According to the June 2016 Britain Thinks survey (commissioned by the BMA), 37% were dissatisfied with the running of the NHS (up from 21% the year before) and 53% expected it to get worse. In contrast, the 2014 report from US research foundation the Commonwealth Fund, found England’s NHS to be the world’s second cheapest major healthcare system while scoring top in six out of nine measures (effective care, safe care, coordinated care, patient centred care, cost related problems, efficiency). The report (Mirror, Mirror on the Wall) compared healthcare provision across eleven of the leading, western nations in a study of healthcare outcomes. The NHS clearly isn’t failing but there’s no room for complacency.
Consider Leon’s experience when he was suffering from chest pains and shortness of breath.
Firstly, Leon called NHS 111. The call handling agent was unable to do much more than take details (1st explanation) and referred to a clinical colleague. The out-of-hours clinician that called Leon back (booked by the 111 agent) carried out a triage covering the same ground (2nd explanation) as had been covered on the original call. Concerned, the out-of-hours clinician referred Leon back to 111 who made a booking into an extended hours hub (a product of the 2015 GP Access Fund). After a one hour wait, Leon was able to see a doctor at [coincidentally] his home practice. The extended hours clinician did (it’s assumed) have access to Leon’s medical history but no access to the 111 details so Leon’s explanations had to be repeated (3rd explanation). The extended hours clinician referred Leon to MIU for chest x-rays. This referral was rather chaotic involving an instruction to go to the MIU connected to A&E and a printed encounter summary. On Leon’s arrival at hospital, the nurse insisted on admittance to A&E (and not the MIU) but was not able to gain sufficient details from the encounter summary so Leon was forced to explain his condition again (4th explanation). The x-ray was booked and a number of other tests (blood, ECG) carried out by rather harried staff in an ad-hoc fashion. After a five hour episode of care, Leon was sent home with no clear diagnosis of what had happened but an assurance that he was OK. Two hospital nurses, two GPs, one hospital doctor, an x-ray technician, one healthcare assistant (who took Leon’s blood) and the laboratory (who mislaid the test results for a time) combined across four care settings (111, out-of-hours, extended hours, hospital) to provide Leon’s care.
All-in-all, a rather disjointed experience with almost no sharing of data between the different care providers. Assertions of the importance of Caldicott principles seem rather hollow when necessary data either isn’t exchanged at all or is printed out and manually handled.
So, what’s wrong with UK healthcare?
Leon’s experience (he was suspected of having a spontaneous pneumothorax) highlights a number of issues. Firstly, those managing Leon’s encounters seemed to share almost no data, meaning that time was wasted with the situation having to be repeatedly explained (four times in Leon’s case). Secondly, communication to Leon through the episode was limited, it was left to him to actively seek updates and clarify next steps. Thirdly, the different care settings appeared as completely different organisations with call backs and re-registration rather than operating in concert to manage Leon’s situation as a single episode of care.
If we look across the world, Japan (not included in the Mirror, Mirror… report) spends more on healthcare, providing for a more elderly population but has a far lower rate of obesity. Japan appears able to deliver significantly more provision at little additional cost but it is note-worthy that the level of obesity (a significant risk factor for type two diabetes) is very low by world standards. This is relevant to UK healthcare where there were 2.7m people living with diabetes in 2013 and (according to the 2015 NHS England Annual Report) one in five primary school children are clinically obese. If we add lifestyle demand (such as alcohol related hospital admissions) we must take the view that demand for healthcare is as important an element in solving the UK’s healthcare woes as is a reconfiguration of the way in which healthcare provision is organised. Interestingly, “Mirror, Mirror on the Wall” placed the UK last in the Health Lives category.
Given a healthcare system that, by some objective measures, performs reasonably well; what can we do to address its pressing challenges? Firstly, citizens (not just patients) need to be supported to manage their own social, mental and physical health. We need to support people in living healthy lives and to intelligently seek out the right medical care when necessary. Secondly, we need healthcare providers to work effectively together regardless of internal, organisational boundaries. This needs patient information to be shared across care settings and for treatment to be organised across provider borders, driven by patient need.
References
Commonwealth Fund, Mirror, Mirror…