As the NHS battles with pressures never before experienced during summer, it is also preparing for what could be the worst winter in its 75-year history.
The headlines of the past two years have mostly spelt catastrophe and many of the solutions needed to address the “crisis” fall at the feet of the government.
Lack of a funded workforce plan, the tricky issue of pensions, the neglect of social care policy and the need for investment in buildings are all issues for the incoming prime minister to address. But beyond the money, could different ways of working help the NHS operate more effectively and tackle its biggest issues?
Dr Malte Gerhold of The Health Foundation think tank told The Independent: “The future of the NHS lies in giving it an effective innovation and improvement engine. Our problem is not that there are no good ideas and new ways of working out there, including through the better use of digital technology and data – it is that they are not systematically trialled, evaluated and then widely adopted.
“The government needs to invest in more coordinated implementation capacity, locally, regionally and nationally, to replace the piecemeal approach we have today.”
Turning to technology
One of the last policies launched by the former health secretary, Sajid Javid, before he stood down was the government’s new digital plan for the NHS. Technology certainly has a role to play in helping the NHS tackle its biggest problems, but the biggest gains are not going to be sci-fi solutions such as artificial intelligence (AI) replacing doctors or nurses.
One focus is the kind of technology that helps keep people well and out of hospital. The NHS has this year promised to introduce a number of “tech” solutions such as wearable watches that monitor the blood glucose levels of diabetes patients.
This idea of wearable technology that supports “self-care” is not new. One project, for example, supported by The Health Foundation, uses a device that monitors people who have cystic fibrosis.
The programme, called Project Breathe, allows patients to track their lung function and allows their doctors to monitor signs of deterioration. In 2019, a study of 120 patients using the device found signs of positive effects, with patients developing a better understanding of their health. Almost all avoided “unnecessary” clinic appointments.
Other tech, such as the Kooth app, which allows digital mental healthcare and support to children, have been around for a number of years. With the boom in need for children’s mental health, could this be an area to supplement the hugely under-pressure child and adolescent mental health services?
A service such as this, of course, cannot replace a face-to-face NHS service but can provide an alternative, and even support patients who are on long waiting lists.
A final key area is the many organisations that are taking steps to collect data on their patients and populations. With this data, NHS providers are better able to understand the inequalities a group might face and predict what interventions could be helpful before the point where they become so ill they need hospital care.
Keeping people well
The NHS’s backlog is growing each month and will continue to do so for the next few years at least, if Mr Javid’s comments earlier this year are correct.
Trust leaders across the country will no doubt have the pressure of reducing waiting lists at the forefront of their minds. There are projects looking at improvement on both sides of the waiting list: speeding up recovery from treatment, but also keeping patients well so they do not need the treatment to begin with.
The Health Foundation told The Independent about one project that trains cancer patients and their families to prepare for and help with recovery after major surgery. The training includes management of anaemia, nutrition and lifestyle advice, an exercise programme and a focus on diet.
The project, called ERAS+, found post-operative complications were reduced by 50 per cent across 1,000 patients at Manchester Royal Infirmary and there was a three-day reduction in how long people were kept in hospital. If implemented across trusts at a greater scale, the benefits could be significant.
Evidence shows populations with the biggest health issues are often those in the most deprived areas or those with long-term conditions. One project started in Birmingham, for example, focused on the support of parents with young infants, according to the NHS Confederation.
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Birmingham has some of the most deprived populations in the UK, the largest proportion of children aged under five and almost 60 per cent of its children up to four are Black or minority ethnic.
Forward Thinking Birmingham is a partnership of Birmingham Women’s and Children’s NHS Trust and local charities. In 2019, a project looked at how the partnership could shift funding to services focused on the first 1,000 days of a child’s life, eventually leading to “infant mental health” roles.
Moving funding is not an easy objective with the many pressures on the NHS and public health budgets, but projects such as this could lead to a healthier population. Another project, in South Yorkshire and Bassetlaw, is focused on reducing smoking rates.
These ideas might not tackle the immediate pressures of winter, but over the next decade and beyond the NHS could reap the benefits.
The ‘greatest crisis’
“We now face the greatest workforce crisis in history in the NHS and in social care,” said former health secretary Jeremy Hunt in July.
While the NHS waits for the big questions to be answered by government, what solutions could be sought to the ongoing problems with staffing as the health service comes out of a pandemic that has pushed workers to the limit?
William Palmer, senior fellow for the Nuffield Trust, pointed to the benefits of improving overseas recruitment. About 38 per cent of nurses joining hospital and community services, as of October 2021, were from overseas.
The Nuffield Trust says attracting staff from overseas is necessary for the NHS to function in the medium term, though key barriers can include perception of discrimination and visa restrictions.
Relying on overseas recruitment also comes with ethical questions. For instance, Britain has announced an agreement to recruit Nepalese nurses, despite global restrictions because of a shortage of healthcare workers within Nepal.
A second focus, Mr Palmer said, needed to be on whether those who train for NHS roles then join the health service. He said: “It comes at a cost, providing this training to the student, to the taxpayer and to the NHS. I think there’s something that needs to be done to really think about: are we making sure we’ve got that pipeline as shored up as possible?
“If you can get a higher proportion of those graduating in the next 12 months to join the NHS, then you can get the short-term benefits.”
The third issue the NHS is exploring is retaining staff. Leaked projections reported by The Independent showed the biggest limitation on nursing numbers was retention rather than recruitment.
Mr Palmer said: “It’s just one of those vicious or virtuous cycles. At the moment, we’re in a bit of a cycle where there are high workloads, then burnout means people leave, which then makes the job harder still. So it’s just about trying to stem that and trying to move into a more sort of positive narrative.”
Some NHS organisations, while acknowledging this, are attempting to understand what other needs their staff have that can be met within the confines of the current situation.
Barking, Havering and Redbridge University Hospitals NHS Trust, for example, opened a school uniform “marketplace” this summer, where staff were offered donated school uniforms and 200 staff members were given vouchers for school uniforms.
Charlotte Elton, who works on the trust’s cost of living team, said: “I’d been donating some of my own things via social media, as well as using these platforms myself because it has become more expensive to buy necessities, which led to lots of conversations with people about the impact this was having on them.”
Outrage at NHS staff needing this support is valid, but it is positive that trusts are attempting to support staff through a difficult time.
Other hospitals trying to limit the haemorrhage of staff are looking increasingly to flexible working, according to the Health Service Journal. Milton Keynes launched a group to promote flexible working at the end of 2019, which has since opened to all NHS organisations and has sparked a big conversation.
An important element in both projects is that they began understanding directly from staff what they needed. While the big question of pay cannot be solved at individual organisation level, these projects are proof of NHS organisations taking positive steps as employers.
Tackling social care
The number of people stuck in hospital beds who could be discharged is a huge issue for NHS services, both in the short and long terms. In July the proportion of people in hospital beds who could be discharged but had not been had increased by 11 per cent – something NHS England attributed to difficulties in social care, meaning there was nowhere for these patients to go.
Data published by Skills for Care, a charity focused on training for the adult social care workforce, showed that in 2021-22 there were 165,000 staff vacancies, equivalent to 10 per cent of roles across adult care services. This is up from 110,000 the year before.
Now some NHS organisations are looking at what they can do to tackle this issue. Northumbria Healthcare, for example, whose chief executive is the chief operating officer for NHS England, revealed earlier this year that it plans to provide home care services directly, putting the trust in charge of social care so it can avoid being constrained by issues outside its control.
The trust is hiring care staff directly. This means they are on more favourable NHS contracts: one of the major problems within social care is that workers can earn more working at supermarkets or other sectors with better hours.
One NHS chief executive for another trust told The Independent that more hospitals were likely to follow suit and healthcare leaders were looking at the possibility of using more flexible visas for oversea workers. He added: “There’s appetite to take on more domiciliary care. It would be the things that help us get patients out of hospital.”