The NHS Today – Professor Sir Ian Kennedy, Chairman of the Healthcare Commission
THE NHS TODAY
I’m just a bit older than the NHS, writes Professor Sir Ian Kennedy, Chairman of the Healthcare Commission so I can claim to have seen it grow from its infancy from both the inside and the outside. I have been asked to comment on the NHS as it is at present. So, in this short note, I will draw on my experience of the past to inform my view of the present. I will do so by reference to the following themes:
- Being a patient
- Safety and quality of care
- Primary and secondary care
- The independent sector
- Being and staying healthy
- The changing nature of needs
- ‘Cinderella’ services
Being a patient
It may seem odd to say so, but until relatively recently you could have been forgiven for overlooking the role and place of the patient in the NHS. The important players were government, doctors, (but rarely nurses) and managers. Health care seemed to be organised around buildings and the ways in which professionals preferred to work — hence the to-ing and fro-ing from GP’s surgery to acute hospital and back again, here for the X-ray, there to see the specialist, there for the prescription and everywhere for something else (with some community and social care thrown in). Hence, also, the long waits in the out-patients department or to get admitted as an in-patient.
Changes began to happen about a decade ago. A series of initiatives announced by the government were aimed at putting the patient at the centre of health care – there was even talk of a ‘patient-led’ system. Perhaps the most dramatic impact has been seen in the reduction of the time patients wait for treatment. This is clearly a welcome development.
Two further strands of policy have focussed on giving patients ‘choice’ and ‘voice’. The agenda of choice proceeds from the premise that in a modern, consumer-oriented world patients expect and deserve some element of choice in the care they receive. Moreover, through offering such choice, and arranging financial incentives for those delivering health care around the ability of patients to choose, the intention is to improve the service patients receive. It is too early to assess the effect of this initiative. Clearly, patients are not a homogenous group, such that choice may mean more to some than to others — for example, those receiving long-term care may value continuity of care over choice. But, that said, the mould of regarding patients as passive recipients of largesse (which to some appeared to be what the NHS was about) is now broken. This again is a welcome development.
As regards ‘voice’ — seeking to give patients a say in their local healthcare services — various attempts have been tried over the years. Engaging the local community in their NHS, giving them a voice, remains a significant challenge. It tests the tension between a national system and the need for local variation to reflect local needs and concerns. It remains to be seen whether recent structural devices (Local Investment Networks (LINks) and governors in foundation trusts) will be more successful than those that went before.
Of course, what patients most want from their NHS is as good an outcome as possible from the care received. Outcome has two meanings here: that the care produces the intended outcome and that the patient’s experience of care is as good as can be reasonably expected. Measuring clinical effectiveness is only now beginning to receive the attention it requires. As regards measuring the experience of patients, it is fair to say that it is still in its infancy. The NHS generates a lot of data. Until very recently, however, there was little focus in this data on what patients had actually experienced and what they thought of it. Yet, such information must be a central element in any strategy for putting patients at the centre of care.
Safety and quality of care
While it has long been acknowledged that health care is a risky business, it is only recently that systematic attempts have been made to identify the factors giving rise to the risks, to find ways of mitigating or avoiding them and to collect accurate data about the incidence of unsafe care. And safe care is not only important in the operating theatre or intensive care unit but also in the GP’s surgery or the clinic.
The importance of safety has been reinforced by the emergence of hospital-related infections, such as MRSA and Clostridium difficile, capable of killing patients. Given the high political profile attending outbreaks of these infections, safety has been acknowledged as a challenge that needs to be recognised and relentlessly pursued. A number of structures have been put in place by government which are beginning to bear dividends (for example, the National Patient Safety Authority and the Hygiene Code). What now remains is the need to embed a culture of safety in the working habits and practices of all those who care for patients and to ensure that the environment in which patients are cared for is conducive to safe care.
As for the quality of care, the challenge is one of continuous improvement. There is no doubt that care is improving, as measured by the number of patients treated and the outcome of the care provided. But reliable evidence is still patchy. In part, this reflects the difficulty in arriving at agreed measures of what constitutes a good outcome and good quality. In part, it reflects the fact that, in the absence of such agreed measures, data is not as good or comprehensive as it, perhaps, should be. The NHS’ goal, therefore, must be to move to a position of having an understanding of what quality of care a patient should be entitled to expect and to be able to measure and report on whether the patient actually received it. The journey has begun and patients can look forward to considerable progress on this front.
Primary and secondary care
One of the defining features of the NHS has been the separation of care into primary (GP) and secondary (acute/hospital), with the GP acting as the gatekeeper to secondary care. Over time, the acute sector came to dominate how funds were distributed and health care was conceptualised in terms of policy-making by reference to hospitals. This is so despite the fact that GPs account for over 90 per cent of all contacts with patients and are responsible for the disbursement of more than £70bn in purchasing care for their patients from the acute sector.
It is now recognised by government that if the NHS is truly to be a ‘health’ service and marshal its resources effectively, it needs to concentrate an increasing amount of effort on keeping the population healthy, preventing ill-health and on moving as much care as possible out of hospitals into settings in the community.
This is one of the most significant developments in the history of the NHS. It is driven not just by concerns for cost and efficiency, although these are important, but by recapturing one of the original aims of the NHS, a reduction in the toll of avoidable illness, and by re-organising care, when needed, around the convenience of patients. These ambitions form part of the rationale behind Lord Darzi’s radical proposals to reconfigure services as part of his review of the NHS. History tells us that re-configurations of services, rather than of administrative structures, are extremely hard to bring about. They are routinely opposed by professionals with vested interests to protect and by local populations averse to change and often less than well-informed of what is being proposed. It is to be hoped that, when the value of rebuilding a service that can respond better, more efficiently and more effectively to those for whom it exists is recognised, change will be embraced. The vision is compelling; the rhetoric is currently somewhat disappointing.
The independent sector
There is a lot of misunderstanding, some manufactured, about the role of the independent sector in the provision of health care. It has always existed for those who want to buy their care from a provider other than the NHS. It has always existed as regards the purchase of all the things that make the NHS work, from bin-liners to beds, from medicines to computers. So, what causes mention of the independent (or ‘private’) sector to raise so many hackles?
Fundamentally, it is seen as a breach in the notion of social solidarity, which the NHS is, now perhaps uniquely, seen as representing. The argument is that it allows some to purchase care without having to negotiate the otherwise complex and demanding system that the NHS has created as a way of controlling demand. And, it allows some professionals to profit personally from the skills acquired at the taxpayers’ expense. Both of these arguments seem out of kilter with the way in which the world of the 21st century operates. First, if the system created by the NHS is failing to meet people’s legitimate expectations, then a modern view would be to change it, not seek to prevent/limit the emergence of alternatives. And, if change involves challenge from outside as well as within, then so be it. Second, professionals should be paid properly, such that the inducement of an additional source of income is no more than an option for those who want it.
The Labour government under Mr Blair sought to embrace a political strategy of continuity with change. Thus, the independent sector has been used to look after NHS patients and dramatic falls in the time spent waiting for treatment have taken place. The creation of independent-sector treatment centres was a key part of this strategy. And professionals have seen their pay increase significantly, although the results in terms of any increase in service provided are less clear. But the use of the independent sector as an integral part of the system for providing care under the NHS is not popular with those who see themselves as guardians of the flame of the ‘real’ NHS. The answer offered to them must be that the NHS is about serving the needs of patients, not who owns what building or even who the professional works for. The argument continues that if care remains free at the point of need and funded from general revenue, and if the tariffs charged by the independent sector match those of the NHS, the historic vision of the NHS is not threatened but merely refreshed.
Being and staying healthy
There has long been a concern that the NHS has become an ‘illness service’ rather than a ‘health’ service. With the dominance of the acute sector, public (or ‘population’) health has tended to be at the end of the queue for funding and influence. The government signalled a change in its White Paper, ‘Choosing health — making healthy choices easier’. The catalyst was the report of Sir Derek Wanless’ warning of the cost of caring for illness unless some urgent measures were taken to improve the health of the population. Obesity, smoking and misuse of drugs were just three of the many challenges to be tackled. And, the distribution of ill-health clearly reflected the divide between the haves and the have-nots.
Saying something in public and making a commitment to do something about it are necessary steps. But, the challenge of public health is enormously hard to meet. First, there is a limit to what government can do and that limit becomes more stringent whenever the words ‘nanny state’ appear. Second, the government, to do anything, must co-ordinate activity across a broad range of departments. Health is as much affected by where you live, whether you or your parent(s) have a job, what you eat, what level of education you have and whether you speak English, as it is by anything that the healthcare system can do — and that’s not to mention the genes you are born with. Co-ordination across the government, however, is like the Holy Grail — much pursued but never found. Third, evidence of a causal link between proposed changes and improved health, once the half-dozen measures on which evidence does exist (for example, smoking) are put to one side, is very hard to come by. It is no surprise that the Treasury is slow to fork out taxpayers’ money for this or that proposal, not least when electoral cycles demand a return on investment within four years at most.
So, public health constantly fights for attention. Currently, there have been dramatic successes, such as the ban on smoking in public places. But, the story is still grim as regards the consumption of alcohol, obesity and the general ill-health associated with relative poverty, isolation and disadvantage. Indeed, the generation currently in their teens and twenties may in fact live less long than their parents — a startling proposition.
The changing nature of needs
The NHS is always confronted with the need to adapt. Currently, that need is driven by at least two forces. First, there is the development of genetics which changes the face of diagnosis and treatment, addressing the particular circumstances of the patient. In turn, the way that care is organised and delivered must change – captured in the current jargon of ‘personalised care’. This is usually understood in terms of making the NHS a real service, existing only for the benefit of those using its services, on the model of consumers in Marks and Spencers. But, it reflects a deeper recognition of the changing face of medicine to which genetics holds the key.
The second driving force is the fact that the population is getting older. As people get older, they need different health care. Many will have a range of illnesses (co-morbidities), all of which will need to be managed. An increasing number will develop Alzheimer’s disease and related problems of mental health. The challenge to the resources of the NHS is obvious. Expensive medicines will be increasingly the order of the day. Carers will need support. Healthcare professionals will need further and different training. The boundaries between health and social care will become increasingly irrelevant to the patient/user, an irrelevance that will need to be recognised in the approach the State takes to funding the various needs. Research and innovation will need to be fostered on an increasing scale, so that the challenges of today and tomorrow are met by new therapies.
And there are other needs which need to be recognised and addressed. Some are obvious and have been referred to — the misuse of drugs and alcohol. One other which deserves special mention is mental ill-health, particularly among children and adolescents. It is too much to say that this problem has reached epidemic proportions, but we are not far from this. The needs of this group are very considerable. The cost of caring for them effectively, that is, in a way which reflects the fact that they are young people who may well be already fairly chaotic, will be high. The cost of not caring for them will be much, much higher.
In the 1970s, certain services were described as ‘Cinderella’ services. It meant that they were never properly funded nor received the attention they needed. They were: the care of children; care of the elderly; and care of those with mental and physical disabilities. It would be good to report that the NHS of today has responded to the challenge. Unfortunately, there is much still to do. Certainly, there are pockets of improvement in, for example, the care of children. But, the Report of the Public Inquiry into paediatric cardiac surgery at the Bristol Royal Infirmary showed how great was the gulf between promise and reality. As a consequence of that report and other initiatives, it is now clear that the care of children in hospital has improved significantly. Similar progress is now needed where children are cared for in non-dedicated paediatric settings. Equally, strongly worded reports from the Healthcare Commission have been needed to catalyse change in the care of those with learning disabilities and problems of mental health.
Fundamentally, the challenge is one of human rights. The NHS is committed to care for all on the basis of need. It must not allow those groups who are least able to speak for themselves and draw attention to their needs to be ignored or neglected while the more articulate press their case. To the extent that this continues, albeit less so than historically has been the case, it serves as a reminder that the NHS still, after 60 years, has some way to go to care properly for many who cannot care for themselves.
The NHS is an extremely large, complex organisation: one of the largest in the world. To be managed effectively, it must generate information that allows it to answer the big question: does it know enough about what it is doing to allow it to say that it is meeting its stated goals and to allow others to hold it to account for the use of taxpayers’ money. Until relatively recently, to the extent that it collected information about itself, whether at a national or local level, it was information about finance, workforce and throughput. While this is important, it could be said that it overlooks the need to collect information on those things referred to earlier that matter to patients and those who look after them.
It is fair to say that the past five years or so has seen a revolution in thinking about information and the role it can play and in beginning to make it available to patients and the public. A number of factors have contributed to this revolution. First has been the shift of emphasis from concentrating on finance and managerial information to a concern to measure performance in those areas that matter to patients, especially the quality of care. Then, the notion of electronic patients’ records, whereby access to information is available to a range of professionals simply by using a computer, will clearly bring benefits to patients — the moment questions of security and access are resolved. The development of a regulatory regime, whereby the performance of organisations in the NHS is assessed and the results published, based on the analysis of large bodies of data, has served to require the boards of trusts to ask the right questions about their performance. The Department of Health’s creation of an Information Centre reflects recognition of the central importance of accurate, independent information to the department as a Department of State and to the NHS. And then there is the emergence of entrepreneurs, such as Dr Foster, who have recognised that in the 21st century knowing which hotel or restaurant is good, but not knowing which hospital is, can only be at best an anachronism.
These developments, taken together, represent the greatest opportunity for improvement in the NHS for a very long time. Patients, taxpayers, clinicians, managers, and politicians will all be able to see how well their NHS is doing. Good practice will be identified and shared; bad practice weeded out. The NHS in 2008 is poised to take its place in the information revolution. Through information and knowledge will come change and improvement. Patients will be the beneficiaries.
Biography of Professor Sir Ian Kennedy
Professor Sir Ian Kennedy LLD is a lawyer who, for the past few decades, has lectured and written on the law and the ethics of healthcare. He is currently Chairman of the Healthcare Commission. He is also Emeritus Professor of Health Law, Ethics and Policy at the School of Public Policy, University College of London and Visiting Professor at the London School of Economics. He is a former Dean of the Law School (1986-96) at King’s College London and President of the Centre of Medical Laws and Ethics, which he founded in 1978. He gave the Reith Lectures in 1980. He was a member of the GMC for nine years and has been a member of the Medicines Commission and the Department of Health’s advisory group on AIDS, Chairman of the public inquiry (1998 – 2001) into paediatric cardiac surgery at Bristol, a government inquiry (1997), into xenotransplantation (the use of animal-to-human transplants), and an inquiry (1998) that recommended changing the law relating to quarantine for animals being brought into the UK from abroad. He is a Fellow of the British Academy (FBA) (2002) and a Fellow of both King’s College, London and University College, London. He was awarded an Honorary DSc by the University of Glasgow in July 2003. He is an Honorary Fellow of the Royal College of General Practitioners (2002), Royal College of Physicians (2003), Royal College of Paediatrics and Child Health (2004), Royal College of Anaesthetists (2004) and Royal College of Surgeons of Edinburgh (2005). He was awarded an honorary degree of Doctor of Medicine by the University of Birmingham (2006). He was Knighted for services to medical law and bioethics in 2002.