Better Health and Care
For health and social care services, the Government’s vision is simple – high quality care for everyone. Lord Darzi’s Next Stage Review set this out for the NHS, and Putting People First did the same for Adult Social Care.7, 8 Health and care services that enable people to live healthy, active and independent lives are at the heart of a fair and strong economy and fair society and are underpinned by the themes of greater user control, professional freedom and a more strategic role for government.
Building on progress
Significant investment, coupled with major reform of the way the NHS works has led to substantial gains over the last few years including dramatic improvements in waiting times and safer, higher-quality services. In the last twelve months alone a new deal with GPs that links part of their pay to the access they give people, means over two thirds of GP practices are now open in the evenings, early mornings or at weekends.9 Following a major national drive, hospitals are cleaner and safer, with much infection control dramatically improved (MRSA rates have been halved).10 And, after over a decade of rising standards and falling waiting times, nearly all patients referred to a consultant for hospital treatment are diagnosed and start their treatment within 18 weeks of a referral from their GP.
New health institutions have been created: hospital trusts and now 115 foundation trusts. Subject to Monitor approval there could be as many as 25 new foundation trusts by the end of 2009. All foundation trusts are built on significant community membership, there are now more than 1.2 million members of foundation trusts, and they are governed by elected community governors, with more autonomy to focus on local priorities, reap the benefits of improved efficiency and make investment decisions.
Health outcomes have begun to improve sharply and we expect to see further service improvements and increases in quality resulting in even better outcomes, although this can take time. We have seen, for example, a rapid decline in premature death from heart disease, stroke and related conditions in recent years. The target of a 40% reduction in deaths, among those under 75 years old, from cardio-vascular disease and stroke on the 1995-1997 baseline has been achieved well before its deadline of 2010.
Innovations in Health Care: The Lakeside Plus Health Care Centre
The Lakeside Plus health centre in Corby opened in December 2008. It is one of the first of 152 new health centres which are set to open across England.
The new health centre will see patients from 8am to 8pm, seven days a week. Any member of the public can use the extended and additional health services provided by the Lakeside Plus centre while staying registered with their local family doctor. Patients can also choose to register at the Lakeside Plus centre if they wish to do so.
The new health centre offers a range of innovative additional services tailored to meet the health needs of local people, including a nurse-led minor illness service, health and well being clinics, screening for health problems such as cardiovascular disease, diabetes and sexually transmitted diseases as well as sexual health services. The centre is one of 12 set to open across the East MidlandsSource: www.northamptonshire.nhs.uk
The next stage of reform
Having made progress in these areas, in common with care systems around the world, we face new challenges. In two decades’ time, 40% of the whole population will be over 50.11 An ever growing proportion of people will have long term conditions, requiring more integrated support across services. As the economy recovers, it will be critical to ensure that far fewer people are kept out of the labour market due to ill health or other forms of incapacity and older people are able to stay in work as long as they wish. This requires a 21st century NHS which is able to diagnose earlier, focus more on prevention and keep people healthier for longer. It must also empower patients and clinicians to work in partnership to keep people healthy and active.
This vision can only be achieved by putting in place a system which gives control and responsibility to those who know their health and care needs better than anyone else – the patients and users themselves. This is being backed up by ensuring that the workforce have the flexibilities, skills and leadership to respond to patients and address the needs of their local areas and by central government providing strategic leadership by working with people across the system to make change happen.
The NHS, having turned 60, is therefore embarking on a further major stage of improvement set out in the Government’s Next Stage Review of the NHS, driven primarily by empowered patients and front-line staff working together to improve health, with central government strategically enabling and catalysing better services.
The Next Stage Review, was conducted during 2008 with unprecedented engagement with staff and patients across the NHS. There are four things that people told us they wanted from the health service, and are equally crucial to social care provided by local councils:
Ensuring high standards with a strategic role for Government
Patients rightly expect the highest possible standards of care when they are interacting with health services. Even in a system with greater choice for patients and greater freedom for clinicians we must strengthen the core standards which are common across all parts of the NHS, from cleanliness and infection control, to safety and guaranteed access. So whilst targets, such as the 2-week standard for cancer patients or the 18-week guarantee for all patients, are no longer the core levers for improving services they must become the guarantors of high quality services for all. Alongside these guarantees, the NHS Constitution is being underpinned by legislation to help address postcode lotteries in areas of service provision, such as entitlements to NICE-recommended drugs, in which we expect the NHS to offer a common service to all who use it. And a new, strengthened regulator, the Care Quality Commission is being established to tackle underperformance where it is found, with new powers to act more swiftly and with greater impact than regulators have been able to in the past.
Strengthening entitlements to good healthcare – the NHS Constitution.
The NHS Constitution enshrines the principles and values of the NHS for everyone.12 It brings together existing rights, such as the right to all NICE recommended drugs and treatments, with new rights, including the right to make choices about your NHS care. To help ensure that the NHS Constitution endures and makes a lasting difference, the Government has brought new legislation before Parliament to ensure that all NHS bodies and private and third sector providers that supply NHS services in England are required by law to take account of the Constitution in their actions. In addition to the NHS Constitution, we will begin to turn the once aspirational targets in core areas of service provision (such as infection control) into national requirements that patients are entitled to expect across the NHS. These will provide additional assurances of safe, high quality provision across the system.
Identifying and addressing poor performance
While the NHS will always aspire to provide the highest standards of care, there will be times when it fails to meet either patients’ expectations or its own high standards. This is unacceptable and is why the Government is introducing a new performance framework for NHS providers that identifies underperformance and ensures swift remedial action.
Under this new performance framework, the NHS Chief Executive will have the option of designating the most persistently and seriously underperforming providers as ‘Challenged’. These organisations will be subject to more intensive intervention at board level, on behalf of the Department of Health, beginning with an independent review of the Board. In the event that serious failings are revealed, decisive action will be taken – including the imposition of temporary appointments, suspension or removal of members of the Board.
Furthermore, provisions included in the Health Bill 2009 set out a clear framework for action in the rare cases where organisations have not turned performance around, or are clinically or financially unsustainable, despite interventions from commissioners and Strategic Health Authorities.
The solutions to address underperforming and unsustainable providers include awarding contracts for the management of services to other healthcare providers, in the NHS or independent sector, or takeover by another NHS organisation such as a foundation trust.
The new health regulator, the Care Quality Commission, which will come into being on 1 April 2009, has enhanced powers to act quickly where services are not meeting essential levels of quality and safety. It will be able to take swift action, ranging from issuing warning notices to closing wards or hospitals where there is evidence to cause concern. Despite significant improvements across the NHS over the last ten years it will not be exempt from some trusts and services failing to meet expectations – and a more powerful CQC will be at the centre of the Government’s strategy to ensure such services are identified and unable to continue seeing patients until performance issues are addressed.
Empowering patients – Improving access and responsiveness
To empower patients and those needing care, choice and accessibility will be increased further. Since April 2008, those patients referred to a specialist have had the right to choose where to be treated at NHS standards for NHS costs, including any private sector alternative that meets these requirements. GPs have been encouraged to offer evening and weekend opening, with many doing so. In the coming year, for example, we are committed to improving maternity choices for women and around 135 new GP-run health centres will offer 8am-8pm access, 7 days a week to anyone who needs to see a GP – without the need to transfer from their existing practice.
The right modern structures that can integrate aspects of people’s care are also critical to getting services that fit around people’s lives. The Integrated Care Organisations pilot programme will focus on innovations in clincally-led models for integrated care. We hope the pilot programmes will become one of the important new NHS innovations – with the potential to work across traditional service boundaries to build partnerships with primary, community and secondary care and with social care. We have invited trusts to come forward with their own views on what form these pilots will take.13
Professionals offering more flexible services – to extend GP opening hours and GP-led health centres across every Primary Care Trust
Extended opening hours at GP surgeries will, it is estimated, be offered in three quarters of all practices by the end of 2009. In addition, 152 new GP-led health centres are set to open across England providing an extended range of services, seven days a week. We anticipate that around 135 GP-led health centres will be open by the end of 2009 across our towns and cities, providing easy access for people either as registered patients or as a drop-in when your own GP is closed. New GP-led health centres and 112 new GP Practices will deliver, each year, around 4.5 million new appointments with GPs and nurses. We want to see year-on-year improvements in patient satisfaction and will be using the results on patient access and experience of the quality of GP services from the GP patient survey to improve responsiveness of general practice.
Healthcare in your own home
Developments in technology are allowing more and more treatments and services to be delivered outside of hospitals or other healthcare environments, often at similar costs to when delivered in a clinical setting. As well as offering greater convenience for patients, such services can allow patients and their families a more supportive environment for their treatment or recovery. Increasingly, services as varied as maternity and cancer care will be offered to patients in their homes, at their convenience. The new End of Life Care Strategy recognises that many people would prefer to be cared for and to die at home, rather than spending the end of their life in hospital. Services are being developed now to allow people to realise that choice. For example, Marie Curie has been working with local NHS organisations and with local authorities to pilot models of care that ensure that there is service available round the clock to be called on as needed, including a rapid response service. This works because it meets the needs of carers and families as well as those of the patient.
Empowering patients – personalised care
The personalisation of care is critical not just to improve the patient experience but to ensure that care is well targeted at need so that the NHS achieves the best outcomes. Dignity and respect are also values that must be reinforced across the NHS. For example, through the Dignity in Care Campaign, a network of over 5,500 Dignity Champions is part of a nationwide social movement leading to improvements in the dignity of care offered to people using NHS and social care services.14
Enabling patients to have their say
Patients can already view comparative information about a range of healthcare services online at the NHS Choices website. Patients can make their own comments, observations and suggestions about hospital services and allow these to be visible to other patients. Often the best way for people to understand whether a service is right for them is to see what other similar users thought of that service. This is the experience of millions of customers who use Amazon.com or iTunes, and while these are for simpler, less important services like books or music, the same principle of valuing the opinions and views of others applies in the decisions we make around our health and care as well. Around 10,000 such comments have been posted since the launch of NHS Choices in 2007. During 2009 the ability to make this kind of comment will be extended from hospitals to include GP practices, and over time we expect patients to be able to make comments on and review all NHS services through the NHS Choices website. At the same time, payment to hospitals for services is being linked to patient-reported experiences and outcomes as one way of driving improved quality and patient-focus across the NHS. And we will see the quantity of this payment linked to outcomes increasing year-on-year as quality measurement improves and commissioners focus on ever higher outcomes.
Empowering patients – greater choice and control
Much greater patient involvement is central to ensuring health services enable people to stay healthy wherever possible and have the best possible care when needed. Personal care plans will allow patients much greater involvement in their care and extended choice of the most appropriate type of treatment as well as when and where they are treated. Legislation now before parliament will allow pilots of personal health budgets to include direct payments to those patients who would benefit from such approaches to meeting their long-term and chronic care needs. Primary care services are changing to enable people to play a much more active role in preventing ill health and managing their own health and care.15
Empowering people with more control – Self-Directed Support and Personal Budgets
Self-directed support in social care offers people control over the support they receive. By making people aware of how much funding is available to them they will be better able to choose the individually tailored care and support that best suits them, their families and lifestyles. The Government is increasing funding from £85 million in 2008/09 to £195 million in 2009/10, to help English councils transform their adult social care systems and enable citizens who are eligible, and who want one, to have a personal budget. We expect councils to have made significant progress in ensuring that people will be able to access adult social care personal budgets by March 2011.16 At the same time, early adopters will begin to pilot personal health budgets to give people more control over the kinds of NHS support that they need.17 The pilots are expected to be up and running in a number of primary care trusts by summer 2009. More widely, by the end of 2010 up to 15 million people with long term health conditions will have been offered a personalised care plan – giving them a greater say in the right care for them and how their care is delivered.18
Empowering patients – a focus on wellbeing and keeping people healthy
Across these four areas of improvement, health, social care and other services will give greater attention to wellbeing and keeping people healthy. Promoting wellbeing means creating a more personalised system. “Putting People First” looked to put choice and control as close to the user and carers as possible. Keeping people healthy requires a range of action, from informing and supporting individuals to make healthy choices, to providing high quality care services that identify and support individuals at risk. As every country in the developed world grapples with the rising cost of healthcare it is critical we continue to prioritise early intervention and encourage healthy lifestyles – so averting illness and keeping people healthier for longer.
Empowering people with better information and earlier intervention – a personal Vascular Health Check.
It has long been a truism that the kind of wellbeing service people wanted was only found in the private sector. However, that is changing as the NHS becomes far more focused on keeping people healthy. Free health checks will give people aged between 40 and 74 an assessment of their individual level of risk for major conditions such as diabetes and heart disease. It is estimated that around a million people will receive a health check of this type by April 2010 in GP or pharmacy settings. The checks will allow people to understand and discuss risk factors for a range of vascular conditions (heart disease, stroke, diabetes and chronic kidney disease). Following the check the right sort of advice and support can be offered, on an individual basis, to help people manage and if possible reduce their own personal risk levels. Some of this will be to do with lifestyle interventions, some of it will involve medication.19
Personalised support for those seeking work
The personalisation of care is also essential if the NHS is to support people into work. Major reforms to the nature of support offered by Jobcentre Plus mean that public services are better prepared to help people back into work than they were previously, but here too, a more personalised NHS offer can be very important. One example of this is in mental health where the Government has invested significantly in improving access to psychological therapies for people with depression and/or anxiety disorders, with new services being developed over the next four years in every area through investment of almost £200m per year. During a period of rising unemployment these talking therapy services will be even more important to ensure that people are in a better position to get back into work and government is therefore accelerating the roll-out of the programme and ensuring it is well targeted on areas of high unemployment. The Government’s programme will enable 900,000 people to be offered counselling and support over the next 3 years. In past recessions, we have seen the number of out of work people on inactive benefits due to mental health problems rise, scarring communities as people were written off to long term unemployment. Alongside these new services, the NHS will be encouraged to use £80 million of savings from the temporary reduction in VAT to offer complementary support including debt advice and family counselling.
Supporting a professional workforce
Delivering these improvements will rest on continuing to grow the capacity and autonomy of health and social care professionals and the organisations they are part of. Over the next year, we expect more hospitals to gain Foundation Trust status, giving them more control over day to day management. In primary care, practice-based commissioning will allow doctors to use their clinical experience to commission the best value NHS services for their patients.
Across the NHS the Next Stage Review has sought to put clinicians and staff far more at the centre of decision-making and has put a highly skilled workforce at the heart of the strategy for a quality focused NHS.
Professionally-led improvement and efficiency
Hospitals continue to roll out the internationally successful ‘nurse-led productive ward’ programme which gives nurses greater control and responsibility over their wards and services – cutting bureaucracy, and releasing more time to focus on care. 2009 will see this approach spread rapidly across Trusts and wards.
Prime Minister’s Commission on the Future of Nursing and Midwifery
Change is most effective and most beneficial to users when it is developed, driven, and owned by front-line staff. Over the last few years nursing has been at the centre of all the major achievements in the NHS, from the shortest waiting times on record to improvements in hygiene and dramatic falls in infection rates. As the Government seeks to renew its strategy for improvement in the NHS, focusing on quality and patient experience, it makes sense to involve professionals themselves in defining the way forward. For nursing, there are few who know better the challenges and opportunities which nurses face than the profession itself. The Prime Minister and Secretary of State for Health are therefore launching a commission on the future of nursing and midwifery. This commission will consult widely within the profession and with allied professionals on the best way for the NHS to make the most of its talented nursing professionals in delivering a world-class 21st century health service.
- High quality care for all – NHS Next Stage Review final report, Department of Health, 2008
- Putting people first, HM Government, 2007
- 71% of GP practices now offer extended opening hours, up from just 12% last April.
- The target to reduce MRSA infections by 50% from the 2003/04 levels was achieved on in first quarter of 2008/09.
- Don’t stop me now – Preparing for an ageing population, Audit Commission, 2008
- The NHS Constitution for England, Department of Health, 2009
- Integrated care pilot programme – prospectus for potential pilots, Department of Health, 2008
- Dignity in care campaign – http://www.dignityincare.org.uk
- NHS Next Stage Review: our vision for primary and community care, Department of Health, 2008
- Putting People First: a shared vision and commitment to the transformation of Adult Social Care, HM Government
- Personal Health Budgets – first steps, Department of Health, 2009
- High Quality For All: NHS Next Stage Review Final Report, Department of Health, 2008
- Putting Prevention First – Vascular Checks: risk assessment and management, Department of Health, 2008