A stethoscope on a desk. Photo: Getty Images
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The NHS needs to change - but how?

When the NHS was founded, chronic illnesses and long-term care were non-issues. Adapting to the new reality means big changes are needed.

The backlash from NHS staff culminating #ImInWorkJeremy shows how carefully politicians need to tread when advocating reform of the NHS. But the pressing and urgent need for reform is going to intensify as this Parliament wears on.

Even with the extra £8bn of funding announced in George Osborne’s Budget earlier this month, the task facing Simon Stevens, Chief Executive of the NHS, is huge. The health service must find £22bn of efficiency savings over the next five years, an unprecedented target not just in terms of the NHS, but for any western health service.

Reform will have to sit at the heart of any plan to achieve this. Indeed, Stevens’ NHS Five Year Forward View sets out a range of reforms which will help us get there including the integration of health and social care and better use of new technologies. But crucial to the success of the Forward View will be the NHS’s ability to empower patients.

Patient empowerment has been an aim of the system for over fifteen years. But as more and more people suffer from complex long-term conditions the majority of care will occur not in the hospital or GP‘s surgery, but at home. By 2025 the number of people with complex long-term conditions will be more than 18 million. Patients and their family taking on the carers role will be the ones making the difficult decisions. If these decisions are good ones, demand on the service will go down. Get them wrong and it will increase. Indeed, the evidence suggests that around one in five emergency admissions to hospital are potentially preventable.

Existing empowerment initiatives – which Stevens’ NHS Five Year Forward View focus on – such as ‘voice’ and ‘choice’ won’t change this. They empower people only after or as they are entering the health service. New empowerment models being pioneered across the country create good health, rather than respond to ill health. These initiatives include giving doctors the ability to prescribe social rather than just medical treatments (cooking classes, gym memberships and community social groups), creating peer networks among those with similar chronic conditions, and working with patients to set technology enabled care plans, which help patients make decisions remotely and allow more flexible contact with healthcare professionals.  

The challenge now for the NHS is how to ensure that every patient who could benefit from these empowerment initiatives can have access to them. IPPR is recommending a transformation fund for the NHS – something backed up by recent work by the Health Foundation and the Kings Fund. This would help spread reform and prevent extra funding being used for steady-state or business as usual.

More money should also be passed over to patients directly in the form of personalised budgets, with patients holding the purse strings. At the moment, less than half a million people benefit from personal budgets but by 2020, IPPR argues that all patients with a long-term condition should be offered one.

And finally, more money and finance should be devolved to the local level. ‘Devo-Manc’ is a good start, but the government promised ‘devolution on demand’ and demand there is. Notably, the ten core cities - Birmingham, Bristol, Liverpool, Leeds, Manchester, Newcastle, Nottingham and Sheffield, Cardiff and Glasgow – recently published ‘A Modern Charter for Local Freedom’ which expressed an interest in following suit. NHS England should start thinking about when and how it will meet this demand now: devolution of this kind can make care more responsive to local populations and should galvanise empowerment focussed reform.

These changes won’t be easy; but they are absolutely necessary. As Alan Milburn’s argues: “Tinkering with change will not save the NHS. It must stop treating patients as passive by-standers and instead enlist them as active agents of change.”


Harry Quilter-Pinner, co-author of Powerful Patients published by IPPR.


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For the first time in my life I have a sworn enemy – and I don’t even know her name

The cyclist, though, was enraged. “THAT’S CLEVER, ISN’T IT?” she yelled. “WALKING IN THE ROAD!”

Last month, I made an enemy. I do not say this lightly, and I certainly don’t say it with pride, as a more aggressive male might. Throughout my life I have avoided confrontation with a scrupulousness that an unkind observer would call out-and-out cowardice. A waiter could bring the wrong order, cold and crawling with maggots, and in response to “How is everything?” I’d still manage a grin and a “lovely, thanks”.

On the Underground, I’m so wary of being a bad citizen that I often give up my seat to people who aren’t pregnant, aren’t significantly older than me, and in some cases are far better equipped to stand than I am. If there’s one thing I am not, it’s any sort of provocateur. And yet now this: a feud.

And I don’t even know my enemy’s name.

She was on a bike when I accidentally entered her life. I was pushing a buggy and I wandered – rashly, in her view – into her path. There’s little doubt that I was to blame: walking on the road while in charge of a minor is not something encouraged by the Highway Code. In my defence, it was a quiet, suburban street; the cyclist was the only vehicle of any kind; and I was half a street’s length away from physically colliding with her. It was the misjudgment of a sleep-deprived parent rather than an act of malice.

The cyclist, though, was enraged. “THAT’S CLEVER, ISN’T IT?” she yelled. “WALKING IN THE ROAD!”

I was stung by what someone on The Apprentice might refer to as her negative feedback, and walked on with a redoubled sense of the parental inadequacy that is my default state even at the best of times.

A sad little incident, but a one-off, you would think. Only a week later, though, I was walking in a different part of town, this time without the toddler and engrossed in my phone. Again, I accept my culpability in crossing the road without paying due attention; again, I have to point out that it was only a “close shave” in the sense that meteorites are sometimes reported to have “narrowly missed crashing into the Earth” by 50,000 miles. It might have merited, at worst, a reproving ting of the bell. Instead came a familiar voice. “IT’S YOU AGAIN!” she yelled, wrathfully.

This time the shock brought a retort out of me, probably the harshest thing I have ever shouted at a stranger: “WHY ARE YOU SO UNPLEASANT?”

None of this is X-rated stuff, but it adds up to what I can only call a vendetta – something I never expected to pick up on the way to Waitrose. So I am writing this, as much as anything, in the spirit of rapprochement. I really believe that our third meeting, whenever it comes, can be a much happier affair. People can change. Who knows: maybe I’ll even be walking on the pavement

Mark Watson is a stand-up comedian and novelist. His most recent book, Crap at the Environment, follows his own efforts to halve his carbon footprint over one year.

This article first appeared in the 20 October 2016 issue of the New Statesman, Brothers in blood