NHS Health Care. By the people, with the people – 1

This week’s two posts are reflections from a Fabian Pamphlet (published this week) that I have co-written with my colleague Charlotte Augst

The content takes seriously a direction which has been at the core of NHSE policy for some time. But we thought it might be an idea to do it – rather than just plan for it.

The NHS Long Term Plan said.

1.2 The longstanding aim has been to prevent as much illness as possible. Then illness which cannot be prevented should where possible be treated in community and primary care. If care is required at hospital, its goal is treatment without having to stay in as an inpatient wherever possible. And, when people no longer need to be in a hospital bed, they should then receive good health and social care support to go home.

This looks like such a good idea we thought we might explore locations where this was actually happening. And then think about how the NHS could expand the practice to many other locations.

We argue that not only do we know enough to make a start, but also that we can already see the green shoots of change in multiple places and If everything is connected to everything else, then there are many places to start making change happen.

One of the main reasons that change stalls is that NHS policymakers tend to leave out the crucial interactions between health professionals and the people who use services as being beyond the policy focus. Recently I have been posting extensively about the NHS Plan. This has included examinations of important issues about incentives and funding flows that I think would bring about a great deal of change. BUT along with most commentators I have not said enough about the crucial interactions in the consultation room.

If you want to change health and health care, changing what happens in the consultation room is vital. The whole NHS needs to recognise that our health care depends to a far larger extent on things that happen outside the consulting room, (in the home, with friends and family, with communities) than those that happen inside it. We believe that if we take this reality seriously our healthcare system will look different: it will get alongside people, tackling obstacles to health with them, and focusing on what helps them to manage their health better.

Our pamphlet contains a number of case studies which exemplify that change. Unsurprisingly many of the ways in which the resources that come from the patient, their family and their community take place in primary care.

But not all of them.

Involving patients who have surgery in improving their own health (better perioperative care)

At first glance, patient involvement in more specialist aspects of health care may seem less intuitively credible. For example, given the specialist nature of surgery, it might appear that a patient could not contribute much to surgical success. But, in reality, the choices people make outside theatre already have a huge impact on outcomes. Recognising this agency and working with patients ultimately brings better results.

Professor Scarlett McNally, deputy director of the Centre of Perioperative Care, explains:


“I realised after 20 years as a surgeon that how well I do things is only a small part of how an operation turns out. The complication rate of surgery can be halved if people are supported to prepare for surgery, if they exercise, stop smoking and eat well. We need the team to work with people, as a team, across the whole pathway. I’ve been involved in karate competitions and, there as here, it is clear that you need everyone to make all the steps better. Getting ready for surgery should be like preparing for a marathon.”

There is evidence from the UK and internationally that this patient involvement can help to:

        • increase how prepared people feel for surgery and what they understand they need to do before, during and after their treatment
        • improve people’s satisfaction with their care and what outcomes they report
        • increase the possibility of operating as a day case – which is far more efficient and reduces cancellations due to lack of beds
        • reduce the use of intensive care and the number of bed days inpatients need
        • reduce complications after surgery, meaning that people may feel well sooner and be able to resume their day-to-day life and employment quicker.

As McNally says: “All the evidence we’ve amassed at the Centre for Perioperative Care shows that the results are even better than we guessed. What improves results for patients and makes them feel empowered, also saves money for the NHS and increases staff morale. The ‘waiting list’ should be a ‘preparation list’. Even better, many patients can also maintain any behaviour changes to improve their future health.”

“The seven things that help prepare for surgery are almost the same as the things that improve health more generally and reduce health inequalities. The time before an operation is a ‘teachable moment’. It is almost never too late for ‘prevention’. With so many people on waiting lists, this is a huge opportunity to improve health for those who need it most. They are: smoking cessation, physical activity, better nutrition, alcohol moderation, a medication or senior review, good psychological preparation and mental health support, and practical preparation (after care, transport etc.)“

For the patient it is never too late for prevention.

For the NHS, 75 years on, it is never too late for prevention.

But now, if we don’t engage the resource that patient’s activity can provide, in another 25 years it could be.

Tomorrow I ‘ll work through a primary care example and discuss how, in the next ten years we need to better spread patient activation across the country.