Filed Under (Healthcare delivery, Patient involvement, Reform of the NHS) by Paul on 25-03-2014
This is the second of five posts exploring the way in which discussions about pressures on the NHS are being framed by its recent leadership and current commentators.
Yesterday I challenged the widespread assumption that the increase of the proportion of elderly in the population would from now onwards be seen as an overwhelming burden for the NHS whereas other industries see older people as possessing assets – assets that would be much more useful for a health service to work with.
I argued that characterising such problems as overwhelming does not bring about change but makes the NHS ‘hunker down’ under the status quo.
Today the second of my five posts focusses on the way we frame the argument about the fact that, in England, disease in the 21st century is different from that of the 20th.
Commentators, including myself, have said that the radical change in the nature of disease is a very big challenge for the NHS. The diseases that the NHS took on when it was founded in the last century have now been if not conquered certainly tamed and this century’s disease battle is very very different.
Health systems now have to tackle non-communicable or chronic disease.
As with the increase in the number of old people this issue is often presented using drowning metaphors – a wave, a flood or a tsunami of need is being talked of. The same enormous increase in figures used in regard to the numbers of the elderly are deployed again.
The first thing to say about this change in the nature of the diseases that the NHS has to deal with is that it is not a future thing, it is already here. Given that even today about two thirds of the NHS budget is spent on chronic diseases we must recognise that the problem has already arrived.
The fact that statistics for nearly every non-communicable disease point to a dramatic rise over the next few decades seem to ramp up the size of the problem to another one that is overwhelming.
Firstly it’s important to see that some of this is a problem of success. All of these conditions are more prevalent with age. The older the population, the more likely it will suffer with long term conditions. The fact that we are living a lot longer is partly due to the NHS, so the fact there are more people with non-communicable diseases is also partly due to its success.
In the pretty nigh unending battle between disease and human endeavour, notch one up to us in ensuring people are living longer.
Let’s take the specific of heart disease.
When I grew up in the 1950s the expectation was that when someone had a heart attack they either died or they quickly had a second heart attack – and then died. That has changed dramatically. Over the past 20 years survival rates have increased and now many more people survive heart attacks. We are now much much better at stopping the attack from destroying the heart and much better at stopping the second attack. We are also much better at diagnosing a ‘weak heart’ before an attack.
All of this means that there are now many more people with ‘heart problems’ than previously. It’s difficult to see this as anything but success.
The same is true of cancer. Go to the Macmillan’s website now and you will read a lot about survivorship as a major issue for people with cancer. Again in the battle between disease and humankind I can’t but see this as another great success. Much more to do, but so many more people surviving is a good thing.
So why is the changed nature of disease with which the NHS deals with such a problem? The main issue is caused by that word ‘change’. The NHS is shaped to do one thing and it now has to do another. It finds that change hard, but such a change does not have to be overwhelming.
The main reason it is described in this way is that the nature of the change the NHS needs to go through involves how 15 million people with long term conditions need to maintain their health. This, as a task, seems beyond the NHS – and in a literal sense they are right, it is.
The only way this new form of illness can be tackled by a health service is to recognise the importance of the people themselves in managing conditions. On its own the task lies beyond the boundaries of any health service. The service needs to find different ways of working to include and involve those people in much better maintenance of their condition.
What patients do to manage their condition – their lifestyle, diet and exercise – is as important as everything clinicians do.
A successful healthcare service needs to enhance the nation’s capacity to look after itself when it is ill.
Of course a really successful health service needs to enhance the nation’s capacity to look after itself before it is ill.
The danger is that the NHS sees itself as being overwhelmed by non-communicable diseases because it has to change to treat patients differently. They need to be seen not as passive recipients of care in a system that denies them both power and responsibility but instead as an integral part of a system that empowers them to take greater charge and more responsibility for their own health.
A model of health care that is controlling finds the necessity of this change overwhelming.
But in reality it is an opportunity is to bring patients inside the decision-making tent. An opportunity to let go of all that responsibility and let patients share the dilemmas clinicians and managers face – rather than keeping them outside.
This is only overwhelming if the NHS cannot let go of this power. What will be overwhelmed is a particular model of health care – not health care itself.