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We must focus on the root causes of NHS challenges and not ‘firefight’ the ABCD symptoms

29th Sep, 2022

Last week Thérèse Coffey, Health and Social Care Secretary, set out ‘Our plan for patients’. Building on the NHS winter plan and the published adult social care reform, Coffey outlined measures detailing A, B, C, and D priorities: Ambulances, Backlogs, Care and Doctors / Dentists. Is it as easy as ABCD or should the focus be shifted to addressing root causes of NHS challenges?

The plan emphasises the right public pain points through greater data transparency; better access to primary care; better direction of urgent care including NHS 111 and ambulances; faster adult social care discharge; expanding physical capacity; maximising independent sectors; and shifting autonomy of dentistry services to Integrated Care Boards (ICBs).

Ultimately, whilst the plan might have the right intentions, the priorities outlined seem to resolve symptoms of the challenges and not the root causes of the challenges. For example, the ambulance backlog (A) is a by-product of B, C and D rather than a root cause problem, so in this instance to resolve the ambulance backlog challenge, the wellbeing of the workforce and the ‘back end’ require significant improvement. Though some ‘firefighting’ of the symptoms must be prioritised, such as clearing the backlog and reducing GP waiting times, resolving historic and current health and social care challenges can only sustain if we dig deep into the causes of an ever-increasing demand of healthcare with a counteractive restriction of supply.

Reducing the demand of health care

Ultimately, to reduce the demand for health care, we want to stop getting people sick in the first place. However, once patients do get unwell, services must be diverted away from the most pressured sites such as A&E departments to community-based healthcare. But to do so, trust in primary care must be re-built and technology welcomed.

  • Health of the population: No matter how efficient a health care system is, an unhealthy population will continue to pressurise the system. Behavioural risk factors represent the largest opportunity to reduce health burdens across the population, making up more than 50% of the preventable DALYs (disability-adjusted life years) as estimated by global burden of disease. Unfortunately, it doesn’t just stop there. There is a steep social gradient in these risk factors. The most vulnerable sections of society are experiencing the biggest impact with a stark 8-year difference in life expectancy between rich and poor, and an 18-year gap in years lived in good health. We’ve witnessed the impact of this on the Covid-induced pressures. The more we work on building a healthier population, the less the pressure on all areas of the health and care system.
  • First point of care: Once patients do fall ill and require care, the first port of call is their GP. With public satisfaction in GPs services at an all-time low, we have reached a significant breaking point, tangible changes must be made immediately. Whilst the published plan does touch on empowering pharmacy-based prescriptions and ensuring patients get seen by their GP within two weeks, how this will be done is not specified. We simply cannot divert all services away from the GPs and must take a thorough look at the GP operating model including hours worked, skills mix of staff and referral systems.
  • Digital transformation: Digitising health care has continued to present its own unique set of challenges. To reduce the demand for healthcare at the pain points in the ecosystem, we must leverage technology and understand and validate our data. This accuracy and relevance of data is particularly important when analysing backlog data to enable the clinical prioritisation of patient lists. We must also learn to adapt and learn from international models that have worked elsewhere such as self-referral systems, which are present in Italy and Germany, where patients are given more autonomy and able to book appointments directly with a specialist without needing a referral from their general practitioner.


The supply of health care: workforce wellbeing

There’s widespread concern across the health and social care sector that the plan has been rushed out without much engagement and the crucial enablers to all the priorities is missing – the workforce plan.

  • Wellbeing of workforce: It doesn’t matter how many resources are thrown into the health and social care system, a demoralised and ailing workforce will continue to be the fire that burns the whole house down. Since the ‘firefighting’ will not stop immediately, health leaders need to nurture NHS staff before they reach a breaking point and put individual wellbeing at the centre of policy. This means ensuring the “personal sacrifice for the greater good” culture is well and truly left behind, and a focus on self-preservation is championed instead.
  • Efficiency: ‘Front door vs back door’: How many and how quickly patients can enter any part of the health and social care system is highly dependent on how efficiently and safely patients exit the system or the ‘backend’. This efficiency is highly dependent on operational models, the culture and mindset of the workforce to drive efficiency and integration of different levels of care. Both front and back end of clinical pathways must be equally prioritised, and quality and efficiency of care must be viewed in parallel. This could aid in releasing over 11% of medically fit patients occupying beds with more nurse-led discharges.

Whilst the detailed plan does touch on pain points, the ABCD is not new to us in the health care system. A lack of specificity on the ‘how’ has been a long-standing criticism with a lack of focus resolving the root causes of the challenges and not just continuously ‘firefighting’ the symptoms. We should no longer put our faith in sound bites but should rather use sound judgement and prioritise resolving the root causes of our demand and supply challenges — with a particular focus on improving the overall health of our population and prioritising the wellbeing of our workforce.