers required, by which time the demographics would have caught up again and we would need more again. And in any case we need different skill mixes from the ones we have just now – and some of the answer to this lies in the third sector and not in the statutory sectors; the private sector will have a role to play too, as it does just now. The real answer lies in fundamental reform of the whole system and not just parts of it.
There are internationally recognised examples of what works. A quick search of the Jonkoping system in Sweden, the Buurtzorg model in the Netherlands, or the NUKA model in Alaska, will demonstrate that health systems can be integrated and can be made to work at lower per capita cost without sacrificing quality, and with better access and better outcomes. A quick search of the official report in Scotland’s parliament or Hansard in the UK parliament will almost certainly yield glowing references to all three systems. One feature distinguishes all of these systems – they are truly local. Each system has a different approach to governance: the NUKA system is owned by the population, for example. But they involve integration and local delegation to an extent that would frighten most politicians here. And for example, Jonkoping would mean that the concept of a national health service be very different, except for the highest tariff (i.e. most serious, complex and rare) cases, because the local hospital system is part of the local delivery system and not run centrally.
One of the lessons of the pandemic is that change is possible, and that it can be made to happen quickly. Another lesson is that technology can play a bigger part in diagnosis, care and treatment, and simultaneously reduce the need for patients and clinicians to travel while increasing the efficiency of the system. Better use of technology and properly joined up, patient-centric digital systems are essential components of any development. Even the best of systems embraces the need for change in response to changing contexts: as Jonkoping’s Chief Learning Officer said, Our current system serves us well, but it will not serve my grandchildren well in the future. (And yes, they have a Chief Learning Officer at the same level as their Chief Executive Officer.)
Unless we are willing to be clear that 2019 is not coming back and we are not starting from where we were then, and that 1948 when the NHS was first established, is lost in the mists of time and demographics and public expectation, we will continue to have a political bunfight while people suffer and die. If the NHS is truly precious, it deserves a robust diagnosis, and it requires radical surgery. Whether there is the courage to take such an approach remains very much open to question. The alternative is that people will quote international examples of best practice, and will criticise the current waiting list and shortage of staff, and objectively they will be quite right. But wherever they are in the UK, unless the opposition is prepared to go beyond beating the government of the day over the head with the present situation, and unless the government is willing to engage constructively in radical change and stop arguing about increasing investment (record investment in something that isn’t working will not make it work), unless the scrutiny moves from telling us what we already know, which is that there are too many people requiring treatment and care, and not enough money and staff to do it now and in the future, to what could be done to make things better, unless we can find a way that the legitimate role of professional bodies and trade unions places public interest ahead of member interests without sacrificing members’ rights, and unless we are willing to engage with all current and potential partners in care constructively and on an equal footing, we will stay on this merry go round.
In order to move on, the contribution of the private sector also needs to be recognised and discussed rationally. Pretending that the private sector cannot or should not have role has no basis in current fact. The NHS does not generate its own electricity, or manufacture its own vehicles, or make its own bricks and mortar. It is dependent on the private sector for much of its equipment and supplies. The private sector has useful experience in designing systems and processes. Some NHS clinicians also work in the private sector; some private sector providers are used when demand for diagnosis or treatment exceeds supply. We would not have vaccines against covid had the NHS, academia and the private sector not worked in partnership. We can do better than adopting a stance of “private sector bad” accompanied by accusations of selling off the NHS; we can equally do better than asserting that the private sector would be better and more efficient at everything – I can still remember being criticised in 2016 for saying that it would take 4 years to achieve our 2020 vision, on the basis that “the private sector would only be given 6 months to do that”. Health and care should remain in the public sector, and should retain its core values, and should hold fast to its commitment to safe, person-centred and effective care.
Three key features of a functioning health and care system are access (can people get what they need, in an appropriate setting, when they need it); quality (are people’s experiences of care acceptable, and are the outcomes achieved appropriate); and sustainability (is the system designed to continue to function effectively with the current and planned resources available to it). Unless we accept that these factors operate in balance, and derive from the way the whole system operates, we will not make progress. More money is welcome, and needed, but it is far from the whole answer; for a start, there is not a cupboard full of trained and experienced professionals just waiting to be recruited. Pointing to failures in access, or promising to fix those failures – largely visible through waiting times – without a willingness to engage on system design or restructuring the way resources are applied is no more than posturing.
I have of course failed so far to mention in any detail some very important issues: in particular, population health and prevention. A sustained emphasis on wellbeing and a real, properly funded and resourced long term commitment to prevention would go a long way to alleviating the rising tide of pressure on health and care services, not to mention its benefits for employers and employability, for the economy, for the environment, for the justice system, and for individuals and communities – particularly those which have been deprived and overlooked for far too long.
But in closing, demanding that everything returns to a golden age would require us to return population health status, quality and outcomes to the levels achieved at that golden moment – all of which would be worse than what we have, worse than we know we can achieve, and worse than what we should aspire to. The system is complex but the approach can be simple: improvements to access and quality will require changes to both system design and resourcing. More money alone will not fix the problem: do we really want to retain and maintain outdated facilities, and continue with skill mixes that are no longer fit for purpose, and outbid other countries for staff even although they need them more than we do, just because we can afford to do so? Or are we prepared to countenance the hard discussions, and the hard decisions, needed to construct a system of health and care that meets the current and future needs of the population, because we believe that to be just and fair?
Certain groups used to practice gyromancy; some may do so still. In some nomadic settings, this technique for prognostication involved the tribal elders dancing in a circle until they fell down from exhaustion, one by one. Once they were all prostrate, the direction of travel was determined by whichever point of the compass has the greatest number of elders pointing towards it. I hope that we can do better here.
Professor Paul Gray was chief executive of NHS Scotland, 2013-19 and NHS Scotland Director of Primary and Community Care from 2005-2007