Professor Sir John Tooke, President of the Academy of Medical Science, discusses how Cornwall could be at the forefront of healthcare reform following his Duchy Health Charity Lecture which was sponsored by the University of Exeter and Plymouth University.
The NHS, one of the greatest institutions a civilised democracy has produced, needs to evolve to be fit for purpose in a very different world from that which saw the passing of the Act in 1946.
A remarkable sense of social solidarity in the aftermath of the Second World War created the conditions for a comprehensive service available to all, regardless of ability to pay.
A recent ranking of national health systems put the UK first with the US 11th, largely reflecting the inclusion of equity and access in the ranking metrics. On some measures, such as survival rates for common cancers, UK performance is far less impressive. There is a huge gulf between life expectancy for the advantaged in our society compared to the disadvantaged, reflecting the economic and social determinants of health.
The success of our health system has helped shift the age profile such that by 2030 there will be twice as many citizens over the age of 85 than in 2010, increasing the burden of degenerative diseases, especially dementia, failing joints, vision and hearing. Life style changes related to diet and sedentary behaviour are resulting in a cumulative expression of diseases such as Type 2 diabetes and ischaemic heart disease.
At the same time the prospect of new, highly effective and specific treatment has never been greater, reflecting our ability to interrogate the human genetic code and vast data sets. Such promise has led to soaring public expectation. While medical therapeutic innovation holds great promise, technological advances that add only marginal incremental benefit are major cost drivers, a critical consideration in the current affordability crisis.
Despite these residual deficiencies and new challenges, society’s allegiance to the NHS and its iconic status make it hard for those in power to question fundamental precepts. It follows that political will can only be galvanised if i) a new social compact can be struck with society that reflects the need for evolution while retaining public confidence, and ii) if clinical leaders champion the need for change, threatening in many cases their own vested interests.
A simple, relatively uncontentious purpose for a 21st Century National Health ‘System’, is the optimisation of health and wellbeing for the whole population in a manner that is accessible and affordable and tackles health inequalities. The requirements include: a service that seamlessly integrates primary and secondary care, public health and social care, organised around the needs of patients/citizens, not professions or NHS structures; a shift towards prevention; empowerment of patients and frontline health workers, and the adoption of genuine shared decision making.
To bring this about I suggest seven key proposals.
- The system should be organised around the needs of patients and citizens, recognising that control lies with the patients, not professionals.
- An holistic approach recognising that environmental factors, social factors and local economy are major determinants of health outcomes. ‘Integration’ needs to embrace that reality and dissolve divisions between primary and secondary care. Public health needs redefining for the changes of the next 20 years.
- Funding per head that reflects local factors such as rurality and health burden, for a comprehensive integrated system (the current commissioning arrangements add cost and risk of aggravating divisions between primary and secondary care). Contract periods need to be long enough (say 15 years) to incentivise investment in primary care, preventive medicine and the ‘new’ public health.
- ‘Digitalisation’ should continue apace to i) act as the ‘glue’ for integration; ii) provide the means to improve productivity of systems and processes; iii) empower patients in the co-development of their own health; and iv) provide the data to drive research, innovation and a ‘learning’ organisation culture.
- Academic alliances should be fostered to: i) Promote excellence, innovation and evidence-based practice; academic health science systems should oversee the faster adoption of therapies of true benefit. ii) Provide the education and training. iii) Take advantage of the digital revolution. iv) Stimulate the local economy.
- The medical profession needs to recognise that many technical procedures and protocol-driven care can be delivered by trained others. Doctors should be advocates for public health as well as the patient in front of them, and recognise a role as managers of resources.
- A social compact should be forged that reflects a mutual commitment to a new National Health ‘System’ that involves rights and responsibilities and reflects economic reality. We should learn from less advantaged nations which are creating high-quality transformative approaches based on limited affordability.
The solutions to health care challenges are often context specific. Cornwall has 31 per cent more residents over the age of 75 than the rest of England; rurality and relatively low population density; economic challenges; and scale and cost effectiveness of specialist services for a relatively small population. But Cornwall could harness its strong regional identity, be in the vanguard, and champion radical, integrative solutions for health, social care and public health, exploiting unitary authority status.
The health system in Cornwall has long championed the importance of education and medical school alliances can be fostered to drive innovation and evaluation. The path will not be easy – specialist services will need to be realistically distributed and health care professionals adjust to new roles and ways of working. But the prize is a locally responsive sustainable health and social care service for Cornwall, fit for the 21st Century, not post-war Britain.
Professor Sir John Tooke is president of the Academy of Medical Sciences and helped create the Peninsula College of Medicine and Dentistry for the South West. He was in Cornwall this week giving the 2015 President’s Lecture for the Duchy Health Charity