Changing the NHS – Preventing Ill Health – 1

Persuading Clinicians to Get More involved in Prevention

In my introductory piece to this series of posts “The Mechanics and Morality of Change in the NHS” I identified six themes that I believe any innovator needs to consider before, during and after the process of introducing change to the NHS. (New readers may want to read that first).

For the past three weeks I have been talking about “Changing the Skill Mix”.

This week and next I will be following the same pattern to say a bit about the prevention of ill health (primary prevention), and much more on the prevention of that ill health from getting worse (secondary prevention).

So how do we persuade NHS clinicians that this is an activity that they should carry out?

The idea that the NHS should pivot some of its work towards prevention is not a new idea. In fact, if I lived in a very large mansion (ed. he doesn’t), I could paper all its walls with the many pages of the many plans that the NHS and others have published. All suggest that this is a good, rational and necessary idea.

In 2024 after all of these reports, the NHS remains unmoved. We are approaching the 10th birthday of NHSE’s own 2014 Five Year Forward View that argued for this strongly. Born in 2014, it will be old enough to go to secondary school this year. But nothing has happened to put its aims into practice.

So, we have the NHSE itself (in 2014 and in 2019) saying that the NHS will do much more about prevention. We have nearly every think tank and commentator on the NHS saying it should do more about prevention. Given this universality of policy direction it is a waste of time of our time for me to make the case here that prevention is important (since everyone agrees, why add more verbiage?)

Today I want to start to explore the opposite idea. Given everyone agrees, including the NHS’ own bosses at NHSE, that this is the policy that it should be following, why day after day, year after year, doesn’t it happen?

Unless we understand the power of the continuity of the current treatment-orientated model, making the case once more for prevention, is a waste of breath.

Clearly over the last decade, medical practice has not pivoted towards prevention. Those arguing for it have been unsuccessful in persuading clinicians to move towards it. So, let’s start with that argument.

Many people who argue the NHS needs to change talk about the ‘NHS current model of care’. Nearly all of that current model (but not all of it) emphasises the importance of treatment. And for millions of people successful treatment improves people’s lives.

In primary, mental health, community and acute care clinicians go into work every day and a million people come to see them with illnesses. Facing this important interaction, at the core of their work, clinicians have no option but to treat them. It’s not morally possible to do anything else.

And the facts that the next day another million people turn up waiting to be treated, and that behind them is a long waiting list, only adds to clinician’s certainty that treatment is what they actually do.

In the light of this experience of clinicians, it makes no moral sense to suggest that this ‘model of care’ is wrong. The patient may smoke, drink and eat too much, and take no exercise. But the clinician’s moral duty is to treat the disease with which they are presented.

Over the last few decades I’ve spent many hours’ talking to clinicians about how they might expand their work to include prevention. I have talked about ‘teachable moments’ – when there is a right time to “teach” patients about their own behaviour and preventing further ill health.

I have mentioned previously the work in Ottawa hospitals where they recognise that the time patients are in hospital is one such teachable moment. They use these teachable moments to help teach people how to give up smoking.

But when talking to clinicians about using such moments, they are often brutally honest about their skills and what they are good at (and what not). Persuading someone to give up smoking requires very different skills from diagnosing a condition. It may not be the case that clinicians possess skills of persuasion (and it’s very likely that they will not have been taught them in training).

So, when I and others ask them to use such moments, we are often moving beyond their skill set. But while this may be true of some clinicians, other people may possess skills of persuasion they can use in those teachable moments. Employing staff who have successfully persuaded people to carry out behaviours that they thought was beyond them (something that makes sense in many areas of life) would be useful for these teachable moments.

In fact, in one area – the diagnosis of type 2 diabetes – the NHS has learnt to use the moment of diagnosis to teach different behaviours. We now know (and achieve with patients) that it is possible by undergoing a really tough diet and exercise regime, to reverse the condition.

The moment of type 2 diagnosis is a powerful teachable moment. At that moment you are given this fleeting second chance which will only work if you change your behaviour. For many people the motivation of the moment really works but they need the help of a health care worker to see them through.

Today we’re looking at the conversations that might persuade clinicians to engage in greater prevention work. As with all change one of the main problems is the sense of loss that comes with ceasing to do something you are good at.

Over years, working as a clinician, you will have become good at diagnosis and treatment. Hearing someone suggest you should do less of this and more of something called prevention may make you worry about losing the skills that you enjoy using. And the resulting gap would be filled only with a set of promised work which you are not at all clear you will be any good at.

If we are to succeed in getting NHS clinicians to pivot toward work on prevention, we will need to place that work alongside, and not in opposition to their core work of diagnosis and treatment.

And that’s a problem with many clinicians’ experience of prevention. For the patient in front of you. here and now, and needing treatment today, should have had the primary prevention that would have stopped the disease years ago. I am a clinician in the here and now, treating an illness that should have been prevented at a much earlier stage. How do I work with that past? Especially a past that didn’t happen.

By definition. the disease I am working with here and now was NOT prevented.

In my opening remarks today I made a distinction between primary and secondary prevention. There are few activities that NHS clinicians should engage in that improve primary prevention. (The ‘teachable moments’ above are some of them) but most primary prevention is the responsibility of other sets of institutions who don’t have responsibility for health care.

That is why, if we are to succeed in this task of pivoting NHS clinicians to more work on prevention, it would be better to concentrate (for NHS staff not for other parts of society) on secondary, not primary prevention.

As a part of their core skills of diagnosis and treatment, it should be possible to suggest to existing clinicians that secondary prevention could help to prevent a disease getting worse. If this is the case, then existing clinicians have the skills and relationships with patients to help make that happen.

This form of prevention – reducing the speed with which diseases and conditions worsen – could be delivered as a part of their existing core skills.

As we shall see over the next few posts, spending more time, effort, and skill working with patents to help to reduce the speed with which diseases ruin their lives, is a noble cause.

Our task is – since there are a million consultations between clinicians and patients every 24 hours – to make sure that a higher proportion of the time and energy expended in them helps patients to much better self-manage their conditions to reduce the speed with which diseases can ruin our lives.

In the next five posts I will work through how to help make that happen.

Addendum. Today’s publication by the Times Health Commission has some relevance here. I will be referring to it in a future post.

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