Once an innovator, always an innovator
I first met David Colin-Thome nearly thirty years ago, he was ahead of his time then and it was great to read his piece on the PCC website recently which suggests he has lost none of his innovative thinking over the years. The big difference now is that with a large majority and a clear recognition from the incoming administration that “more of the same” is not the answer the time is right for some very significant innovative thinking. With his background in primary care it is not surprising that David rightly believes that the recovery of our secondary care services and improvement in overall outcomes can only be delivered by resolving the many legacy issues we have, left over from the introduction of the NHS in 1948.
The demography of our population has changed way beyond the imagination of those involved in 1948, life expectancy is about fifteen years longer, we have a much more diverse and sophisticated workforce and a range of advanced techniques and effective medications which could only have been dreamed about 75 years ago. There is a long overdue acceptance that the NHS we have now, which in many ways has become a National Treatment Service needs to change fundamentally. I remember speaking to people about change and innovation and the word “disruptive” was often used, what people meant was that those comfortable with the status quo were nervous and worried about their own positions. I remember a highly placed public health professional told me when I was in post that change is a constant and if you are fighting to maintain the status quo you are actually fighting to go backwards.
David quite rightly focused on the obsession in the press with targets in secondary care but there needs to be some acceptance in the secondary care sector that much of what they do could be provided in primary care, without any reduction in the quality of outcome, and save the NHS valuable resources. It is always dangerous to generalise but when you have seen it happening first hand it is difficult to ignore. In my time as Chief Dental Officer (CDO) I visited a dental hospital in the North of England after a conversation with the clinical director who was complaining about dentists referring in paediatric cases which it was felt should be dealt with in practice and were overwhelming their department. I said that they should refuse these referrals; this was agreed in principle but they had been told by the finance people not to do this as the tariff was so attractive that they made a very significant contribution to their finances, ignoring the fact that this was a waste of limited NHS funds.
In dentistry, when I was in post, the secondary care sector provided around 4% of the service and took around 20% of the budget. Some of this work was clearly wholly appropriate for secondary care provision but a significant proportion could, and should, be delivered in primary care.
David also suggests there needs to be a much closer relationship between social care and the healthcare system. In many areas the NHS is overwhelmed by patients who could and should be seen and looked after in the community by the social care system if it was adequately resourced and connected.
In a Trust close to my home they have a frailty team and nobody from care homes or home care is referred into hospital without an assessment by this team, this has significantly reduced inappropriate admissions and reduced bed blocking.
Possibly the biggest change since 1948 has been the growth in the skills of the non-doctor (or non-dentist or non-pharmacist) workforce, nurses no longer just make beds, take blood pressures and change bedpans! Advanced nurse practitioners work on medical rotas and carry out many surgical or invasive procedures, similarly practice nurses deal independently with many routine issues. In many cases GPs with a special interest can deal with conditions in primary care, scanning, monitoring, diagnosing and advising and referring only when it is necessary. Everybody involved in healthcare provision in the NHS should be working toward the top of their skill set and that is patently not happening.
Accident and Emergency should be where you go when you have had an accident or have an emergency, not where you go when you cannot find care anywhere else.
Professional barriers need challenging and healthcare needs to be seen as a whole team effort, not segmented by professional protectionism. I remember we organised a pilot, screening for chlamydia in a dental practice based in a Darzi centre, alongside a medical practice, the dental practice identified more undiagnosed cases than the co-located medical practice, purely because they saw more males between the ages of 18 and 50. A successful outcome you might think but it was terminated by the CCG because, I suspect, the medical leadership locally felt it was encroachment on “their territory”. This different demography of attendees should surely be put to use monitoring for undiagnosed hypertension or diabetes before symptoms become noticeable and medical advice sought,
Historically leadership of the NHS has largely been the role of secondary care big hitters. When I became CDO I was the first dentist with a background in primary care to hold the post, despite the vast majority of the care being provided in primary care. When we suggested that new dental schools deliver the clinical training in primary care I was told by the Dental Schools Council it was bound to fail because a) it has always been done this way: and b) dentists working in primary care could not teach. Wrong on both counts!!
So quite rightly the NHS needs a major overhaul but there has to be input from people not wedded to what we have now and are prepared to ask some challenging questions.
Most importantly it needs to be more community based and be a National Health Service not just a National Treatment service.