[Check against delivery]
When we are ill, what matters most, is that the NHS is there for us.
That it listens, understands and provides us with the best possible care. The best outcome.
Of course, the best outcome is for people to stay healthy.
But for the many of those who have long-term conditions, the best outcome is about reducing and minimising the impact of their symptoms, and wherever possible keeping them out of hospital.
This government is on the side of people with long term conditions.
And when it comes to respiratory diseases, which I use as an example here, we have a lot to do.
• Between 3 and 5 million people in England have asthma, among the highest prevalence in the world.
• Around 1,000 people die from asthma every year, 90% of which are preventable.
• And it’s been the same story for years.
We want people, whatever their background, to be free of symptoms and to stay healthy and out of hospital. For this to happen there needs to be:
• a fast and accurate diagnosis
• shared decision making about treatment,
• on-going support for self-management
To do that, the NHS needs to evolve. It’s not about a revolution. It’s about a constant forward momentum, and evolving the service we provide.
For too long patients and staff have had to deal with an NHS that focuses on hospitals and hospital admission as the default, and often the immediate, answer.
OK when the biggest challenge was the fight against communicable diseases.
Not right for today.
Today the main challenge is long term conditions, like asthma and COPD.
The system doesn’t fit.
And it’s those with long-term conditions, possibly more than any other group of patients, who have to put up with the overly-bureaucratic and process-heavy organisation.
An NHS that is, all too often, not joined up. With services designed around the convenience of institutions, not the needs of the patient.
And patients don’t only have needs, they have insight.
The consultation room should be “a meeting of experts” - one, the medical professional, the expert on the condition, the other, the patient, the expert on their own life, their habits, their motivation and their preferences.
It is only when these two experts come together as equals that a clear and sustainable way forward can be found and carried out.
That is the ideal, but while there is excellent practice in some areas, in others it is poor.
The Atlas of Variation, which we published in November last year, shows a five-fold difference between the best and worst performing Primary Care Trusts when it comes to adult emergency admissions from asthma.
Six-fold variation for children.
And there is a four-fold variation among PCTs in emergency bed-days for COPD.
It means that the quality of care you receive is more determined by where you live than by anything else.
And that is not good enough.
So progress must not only be about the best getting better, it has to be about narrowing the gap between the very best and the rest.
With the poorer performing areas getting better, fastest.
Publishing details about how good different areas and different hospitals or clinics are will be a big part of this:
• allowing doctors and clinicians to see how good they are and learn from their peers
• and allowing patients and the public increasingly to hold their local NHS to account.
As distinct from previous attempts to reform the NHS, our changes will, for the first time, truly put GPs, specialists, clinicians and patients themselves at the heart of a clinically and locally-led process for reforming and managing services.
Things are already changing.
Acute and community services are coming together in many parts of the country.
Let’s take an example.
The Asthma Service at The Respiratory Centre in Southampton General Hospital has been transformed.
• frequent hospital admissions and readmissions for asthma,
• no local asthma management guidelines,
• little specialist follow up of asthma patients,
• little education or encouragement for patients to self-manage
The action taken:
• Multi-disciplinary team came together, including respiratory consultants, GPs, nurse specialists, pharmacists and patients to redesign the asthma care pathway. This is truly what we are aiming for when we talk about integrated care and redesigning services along care pathways.
• admissions referred to nurse specialists
• specialist follow up after four weeks.
• Close links to primary care.
• Their urgent referral service means GPs, community nurses, even patients themselves can get an urgent specialist review when not in hospital.
What is the result? A 3 month study showed that…
• 100% of patients now seen by an Asthma Specialist Nurse and have a specialist out-patient review within 4 weeks, in line with the British Thoracic Society Guidelines.
• NONE of these patients were readmitted within 28 days of discharge.
This is just one example but there are happily many others…
• At St Guy’s and St Thomas’s, A&E staff have been trained to provide more appropriate care, improving self-management and reducing re-admissions.
• In South West Essex, using pharmacy services to target asthma patients in deprived areas to improve self-management.
• And in East Surrey, the ESyDoc Pathfinder CCG is working with AstraZenica and the acute Trust to improve the whole asthma pathway and reduce admissions.
This is exactly the sort of action I want to see across the country.
Doctors, nurses and other health professionals - working with their patients - to create new services, providing the right treatment, in the right place at the right time.
• Empowering the NHS.
• Freeing people to come together to design the best local services.
• Supporting them in attaining excellence but leaving it to their professional judgement as to how they best achieve this.
Outcomes Framework & strategies
The Outcomes Framework does this. Setting high-level objectives.
Beneath that, condition specific Outcomes Strategies.
Strategies that reject the top-down approach that stifled innovation and creativity.
Instead, we set the high-level outcome objectives that the NHS, Public Health and Social Care services should aim for. Clear about what the objective is, clear about the necessity of providing the evidence-base, and the evidence-based Quality Standard in support of that, but clinically-led in determining how it is achieved.
The outcomes strategies focus on:
• the latest evidence of what the best care looks like,
• on how patients and service users can be empowered to make the right care decisions for themselves,
• and on how clinicians on the frontline can best be supported to deliver what matters to patients and service users: high quality and improving outcomes.
High quality services and continuously improving outcomes.
The Outcomes Strategy for COPD and asthma, the third Outcomes Strategy to be published, followed extensive consultation across the sector.
I know that Neil [Churchill, Asthma UK Chief Executive] was himself instrumental in its development.
The strategy supports public health, the NHS and social care to manage and develop services more effectively, and supports patient choice too – so people get the right care in the right place at the right time.
It will improve access and reduce inequalities in service provision.
It focuses on:
• prevention and awareness;
• identification and diagnosis;
• acute and chronic care
• and end of life care.
Support for CCGs and providers
But enhanced autonomy in the way I have been describing does not mean being left unsupported.
a. the National Review of Asthma Deaths (which is run by a consortium led by the Royal College of Physicians) will look into the circumstances surrounding deaths from asthma - looking at what can be improved.
b. Good Practice Guides for people developing asthma services to be published later this year. A description of the kind of services they should make available to achieve the goal of asthma care - freedom from adverse effects and symptoms.
c. And a Quality Standard for Asthma, from NICE, to be published next year. The standards that should be delivered by commissioners in the services commissioned, and that all providers should be seeking to meet.
That’s our objective - by example of what we’ve set out to do together in the outcomes strategy for COPD and Asthma.
By setting the destination but not defining the route,
By empowering clinicians and not tieing them up in bureaucratic knots,
And by seeing patients as themselves, potentially the most powerful catalyst for better outcomes and not just passive recipients of care,
By which our intention is that we can transform care not only for asthma and other respiratory conditions, but for all care within the NHS.