The NHS in England needs a fourth shift to transform care and outcomes

Wes Streeting has argued that three shifts are required to make the NHS fit for the future: from analogue to digital, from treatment to prevention, and from hospitals to the community. These shifts are certainly necessary, but they are not sufficient. A fourth shift from providers to patients, people, and communities is also needed if the NHS is truly to be transformed.

The changing burden of disease illustrates why the fourth shift is so important. Long term progress in reducing premature deaths from heart attacks, strokes, and cancers has gone hand in hand with the increasing prevalence of chronic diseases. As the Global Burden of Disease study has shown, the number of years spent in chronic ill health is now greater than the number of years lost to preventable deaths, and yet healthcare systems around the world have been slow to respond.1

If the primary purpose of the healthcare system was once to provide mainly episodic treatment for people with acute illnesses, it is now to deliver joined up care for older people and others living with chronic conditions. Ongoing care for the growing number of people who have survived cancers and other major causes of preventable death is also a priority. Much of this work is done in general practices and community services, but in England their share of NHS funding has fallen in recent years as the share allocated to acute hospitals has risen.

The chronic care model developed in the 1990s portrayed the healthcare system as supporting “productive interactions” between patients and practice teams. The model emphasised the critical role of patients living with chronic diseases and how their actions contributed to care outcomes. It advocated an active partnership between patients and providers drawing on resources in communities beyond the healthcare system.2

The Realising the Value programme in England was designed to show how active partnerships could be supported across the NHS.3 It appeared to signal that the national leadership of the NHS was committed to this way of working and bringing person-centred care into the mainstream. A dedicated team was appointed to take forward the work drawing on analysis of available evidence and ten actions that were needed to put people and communities at the heart of health and wellbeing.

A well-established expression of active partnership is self-management support for people with chronic diseases. Many of these people are in contact with healthcare providers for a limited amount of time each year and their own decisions and resources influence how effectively their health is managed. Educational programmes and digital technologies can help to build confidence in self-management with support from peers, health coaches, and primary care teams.

Patients vary in their knowledge, skills, and confidence in managing their own health and care. The Patient Activation Measure has been developed to compare patients’ own assessment of their activation. Research shows that their scores are closely correlated with clinical outcomes, the costs of care and patients’ ratings of their experience. Better outcomes have been reported for mental health disorders as well as other chronic conditions.4

Research has also identified a relationship between how confident patients are in managing their conditions and their use of urgent care services. One study showed that patients who were most able to manage their health conditions had fewer A&E attendances and emergency admissions than patients who were least able to. They were also less likely to attend A&E with a minor condition that could be better treated elsewhere and had fewer general practice appointments.5

In the case of elective care, shared decision making between patients and providers in considering treatment options may result in patients making more conservative decisions than those made by healthcare providers alone.6 Shared decision making draws on patients’ preferences in assessing the risks and benefits of alternative courses of action to inform their choices. A review found that “patients who are active participants in managing their health and health care have better outcomes than patients who are passive recipients of care.”7

A well researched example of the benefits of active partnership is work in general practices that helps people with type two diabetes to go into remission. Now incorporated into the NHS type 2 Diabetes Path to Remission programme, this work enables patients to lose weight with the support of general practices and health coaches. Evidence from randomised controlled trials and real-world settings shows that patients can achieve remission in this way, although the results vary between patient groups and populations.89

There are many challenges in embedding active partnerships between patients and providers into routine care notwithstanding evidence of the benefits. These challenges include variations in the motivations of patients and clinicians, the resources they have at their disposal, and the difficulty in finding time to work differently in the “productive interactions” where care occurs. Programmes such as those focused on helping patients with diabetes go into remission face a challenge in adapting to the needs of different communities.10

These factors may help explain why NHS policies that have espoused the need to develop person centred care have yet to be fully realised. The response to this is surely not to give up on these policies but rather to draw on knowledge of what is and is not working in different communities and settings. It also means providing the resources and support to make person-centred care the easy thing to do as well as the right thing to do.

Progress hinges on seeing this work as first and foremost a cultural change in which patients are treated as partners in care. The decision to disband the dedicated team in NHS England leading this work in 2023 shows the limits of change driven from the top. Cultural change is best developed from the bottom up harnessing the energy and commitment of providers and patients and leadership by the health professions.

The 10 year NHS plan should create the conditions for this to happen in support of the shifts in care the government is committed to.