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PATIENT CARE


Four factors to tackle long-term issues


The headlines in the mainstream media over the 2017-18 winter period highlighted the scale of the challenge faced by the UK’s National Health Service. Graeme Currie, professor of public management at Warwick Business School, asks what can be done to tackle this issue.


During a difficult flu season, accident and emergency services across the country were under severe and sustained pressure. Ambulances queued, patients waited on trolleys in corridors due to a lack of beds, waiting times stretched to six hours and beyond. Terms like ‘crisis’, ‘disaster’, and ‘breaking point’ became synonymous with the state of the nation’s healthcare provision. Like many other healthcare systems across the world the NHS is facing a set of factors that make the delivery of effective affordable healthcare far more difficult than in the past.


A population that is both growing in numbers and living much longer, technological innovation that increases the healthcare options available, rising costs of treatment in many cases coupled with constrained resources, all of these factors mean that significant change is required to ensure a healthy NHS.


There are frequent calls for wholesale structural change, indeed major restructuring in order to make the NHS fit for the future seems to be permanently under discussion. Rather than consider the transformation of the NHS in its entirety, though, a topic which could easily fill several books rather than a brief article, I want to focus on a specific area of care that presents one of the most difficult challenges for healthcare systems in developed nations: the way that we deal with long-term conditions. Here, I am referring both to conditions that may be physical such as diabetes, ulcerative colitis, or obesity, for example, and also some


that are more specifically mental health related, such as dementia. These long-term conditions affect all age ranges, but many disproportionally affect older people. The negative impact of poorly managed long-term conditions is huge. Care of some 15 million people with long-term conditions consumes 70 per cent of the NHS budget in England, that is £77 billion annually, as well as £10.9 bn of the £15.5 bn spent on social care in England. Without the appropriate action on long- term conditions, for example, you will continue to get unnecessary acute admissions. Patients end up at Accident and Emergency (A&E), then being discharged unsafely back into the community, and then returning to A&E. It is a revolving door and unsustainable. Yet, attention to a few distinct measures would make a considerable difference to the effectiveness of dealing with long-term conditions and, in doing so, to the overall effectiveness of the NHS.


Structural reform


Of course structural reform of the NHS is nothing new. Yet, despite the best efforts of policymakers, the provision of care for long- term conditions remains inadequate. Much of the structural reform thus far, notwithstanding some recent reforms, has focused predominately on healthcare. However, long-term conditions offer a different set of challenges from situations that take up a finite, short-term period of time, that might involve, for example, diagnosis, surgery,


Structural reform of the NHS is nothing new. Yet, despite the best efforts of policymakers, the provision of care for long-term conditions remains inadequate.


NOVEMBER 2018


Graeme Currie, professor of public management at Warwick Business School


possibly a brief hospital stay and then being discharged home to recover fully. Instead, long-term conditions involve discontinuous intervention, in and out of different care settings, and across domain boundaries. Someone might have a more preventative problem that could be dealt with in the community by the GP, around lifestyle and diet, for example. They may have an associated mental health problem. They may have issues relating to social care - a housing problem, perhaps. An education setting may be involved, given that many mental health issues increasingly affect young people, like eating disorders.


When an older person is discharged from hospital, there is often nowhere for them to go because it is not possible to put a social care package in place. You get admission problems due to ‘bed blocking’ but arguably these are social care rather than healthcare problems. Long-term conditions need to be managed effectively by the different agencies that are involved. Reform has to be seen at an integrated system level, extending beyond just healthcare. Unfortunately, though, measures such as separating the commissioners of healthcare from the providers of healthcare in Clinical Commissioning Groups (CCGs), following the Health and Social Care Act in 2012, or the increasingly competitive environment and marketisation of health and social care generally, have tended to fracture and fragment rather than integrate services.


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