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Let’s reshape frontline care for patients from the bottom up – David Nicholson


On the eve of his retirement, NHS England CEO Sir David Nicholson - who will be among the main speakers at the Health and Care Innovation Expo at Manchester Central on March 3 and 4 – sets out the transformational changes needed to improve care in the coming years:

For the past eight years I have had the privilege of leading the NHS, one of this country’s greatest institutions.
In that time we have successfully fought some major battles, not least against unacceptable waits for treatment and the scourge of healthcare-associated infections.
Now I believe the NHS needs to embark on a programme of transformational change to frontline care, arguably the most significant since its creation.
There are two big reasons why we need to do things differently.  Firstly, the NHS has to transform the way it provides care in order to deliver better outcomes for patients.
We have an ageing population, with a rapidly growing number with at least one long-term condition – currently 15 million people. If the NHS is to truly serve the public, we must offer the best possible quality of life to this expanding group of patients.
Secondly, the NHS has to change because, like every major health system in the world, we face a big financial problem for the future: the sums don’t add up. If we don’t change, we face a funding gap that could be £30 billion by 2021.
Our costs are rising as people live longer and we constantly improve our ability to treat and manage conditions that were once life threatening.  At the same time, we live in a time of austerity and we cannot bet on further funding increases.
Some will point out that we recently embarked on a major NHS reorganisation, which took effect only last year.  But this government’s Health and Social Care Act focussed, with good reason, on administrative structures.
These next changes must focus on the practical ways we deliver front-line care in our communities.  They must be recommended, led and built by clinicians on behalf of patients, from the bottom up rather than top down, harnessing the innovations and ideas of our people.
In my final year at NHS England, I have worked with patients and clinicians all over the country to establish what we need to see within five years’ time if this type of care is to be achieved.
Sir Bruce Keogh, NHS England Medical Director, has already set out a vision for urgent and emergency care, including different ways to get to help for minor problems – over the phone, online or close to home – and co-ordinated networks of emergency departments, with designated units for the most serious cases.
We must put this into place.  Access to the highest quality urgent and emergency care is fundamental, but our current system has evolved in such a way that it is now fragmented and confusing for patients.
We know that centralised, large units, with concentrated expertise and technology, work best in providing the most effective care. So we need to ensure this approach is applied to other parts of the health service, for people with very rare conditions, and for significant planned surgery.
As hospital services become more specialised and centralised, we will need a modern model of integrated care.
For example, people with multiple long-term conditions, often compounded by being elderly or frail, need a senior clinician taking responsibility for active coordination of the full range of support, from lifestyle help to a stay in hospital.
And those people should have access to a wide range of GP, nurse and other primary care services, which will mean we need much wider primary care, provided at scale.
This means giving people access to a broader range of services and a much bigger role for our GPs who would coordinate and deliver comprehensive care, working with community services and expert clinicians.
Underpinning all of this, we need a new approach to ensuring that citizens are fully empowered and included in all aspects of the NHS.
This means giving the public more control over their care, booking appointments on-line for example and doing more to look after themselves.  Technology has triggered massive changes in the banking and retail sectors that can also apply to healthcare.
It also means improving the way we listen to patients and act on their concerns.  And it means giving people still more information about the quality of services and ensuring the power of information is harnessed and used more intelligently.
Taken together, these changes add up to a radical transformation in the way people experience healthcare. They would enable our clinicians to save more lives and do more to improve the quality of the population.
Our NHS does a superb job for millions of people, day in day out, but it cannot stand still – it needs to adapt to survive.
But the NHS proposals for change always come with controversy. Too often the overall public interest gets lost in a debate about winners and losers with too much focus on buildings and not enough on services.
This time I hope the NHS, the public, policy makers and politicians will join forces to make it happen.  As someone who has spent 30 years working in the NHS, I know it matters too much to get it wrong.

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