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Creating a patient-centred NHS

Published on 08/10/03 at 02:22pm

First the good news. Everybody  from the Government, to patients and all the NHS bodies in-between  agrees that the vision of creating a truly patient-centred service is the right way forward if the existing equitable, free-at-the-point-of-access NHS ideal is to survive.

The challenges facing an organisation as vast and complex as the NHS are not to be underestimated, however. The most important challenges are at the frontline of service delivery, and Health Secretary Alan Milburn and NHS Chief Executive Nigel Crisp reaffirmed their commitment to letting NHS professionals lead the reform themselves.

The bad news, at least for NHS professionals, is that to build services around patients, and not vice versa, personal battles - often with other NHS professionals - over money, human resources and decision-making powers must be fought and won.

Champions of change

These frontline reformers, often 'ordinary' nurses and GPs, have a support structure of champions and exponents to help them fight these battles, including the Modernisation Agency, the new Integrated Care Network and the free-roaming health czars including Harry Cayton, Director of Patient Experience and Public Involvement.

Mr Cayton, also the Chief Executive of the Alzheimer's Society, told health professionals at the recent NHS Alliance conference 'Vision into Practice' that the relationships between individual patients and care professionals, and between health services and the communities they serve, must be transformed.

"For many users of the health service their journey through it is uncomfortable, inefficient and unco-ordinated. The new structures for primary care and the new links that PCTs create between primary and secondary care and the communities they serve aim to build health services around their users. Listening to users, listening to communities, is essential if those changes are to be effective."

Mr Cayton gave one example of how services are being re-designed in local pilots around the country.

"In the south west peninsula, people with suspected heart failure were referred to a cardiologist at out-patient clinics for their echocardiograph. They had to wait four to six months for this appointment. Now, their GP is able directly to book an echo-test using a form jointly developed between GPs and cardiologists. The patient knows when their test will be instead of waiting for a distant date in the future. The majority of patients receive their test and have the results in 14 days. Patient experience is vastly improved and better health outcomes too."

This is just one of many new patient pathways that have produced apparently semi-miraculous reductions in waiting times and improvements in patient care, at very little cost. These projects can only prosper when there are some basic pre-requisites in place - primary care personnel willing to take the lead, PCTs willing to fund and support the experiment, and secondary care clinicians open to primary care innovation.

The success of an innovative primary care-led service to diagnose and treat heart failure in Darlington depended greatly on winning the support of a lead secondary care cardiologist to support the GP lead.

Cardiologist Jerry Hall said: "I know from personal experience that there are lots of cardiologists who are not suited to getting involved in this non-glamorous end of services. As a profession we are appalling at accepting the input of general practitioners."

Similar stories of lack of dialogue and collaboration are emerging wherever primary care professionals - especially upstart nurses - are leading radical changes to services.

Non-executives

One of the biggest controversies to emerge in recent weeks was plans to cut back the working hours of PCT non-executives to just two-and-a-half days a month. Unpaid non-executives are intended to be advocates for the public and patients within PCTs, but the extent of their role remains undefined. Vilified for the idea by many, NHS Appointments Commission Chairman Sir William Wells defended his suggestion at the NHS Alliance conference as good for the NHS and patients.

"We believe non-executives have to be somewhat detached from the executive  the more they get sucked into what the executive is doing, the less able they are to stand back and challenge and be seen to representatives for the patients and the people they represent. This is a fine line, and it will be different for different people, and different parts of the country."

Sir Williams plans were hotly contested by conference delegates.

"Our experience has been that our non-executive has really contributed and has got under the skin of our organisation. As a clinician, I get an incredibly more searching set of questions from the board." said Dr Stephen Earwicker, Personal Executive Committee Chair for Broxtowe and Hucknall PCT.

"I am no longer asked about my prescribing overspend, I am now asked, So why do you prescribe statins to this group of patients and not that group? How do you justify it? If we keep them at arms length we wont really get the benefits of those people."

Sir William's critics could not, however, dispute his point that existing non-executives were not representative of patients and the wider public. The vast majority being white, middle class and retired; undoubtedly committed advocates, but not always the best placed to reach out to all sections of society.

Meanwhile, concerns about adequate funding for patient involvement were also raised.

"In organisations that are pressed financially, it is one of the first things that gets dropped. This is not least because the public themselves ask, 'Why are you wasting money on asking us what is required, we need more doctors and nurses'," said Diane Evans, Director of Planning, Bournemouth PCT. "We need to change that perception by demonstrating that involving patients, carers and the public will actually lead to better services and better health."

Harry Cayton responded by saying that NHS professionals should not try to create a monolithic 'superstructure' to process patient experience, and that "going round a ward with a clipboard asking questions" would be a more fruitful exercise.

Many other serious complaints are now arising, including PCT complaints that strategic health authorities are allowing acute trusts to monopolise clinical network funding and thus distort clinical priorities.

48-hour access

At the same time, Nigel Crisp confronted GPs and their PCT colleagues with an uncomfortable truth about the 48-hour access target set for general practice. "We have insisted on pushing through these targets because this is what patients and the public have told us thats what they want."

This controversy is certain to rumble on and could be a make or break element of the new GP contract; it nevertheless also represents a political imperative for a Government that must be seen to be improving the NHS through its recent tax increase.

Finally, the new lines of accountability have undoubtedly created a very healthy debate about how patients can be best served, but translating this into positive action will inevitably be a different story from health economy to health economy. The pharmaceutical industry is, as ever, willing and able to help, but companies must make sure they understand the complexity of challenges the NHS faces when it offers to lend its expertise.

Harry Cayton's three messages to create a patient-centred NHS

Trust me, I'm a patient

No one has greater interest in an effective health service than patients and the public. Use us as partners, trust our expertise and interest and let us work with you to transform healthcare.

Tell me the truth

At individual, community and national level we need more honest and open dialogue. Patients deserve to know and need to know the truth about their condition, about the options open to them. Communities need to know that health economies are acting in the interests of the community. At national level we need a more realistic debate about what the health service does well and what we can realistically ask of it.

Nothing about us without us

Its our health service. We pay for it. We use it - and sometimes abuse it. But we value it. Bring us inside so we can work together in the interests of all.

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