For an NHS consultant, a nurse, an allied health practitioner or any of the wider health professions, returning to the way life was before the demands of the last year may not seem attractive.
We were already falling short of expectations in urgent care delivery, waiting times and outcomes of critical diseases, such as cancer and heart disease. Taking an executive and regulator perspective, we were struggling financially and across the key performance metrics. Simply going back and trying harder doesn't seem like a good idea. Witness the numbers of consultant practitioners reporting their imminent retirement or reduced hours in the coming year.
The Integrated Care System (ICS) concept is an excellent opportunity to do more than reversion. A legal entity sitting above the separately sovereign activities of NHS providers and bringing that together with the service commissioning function can be an excellent basis for alignment, collaboration and delivery of strategic change. But it needs a route to change. It needs to be about more than improvement.
We're in an era of science and technology, which after a few false dawns, offers us massive technical change. For health, rather than thinking about the next 'gizmo', we prefer to think of the five key platforms:
1 remote consultation
2 remote monitoring/surveillance
3 decision aids
4 machine learning/AI
5 precision diagnosis/treatment
Much of this has already arrived. Hence, the rapidity with which we moved to so much remote consultation during lockdown. But more is moving in, such as the use of a range of tests for precision diagnosis and treatment with a journey for patient populations that involves risk stratification, targeted diagnosis and treatment regimes and a lot less use of the traditional diagnosis and treatment routes, as illustrated below.
| Tests under development for precision medicine | |
| Future health risks | Cardiometabolic |
| Probability of a primary CV event within 4 years Probability of a secondary CV event within 4 years Probability of diabetes diagnosis within 10 years |
NASH two-year expected liver biopsy result Functionally relevant coronary heart disease CV one-year event risk/presence Heart failure one-year hospitalization risk Heart failure sub phenotype Near-term diabetes risk/secondary complication risk Renal function prognosis |
| Current health state | Respiratory |
| Glucose tolerance: impaired (vs. OGTT) Lean body mass (kg. vs. DEXA) Body fat (% vs. DEXA) Visceral fat (kg. vs. DEXA) Bone mineral mass (kg. vs. DEXA) Liver fat (category vs. ultrasound) NASH fibrosis, ballooning, inflammation & steatosis (vs. biopsy) Kidney eGFR (vs. creatinine, age, sex, race) Aerobic fitness (vs. VO2 Max) Resting metabolic rate (vs. VO2 resting) |
COPD exacerbation risk |
| Modifiable behaviours | Cancer |
| Current cigarette smoking Alcohol consumption above 1 drink/day Physical activity (vs. actigraphy and heart rate) Statin use (vs. population prescription) Training status (vs. known status) |
Cancer risk/presence |
| Mental health/illness | |
| Alzheimer’s risk | |
| Prognosis & monitoring | |
| Fitness/risk for surgery Frailty Drug compliance/effect/complications |
|
| Modifiable behaviours | |
| Nutritional status Biological age Social deprivation Physical activity & fitness Lifespan/death risk |
|
Figure 1. Tests under development for precision medicine
The future is here, but it needs gripping. Small wonder that some perceptive trusts have chosen to pursue digital development over estate redevelopment, and others have become clear that you can’t do one without the other.
If the technology is here how can we adapt to deploy it? I think this is beyond the traditional and even the emerging improvement methodologies.
These broadly take the existing system as a given. But the technology offers the opportunity to move services out of hospitals at scale, to change the relationship between consultant practitioners and primary care clinicians very fundamentally, and to bring the patient and carer into play as providers of their own health. All goals of the NHS Long Term Plan.
This needs the right kind of conversations between practitioners and their communities. This, in turn, needs trust and respect between the players.
I understand and encourage ICSs to go out for advice and support for their change journey. But that advice cannot be based largely on young, clever people, valuable though these are. The change dialogue will need knowledge, experience and wisdom.
Professionals in the ICS are the local experts. To help them critique science and technology, understand what to adapt, and how to arrive at the right organisational solution, they need to be supported by genuine expertise – “our experts with your experts”, as we like to say.
There has to be clear clinical and scientific credibility from the adviser to tease out the ambition of the teams.
This needs real expertise - knowledge, experience and wisdom - to co-develop with your experts.
Supporting your leadership process to get the baggage out and select your services for consideration.
An engagement process with clinical leaders across the system for vision and principles for future service based on technology policy and context.
A system look at pathways and population segments with real time demand capacity and options modelling.
Co-production of realistic but very challenging plans eg PAHT Northern Devon, Cardiff and Vale.
The dialogue for ICS must be wrapped in the right processes. It must be heavy on workforce, patient and public engagement across the ICS. It must be based on a collective vision, principles and focus on needy population segments and the pathways they use. And it will need programme discipline.
But if the experts work together, as we have found consistently in the last year, the vision for and commitment to transformation becomes remarkable.
To discuss the future of ICS further, get in touch with Christine Armistead.
