Monday 20 May 2013

Prevention is the word that will save the NHS

The influential NHS blogger Roy Lilley asks precisely the right question this morning. Why is the Accident and Emergency service not like the Fire Service?

If the incidence of fires has dropped by 40 per cent, and it has – as we know thanks the review by Sir Ken Knight – what can the NHS learn from that? The answer lies in the neglected word ‘prevention’. The Fire Service has been devoting increasing energy and ingenuity into preventing fires.

Partly the success is down to smoke alarms, which are now in 86 per cent of homes. Strictly speaking, this isn't prevention exactly, it is early detection – but it still helps.

As Lilley says, the real problem is people with Long Term Conditions, who account for 70 per cent of the costs of primary care. It so happens that the NHS is at its very least effective here, trying to maintain patients in their conditions at huge expense for the rest of their lives – rather than helping them find ways of managing and improving the conditions themselves (I write as someone with chronic eczema, when the mere thought of NHS dermatologists now makes my skin creep).

I’ve written about this before, and regular readers (if there are any) will know that there are lessons to be learned from:

  • Flexibility, and the power that patients have to vary the way they are treated and the arrangements around that, as I said in my review on barriers to choice. 
  • Co-production: the People-Powered Health project at Nesta calculates that this aspect of self-care and mutual support would save the NHS at least £4.4 billion, and may save as much of a fifth of the cost of treating long-term conditions.
  • System thinking, and the way that the public services need to be seen as a whole system rather than an alphabet soup of overlapping and conflicting jurisdictions. 
But here lies the real difficulty and the real reason why the Fire Service is different from the NHS. The Fire Service is vertically integrated and is the only agency that deals with putting out fires, while navigating the health an social care system is a full-time job in itself.

That means that investing in effective innovation in one area of public health will accrue to somebody else’s budget. It is a recipe for waste and stagnation.

Now, say what you like about the health reforms – and I have – but putting the doctors and local authorities in charge of paying for the NHS (the new CCGs) does provide a structure that has some motivation for innovating.

The trouble is that they can still load all the costs on the local foundation trust's A&E service. We also need to find ways that the big hospitals can reach out into the neighbourhood and stem some of the demand that floods through in ill-health – and this is a perfect project for hospitals and CCGs combined.  Both need to invest and both stand to gain.

Either way, prevention has to be the new buzzword in public services. It is the pathway to a solution to rising costs and struggling effectiveness – but it means structuring the system so that it is flexible.

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