Urgent need for reform to avert a deepening crisis in health & social care

(30 June 2015) There is a looming crisis in health and social care in the United Kingdom. Our care systems have not changed in more than half a century; they are misaligned with the needs of modern society; they are wasting public money and the country cannot afford to sustain the inexorably rising demand in the long term. There is a risk of catastrophic collapse unless there is fundamental change. That is the case for reform set out in a pamphlet that advocates change to a joined up integrated health and social care system.

It is co-authored by brothers Ian and Stephen Smith.

Ian R. Smith is Chairman of Four Seasons Health Care, the UK’s largest independent health and social care provider. He has been CEO of a group that operated nearly 70 private hospitals and has had a book and articles published on health reform. Stephen K. Smith is a Professor of Medicine and set up the first academic health and science centre at the Imperial College Healthcare NHS Trust in 2007. The pamphlet, which they have written in a personal capacity, is entitled: “Away from the past and to a sustainable future. How the UK’s health and social care systems can be reformed to better align with the needs of today’s society.”

Their case for change is that the UK model of care was created in 1948 when the epidemiology of disease, social policy and people’s lives were very different from today. In that year, someone aged 65 would already have exceeded average life expectancy at their birth of 44 years for men and 48 years for women. People died quite suddenly, most of the time within six months or less of contracting a disease. The NHS was founded on an acute care model, based on district general hospitals – which at the time performed relatively simple clinical procedures – and GP surgeries handling minor ailments. Social care was not a large part of the system.

Advances in diagnosis and treatment mean people are living longer. With an ageing population comes a rise in chronic long term conditions, people with co-morbidities, increasing demand for longer-term elderly care including dementia care. There is also a rapid growth in ‘lifestyle’¹ diseases such as obesity and a growth in the need for improved care for mental health in the community. But the health and social care systems have hardly changed since they were set up 67 years ago.

Consequently, despite our having world class medical sciences and clinicians, the United Kingdom now has some of the worst health and social care outcomes in the developed world.

The proportion of the population who are retired is growing while those of working age is shrinking. Already parts of our system operate at crisis point and yet the pressures are forecast to increase.

Ian and Stephen Smith argue there is a funding imbalance that is wasting taxpayers’ money, with social care being chronically under-funded. This produces a spiral effect whereby more and more money is directed into the NHS to meet a burgeoning need, whilst the lack of funding for social care in the community means that more demand flows into the NHS with the “back door exit” to care in the community being partially closed. This is actually increasing costs in the NHS. GP surgeries, ambulance services, A&E departments and acute hospitals become overwhelmed. An estimated third to 40% of hospital beds are occupied by people, mostly frail older people, long after the medical condition for which they were admitted has been stabilised.

The authors retain the core principle that the care system should continue to protect the most vulnerable in our society and free all from anxiety about health care costs.

They believe that to avoid a deepening crisis the country needs to move to integrated care organisations (ICOs) that will remove artificial boundaries between health and social care and between different parts of the healthcare service such as acute and chronic medicine; treatment and preventive interventions and physical and mental health.

We need to complement the ICOs with Academic Health and Science Centres (AHSCs) that allow hospitals and universities to focus on clinical excellence by building deep competencies in clinical specialities and by leveraging the developments in genetic medicine to advance scientific discovery at the level of ‘big data’ (extremely large data sets that may be analysed computationally to reveal patterns, trends, and associations). We need to translate that into personalised medicine that improves the health of each individual.

Their care model would enable social care and health care providers to work together to deliver patient and service user centred care that manages their needs, whether physical, social or mental. It would support personal life-time care pathways rather than individual episodes of care (E.g. from home to intermediate care facilities to hospital and back home), with each patient having a ‘case manager’ who will navigate them through the system. These pathways will be made possible by electronic patient records set within a connected digital network.

The changing epidemiology of disease logically leads to a separation of expertise between two types of clinicians. On the one hand there are generalists who can consider the “whole person”, in their social setting. Within hospitals, advancing medical science and practice requires greater clinical specialisation. Ian and Stephen Smith argue that while the ICO would need to draw on a balance of specialists and generalists, there is a strong case to consolidate the available specialist expertise in cardio, cancer etc into centres of excellence. This will mean fewer but larger clinical units. The existing structure of sub-scale specialist facilities existing within each local hospital is less than the optimum way to meet patient needs. Instead of the conventional GP surgery the holistic approach to care would require larger health centres in which GPs would be co-located with social workers, mental health experts, pharmacists and diagnostic technology.