A new contract between NHS England and its tax-paying patients will buy a lot of changes…

This week I have written three posts to outline some of the contractual promises that the NHS can make to the British people in return for the extra money they are going to raise through paying their taxes.

On Monday I talked about how increasing diagnostic cancer tests can increase cancer survival rates. Yesterday I argued for a return to the strategy that delivered a successful diminution of the inequality of life expectancy by targeting people in poorer areas – who would otherwise have died in their 50s and 60s.

Today I want to describe ways in which we can help more people that have been diagnosed with diabetes can reverse that diagnosis through diet and exercise.

All three of these issues are very important in their own right. We must improve cancer survival rates; we must traduce the inequalities of life expectancy, and we need to help people not to succumb to diabetes. But each of these posts make an additional point about the necessity of reform of the way in which the NHS carries out its core business.

I have made the point that, over the next few years, we must improve NHS’ capacity to use Artificial Intelligence (AI) because in the future we will not have enough consultants to carry out all the necessary cancer diagnostic tests. So to improve survival rates we will have to speed up the application of new technology to what has traditionally been the work of the consultant.

I hope also that I have demonstrated that we need to target people who are prematurely ill in much more specific ways. It’s true that we are better now than we used to be but developing anticipatory medicine in those areas where people will otherwise die too young is a necessary reform to save lives.

And today, I want to show how, if we are going to succeed in reducing the incidence of diabetes, we are going to have to marshal the expertise of the hundreds of thousands of patients who have been diagnosed in the past to work with the newly diagnosed.

In the next five years the NHS will only succeed in meeting these promises if it gets much better at using new technology; at anticipating mortal illness and in substituting the skills of patients for the skills of doctors.

If we carry on as we have been, none of this will happen.

There is a growing epidemic of diabetes which is very bad news for both the patients affected and for the NHS. It would be good if society at large joined with the NHS to decrease the rising numbers of sufferers but even with society-wide interventions it is still likely that by 2028 there will still be a rise in the number of people being diagnosed with type 2 diabetes.

The NHS therefore needs to act and intervene with more strength where it has a powerful locus – at the point of diagnosis. It is at this moment, when the patient is most likely to feel a sharper motivation to change their life style, that we need to intervene.

In the last two years we have learnt how patients can work hard to reverse the diagnosis of type 2 diabetes. A very strict diet and a lot of exercise makes it possible to reverse the diagnosis of type 2 diabetes and go into remission[1]. In 2018, this is still an unusual outcome. By 2028 it must have become the norm.

To succeed involves a considerable extension of what primary care can achieve at the moment and will require a prolonged and sustained intervention with the patient during the year following diagnosis.

A few weeks ago I posted about social prescribing. We already have some experience of developing strong partnerships that work between the NHS and civil society through social prescribing. Over the next 5 and 10 years this relationship needs to become the norm for all patients being diagnosed with diabetes.

We know this approach works, but to expand its reach there will need to be a transformation in normal communications with patients at the point of diagnosis and comprehensive follow-on support for patients, their carers and their families to see it through. This will take very strong and prolonged motivation reinforced by a fear of what diabetes will mean for their future lives.

This process can be improved by contact with patients who have had diabetes and who know how bad it gets. The patient will need weekly assistance from voluntary sector bodies with diet and exercise, and monthly back-up from extended primary care staff.

The biggest threat to achieving this type of reform lies in the difficulty of changing patient behaviour which will need much wider social interventions than simply the NHS. We need a social movement to back this up.

We already have about half a million patients undergoing a partnership between civil societies, patients and primary care through the practice of social prescribing. We know how to make that partnership work (and we know what factors make it more, or less, effective). We also know how to train and develop those who will provide the backing for change for the patients. In broader terms this will be part of the necessary extension of primary care that will be required over the next decade.

If we can successfully construct this diabetes support infrastructure creating a larger infrastructure for using social prescribing with primary care will help us to meet other targets.

This is exactly the sort of mass level intervention that a modern patient-orientated health service should provide. The cure for many people with very early diabetes is taking control of their own lives.  A modern NHS will only work with millions of more empowered, motivated and active patients.

Diabetes provides just one exemplar of this kind of intervention and in actual delivery these can be designed to treat different conditions with a single intervention – hypertension also requires weight loss and exercise so it would be daft for a patient with diabetes and hypertension to do two exercise programmes.

For all this to work there will need to be a genuine transformation in the nature of the communication between primary care and patients. Patients need to understand a great deal more about their diagnosis, their day by day actions and the consequences of them not seeing this through. It will need a very considerable change in hundreds of thousands of people’s behaviour but it is precisely because of this it is a significant pointer to what active patients can achieve in improving their health.

[1] Diabetes UK research on low calories diet has 45.6% going into remission after a year. 86% of those hat lose 15kg or more and 57% for people 10-15%.