Radical redesign of services – 4 priority areas to help tackle the NHS demand problem

by Mehdi Juma

By Joachim Werr, Dr Steve Laitner and Prof Matthew Cooke

The number of patients waiting to start elective treatment grew to a record 6.4 million in March. This number could yet grow larger – and could reach 13 million according to Health Secretary Sajid Javid.

It’s not just elective treatment facing a lengthy backlog. Services across health and social care are facing increased demand with cancer treatments and A&E similarly affected. Once you add in a further 30% increase in chronic disease prevalence expected in the coming years, driven primarily by an ageing population and dementia, falls, and cardiovascular disease, the picture begins to look even more bleak.

The key issues facing the NHS and social care are well-publicised. Workforce is a top concern for NHS trusts across the country, with staffing challenges now as pressing as the financial challenge. All of this makes the Govt’s Build Back Better ambition to increase NHS elective care output by 30% within 3 years, all the more challenging. By way of context, in 2015-20, NHS elective output grew 14.8%.

To stress the workforce point, the NHS currently has a staggering 110,000 unfilled posts – including 40,000 nurses and 8,000 doctors. The Kings Fund recently concluded that “…the workforce crisis will be the key limiting factor on efforts to boost NHS activity and tackle the rising backlog of care.” So while ambition is important, we must note that health workers cannot be cloned and we are fast running out of time to increase the workforce. The Health Foundation recently estimated an extra 488,000 health workers and 627,000 social care workers will be needed in 2030/31, a 40% and 55% increase in staff from today and more than double the growth seen in the last decade.

How can the NHS increase its capacity to meet this tsunami of NHS care demand?

It’s clear from the myriad challenges facing the NHS and social care that NHS demand vs supply equation cannot be solved without radical change and service redesign.

As the authors of this blog post, our experience spans the breadth of the health service including emergency and primary care, quality control, academia, public health and technology innovation. Coming together to assess this vast challenge, we identified four areas for the radical change we believe is needed:

  1. Shift out, at large scale, the least complex tasks from clinical NHS staff to non-clinical service providers (yes, even less complex clinical tasks). There is an industry for task-shifting and outsourcing and it’s time for the NHS to seriously engage with this industry. It’s clear that the NHS doesn’t have the luxury to deal with any task that others could do with limited training. The largest opportunity may in fact be to actively shift out tasks to patients/carers themselves, as we know that patients’ capacity and willingness to engage in supported self-care is much higher than currently leveraged by the NHS. As the saying goes “the greatest untapped resource in healthcare is the patient”! Let’s start with the most resource driving clinical pathways for routine management of chronic conditions. What tasks in these pathways could be delivered by a non-clinical workforce and the patients themselves? Of course, with the right training, instructions, support and digital tools.
  2. Offer credible alternative clinical pathways to hospital admission that are less staff intensive: This work is ongoing within the national Virtual Ward programme, but the challenge is scaling these models and designing them in a way so they don’t “cannibalise” hospital staff. The focus also needs to be on patients and how they best can be supported rather than technology and how we potentially can deploy more of it. The opportunity to scale relatively low-tech telephone-based models is far from exhausted and these technically simple models reduce the risk of digital exclusion that comes with many remote care models. We need to remember that the single largest driver of digital exclusion is age, and the target group of virtual wards are primarily elderly and frail.
  3. Engage in data driven secondary prevention: Using data to predict and prevent care need rather than react and deliver care. This is a crucial point. HN’s work shows that through the use of AI on routinely collected healthcare data, the NHS can detect 8 out of 10 patients at immediate (within 3-6 months) risk of exacerbation and hospitalisation. Acting on this information and supporting these high-risk patients, we can enable them to prevent at least one in three unplanned care events. Without doubt, it’s time to start predicting and preventing – instead of reacting and treating.
  4. In the long run, we need to engage in primary prevention more actively. Covid accelerated the use of digital channels between healthcare and citizens. Could these channels be leveraged for targeted interventions; support for people we already know have risk factors (often multiple) for future Long-Term Conditions through holistic clinical health coaching support

There’s little doubt that it will take time to redesign and implement new ways of working in order to make a great impact. But we must act now in order to stem the tide of rising demand, and support the health service and social care to provide high-quality and sustainable healthcare to the patients for the years ahead.