Rediscovering the basics...

Posted 2023.08.15
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Rosemary Hollick, Senior Clinical Lecturer of Rheumatology at University of Aberdeen, shares her insights on two overarching themes from #HSRUK23: service and organisational futures and why people matter...

This year’s Health Services Research UK conference was held in Birmingham in the same week that celebrated the 75th anniversary of both the NHS and the arrival of the Windrush generation. It also marked exactly 19 years since I graduated fresh faced from medical school, full of enthusiasm at the thought of beginning work in our NHS - free at point of use, comprehensive, and available to all. I was also terrified - my first junior house officer job was in orthopaedics, and I started on a week of 12-hour nightshifts. It was a ‘baptism of fire’ that medical school doesn’t really prepare you for, but we were a team and those formative experiences brought camaraderie and lifelong friendships. 19 years on the NHS feels very different and the uncertainty around its future is palpable in a year where three of the most influential health think tanks co-signed a letter warning political leaders that without a major shift in strategy, the NHS might not reach its 100th anniversary.

 

Is there any hope for the NHS?

 

A broad range of speakers across five plenary sessions considered the future of the NHS, with two overarching themes: service and organisational futures and people and why people matter.

 

Service and organisational futures

 

Nigel Edwards looked back across 75 years of the NHS and forward, posing some fundamental questions (many without an immediate or easy answer) - what do we mean by healthcare, what are aiming to do, what care can (and should) the NHS provide and how? There is certainly much that is wrong – we have an ageing, increasingly frail population with increasing co-morbidities, and the NHS is inextricably linked to a short term, adversarial political system bounded by efficiency and cost control, with a new set of ‘priorities’ every political cycle. This is reflected in ‘short-termism’ and a focus on annual targets. There have been numerous NHS scandals over the years with interesting lessons, not all of which have been learnt. We have ‘postcode lotteries’ of care and debates about the affordability of very high-cost treatments. And then there is the constant search for structure. As the most reorganised health care system in the western world, the NHS is facing yet another reorganisation of care in England with the introduction of integrated care boards. How do we strike the right balance between central control and devolution?

Reflecting on the future role of the hospital in the NHS, Sir Julian Hartley discussed the role of hospitals as anchor institutions within communities – large employers supporting local economies, hubs of innovation with wider benefits beyond immediate clinical care, supporting preventative approaches and working more closely with primary care. Dr Vin Diwakar discussed the dizzying number of new digital innovations within the NHS, but as patients frequently tell us, Apps aren’t everything. How do we ensure that digitalisation isn’t the tail wagging the dog?

Much of the discussion touched upon the workforce crisis within the NHS. In a week which also saw the launch of the new NHS workforce plan, we heard how national workforce policy neglects the role of place, and that work outcome inequalities can become health outcome inequalities. Losing the joy of practice leads to workforce burnout and moral injury, so how do we address this? We heard from Dr Charlie Siderfin about a programme to address GP recruitment issues in rural Scotland. Rediscover the Joy of General Practice is targeted at senior doctors coming towards the end of their career and aims to rediscover the joy of practice, drawing on the values-based approach to care embodied in the Realistic medicine agenda for healthcare delivery in Scotland. Incidentally, the stark differences in the way the NHS is organised and funded across the devolved nations, and the opportunities to share learning, could be an important topic in its own right for a future conference.

 

Why people matter…

 

My experiences of working with many different people in a range of very different healthcare settings over the past 19 years have fundamentally shaped my career and the doctor I am today: from the patients who have taught me many important lessons about what good care means, and the little moments of kindness such as the ward sister who made me tea and toast after a particularly horrific nightshift, to the informal mentorship I’ve received over the years from many inspiring people. I never set out to be a rheumatologist, but I was warmly welcomed into a dynamic team where research to improve patient care was firmly embedded in clinical practice. This set me off on a journey which has brought me to where I am today – an academic rheumatologist with a focus on applied health services research.

Dr Louella Vaughan challenged delegates to remember these basics – delivering good care and being human. The NHS is drowning in a battery of quality and assurance metrics, but care isn’t getting better. Are we measuring the right things? We tend to measure what we can measure, not necessarily what really matters. Internationally, hospitals are closing because of staffing issues. Digitalisation of work impacts communication and relationships and can be alienating, so how can we create jobs that people really want to do? A relentless obsession with innovation and targets e.g., reducing front door admissions, has meant we’ve lost sight of what matters in day-to-day care.

The importance of relational aspects of care was also reflected in the plenary sessions exploring what will become of general practice. Prof Kath Checkland reflected on what is illness and what are health services for? She provided a salient reminder that we are not simply caring for ‘faulty machines.’ People often have complex problems that need an expert generalist. However, care has shifted from a relational based model to one that is task-focused, working on the premise that patients present with discrete problems that are directed to a person with a specific skill set. Current infrastructure and processes of care provide fewer opportunities for the relational continuity valued by patients and staff.

However, for marginalised and excluded groups of people, care experience and outcomes can be very different so how do we ensure that everyone matters? Dr Aaliya Goyal emphasised the importance of local solutions for local communities, particularly those who are marginalised and excluded: knowing the community, identifying the gaps in care - who is falling out of the system and where - and directing our valuable resources to address these. In another plenary session focused specifically on research with marginalised and excluded people, we heard about the Tapestry Tool from Prof Stirling Bryan. This online learning platform has been successfully used to facilitate patient-oriented research with marginalised groups. Prof Dawn Edge reminded us of the fact that people of African and Caribbean heritage are several times more likely to be diagnosed with psychosis. She discussed co-creating and evaluating a Culturally-adapted Family Intervention (CaFI) with Sub-Saharan African and Caribbean descended people in the UK who have been diagnosed with psychosis and their families. Dr George Julian highlighted the stark evidence that people with learning disabilities have poorer outcomes, and that 49% of deaths are from avoidable causes. We shouldn’t seek to ‘make people matter’, they already matter, and rather than gathering new evidence, she suggested we need to implement existing evidence better to improve and save lives.

 

Some glimmers of hope?

 

This year’s conference was held just a few steps away from King Edwards School, Edgbaston where in 1945, the Six Triple Eight US Army battalion of 855 black women were stationed. They had one very simple aim, to revive troop morale and clear a two-year postal backlog of 17 million parcels waiting to be delivered to troops on the frontline in Europe – a moral boosting exercise to enable them to receive messages and parcels from loved ones at home.

This got me thinking, across the hundreds of research discussions, workshops, posters and plenaries at this year’s conference there were common themes – communication, relationships and kindness fundamentally matter. How can we move away from transactional, task-based care to one that’s build on trusting relationships? How do we motivate and retain our staff, particularly post pandemic? Specifically, how do we shift the focus from assurance to quality, from structures and processes, vertical and horizontal organisation of care, to enabling diverse groups of health and social care staff across the NHS to work better together – providing opportunities to meet, chat, have computer systems that work and speak to each other, and work in buildings that aren’t falling down? I’m reminded of the time when we complained to Estates that the roof was leaking and water was pouring onto one of our bone density scanners and we were simply told not to scan when it was raining...And how can we improve population health upstream to address the wider determinants of health and health inequalities and ultimately produce less demand on our health services?

Dr Julian George challenged us to ask three questions of our research: does the world need your research, are you working with people from the start, and is the money going to the right places? And how do we effectively coproduce research with patients, exemplified by this year’s Inclusion and Innovation award winners.

Engineering impact from our research in the heady maelstrom of 21st century media and politics also brings a unique set of challenges. Researchers who have been ‘in the eye of the storm’ – Prof Mike Tildesley, Prof Katie Featherstone, and Anita Charlesworth, shared their experiences and advice.

 

So, what are my take home messages? In focusing on structure (and re-structure) and process we’ve lost sight of what we’re trying to do. In a nutshell, we need to rediscover the basics – people matter, and communication and relationships between people underpin good care and good jobs. Looking forward to seeing you in Oxford for HSR UK 2024.