NHS crisis: are professionals and politicians prepared to change and lead?BMJ 2023; 381 doi: https://doi.org/10.1136/bmj.p1154 (Published 19 May 2023) Cite this as: BMJ 2023;381:p1154
- Cyril Chantler, honorary fellow UCL Partners
Patients need the NHS to improve and for this to happen both the professionals and the politicians will have to accept the need for change. We sometimes forget that patients are customers, not just service users. Customers exercise choices and this improves the service that they receive. As a monopolistic provider the NHS does not offer many choices for patients although their right to choose—not least a particular general practice—is enshrined in the NHS’ constitution.1 Measuring customer satisfaction is essential in competitive markets, but there is also a need to do so within a monopoly. The latest King’s Fund review of public satisfaction with the NHS and care services shows a record low.2 In addition, the Organisation for Economic Cooperation and Development (OECD) found that the NHS does not compare well with similar countries for preventable and avoidable mortality.3 If we are concerned about these outputs, what about inputs? In 2020 we spent 12% of our Gross Domestic Product on health which is about the same as other similar countries. We do have fewer doctors per capita, but the number is increasing yearly and is only slightly less than similar countries.4 The number of secondary care doctors has increased by 34% since 2010 while the number of GPs has hardly grown.56
There is wide agreement that health systems with strong primary care have better outcomes. The need to strengthen primary care was the subject of a recent policy brief from the European observatory on health systems and policies.7 In 2017, a paper from the National Association of Primary Care discussed extending the then 190 primary care homes (PCH) across England. PCHs serve around 50 000 people and provide comprehensive care services both medical and social.8 The concept is similar to the Wagner chronic disease model and it is not a new notion.9 It was proposed by Peter Draper in 1967 when he pointed out the need for community hospitals to facilitate the integration of general practice with the new District General hospitals.10 It was proposed again in 2002 by way of integrated intermediate health centres as hospitals became even more specialised and in 2007 as polyclinics in a review of health care in London.1112 Community hubs bring together general and specialist medical practitioners, social workers, community nursing services, diagnostic and laboratory equipment and local government services. They serve as out of hours health care centres in addition to their focus on managing the many patients with chronic conditions. They provide services to improve public health and reduce health inequalities as emphasised by a report from the Centre for Progressive Policy, entitled Beyond The NHS in 2019.13 They are or should be joint enterprises between the NHS and local government.
We urgently need to invest in primary care and the PCH model if we are to make our hospitals safe. Hospitals in Holland run at 85% occupancy because they have strong primary care with out of hours care centres and the superb Buurtzorg community nursing service. In Holland it is difficult to get into hospital and easy to get out whereas for the NHS the reverse seems to be the case. But if this is to change we need our professions and our politicians to change.
For the medical profession we certainly need more GPs, but we also need GPs to work together in primary care networks and for people with chronic conditions to be able to choose their own GP to act as their care navigator for continuity of care improves outcomes.14 Maybe the annual capitation payment could be increased for patients with chronic conditions. Specialists need to work alongside them as consultants in the community hubs. We need some specialists to be less specialised too. Nurses could try the Buurtzorg way of working in non hierarchical teams.15
Change is also needed from politicians. Aneurin Bevan nationalised the hospitals, but he did not nationalise primary care, community nursing, or social services.16 We now need local politicians to take responsibility for coordinating these services and national politicians to allow them to do so and to ensure they are properly funded. Health and wellbeing boards provide the vehicle for local government and the NHS to integrate health and social care while local government can act at neighbourhood level to ameliorate health inequalities.13
The question now is whether the professions and the politicians are prepared to change and to lead.
Competing interests: Non Executive Director Private Health Information Network and Member Medefer Advisory Board.
Provenance and peer reviewed: commissioned, not peer reviewed.