“The future of health”: David Prior

4 December 2014

Value in a 21st century NHS

The fact that for many years the NHS has been treated, in the words of Nigel Lawson, as “the nearest thing we have to an established church or a national religion”, partly explains why the vital improvements that today’s patients need have been so difficult to make and so frustratingly slow. The CQC’s primary role is to shine a bright light into these holy places, to celebrate great care, to expose bad care, and to give a voice to its congregation (to continue the metaphor). That will enable them to become more powerful and informed consumers, rather than grateful supplicants.

We will do this with the help of risk based intelligent information, expert clinicians, comprehensive inspections, announced and unannounced, and greater enforcement powers. Our focus is on culture and behaviour not narrow and sometimes politicised measures of success. We have to be independent for our judgements to be credible and trusted. We will publish our inspection reports and give an aggregated rating (and a rating by service lines, locations and population groups where appropriate) to all hospitals, care homes and GP surgeries. Intelligent transparency will facilitate and enable change to happen; it will help drive patient choice and clinical benchmarking. Our role is both to ensure encourage improvement.

But we cannot and will not restrict ourselves to inspecting the existing system. As stated in The NHS Plan published in 2000, we have “a 1940’s system operating in a 21st century world”. This is a theme eerily echoed in NHS England’s Five Year Forward View published in October this year, which demands “a future that dissolves the classic divide, set almost in stone since 1948, between family doctors and hospitals, between physical and mental health, between health and social care, between prevention and treatment”. The two documents could almost have been written by the same person.

The existing system was not fit for purpose in 2000 and as every year goes by it gets less fit. The power of medicine and surgery to prolong and enhance life has grown hugely but it has not been matched by the capacity of the system to care properly for the millions of elderly people living with long term conditions. The CQC inspects and regulates primary care, community care, mental health care, adult social care and acute care. We have a duty to see that the health and care system is joined up so that people are treated in the best possible settings for them. The typical patient in 2015 is very different from 1948. Our demography and disease profile have changed fundamentally. Today, many patients will be over 75 years old and suffer from a number of complex, hard to manage, long term chronic conditions. Frighteningly, between 30 and 40 per cent of patients in acute hospitals have dementia, and almost five million people suffer from three or more long term conditions.

The current system treats far too many of these people in acute hospitals and their admission process could hardly be worse: “blue lighted” in an ambulance into a busy, over stretched A&E department, thence to a ward often determined by bed availability, not clinical suitability. This in turn can lead to cancelled operations as surgical beds fill up with medical patients.

The discharge process is not much better, with too much delay, especially in the interface between NHS funded and local authority funded social care. The current payment structure, some of the targets, and the lack of capacity in primary and community care, have had the unintended consequence of driving resources and patients into inappropriate acute settings (poor care at high cost).

We must look after and manage the conditions of these people in their own homes whenever possible or in settings outside the acute hospital, for example in day centres, nursing homes or community hospitals. Acute hospitals cannot provide high quality, personalised long term care, they are not designed to do so and they are also very expensive. Most importantly, the system must be incentivised to work for the best interests of the individual not the best interests of the existing institutions. The artificial divisions within healthcare and between health and social care must be
buried, fast.

These changes will not be easy. They were not achieved in 2000 at a time when the NHS received huge increases in funding. They have now got to be achieved at a time of austerity, at pace and scale. They will not be pain free; change never is. Politicians need to be honest about that. The drivers of change are both affordability and better patient care. We need an affordable care system designed for people living today not in 1948.

David Prior, Chairman, Care Quality Commission
@CareQualityComm

This blog was taken from an article written for the brochure that accompanied Reform’s major health conference on the 2 December 2014.

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