Drivers to Services

National Public Health Service for Wales / DRIVERS TO SERVICES
TAO/DR/Designed for Life 2005/Drivers to Services – v 3 / FINAL

DRIVERS TO SERVICES

Aim:

To describe the key drivers which lead people to use secondary care services, and also the drivers which allow people to be managed outside the acute sector.

Rationale:

Providing health services and health care is a complex process, which is always undergoing change, but in the last 15 years the speed of these changes has increased. Some of these changes are because of health sector developments such as new discoveries and new treatments in health care and a greater awareness of the effects of the environment on population health, while others arise because of social developments such as ‘globalisation’ and the growth of the Internet. Changes such are these are likely to increase in the future, and new developments will take place (Nuffield Trust 2000). In the past, system changes within the health service have largely been reactive, driven by external factors often synonymous with loss of local services. However, the need now is for a more proactive and positive re-shaping of services designed to deliver the new models of care where the public have central roles in the shaping of future services. In general the current health care model favourspatients and public at the centre of the system and professionals moving backstage with greater supporting roles. The Health Evidence Network (2004) highlight the advantages of health systems which rely relatively more on primary health care in comparison to more traditional secondary care services

Therefore where possible it is important to consider the trends, levers and drivers, and subsequent implications within the health sector when planning primary, secondary, tertiary, and other health care services. It is impossible to say what the future will look like, but all the drivers for change are pointing to the fact that the status quo is not an option. However trends must not be viewed in individual isolation. We should consider the whole picture – where services from all sectors are valued without an acute sector dominance (Modernisation Agency 2004). Some evidence as summarised by Wagner (2004) shows that closer integration of primary and specialist services improves health care outcomes for individual and populations of patients. In addition, the Modernisation Agency states the need for ‘…courage to break with ingrained habits and practices…’, and this is required at both individual and strategic level. Continuing advances in medical science and changing social attitudes mean that we must ‘…revisit and update our ideas on future directions’(NHS Wales 2000).

Methodology:

Because of the short timescale available to undertake this piece of work, the author does not claim to provide a definitive list of the ‘drivers’ into the various health services. Instead it has only been possible to provide an overview of the main drivers and trends, using a basic evidence review formed through a search of already known literature, relevant and well respected web-sites and information sources. The author accepts the oversimplification of the issues, but the paper provides a platform for discussions and further detailed reviews where required. Ideally, having scanned the literature for key documentation, the next stage in describing key ‘drivers’ would be to meet with stakeholders and identify the key issues, and ‘flesh’ these issues out with evidence based information and guidance to inform decision making.

Defining the ‘Drivers’ to services:

In terms of undertaking a search,‘drivers’ is a rather elusive term, and its usage varies. The One-look online dictionary includes one definition which reads: ‘…one who, or that which, drives; the person or thing that urges or compels anything else to move onward’ (Online Dictionary 2005). For this piece of work, other similar terms which are commonly used within the health service literature were considered, and included, thus terms such as levers, forces, barriers and access, and other similar terms have all been considered.

The key questions:

What are the overarching trends and drivers within the health sector?
What are the drivers into secondary care?
What are the drivers into other services?

What are the overarching trends and drivers within the health sector?

Current Policy Drivers:

The key document which describes the overall plan to developing NHS services in Wales was ‘Improving Health in Wales: a plan for the NHS and its partners’ (NAfW 2001), which addresses the main areas of health and social care policy. For the primary care sector, it outlineda programme of gradual reform with a central role for GPs, and an expanding role for other professionals. Primary care is the appropriate setting to meet 90-95 per cent of all health and personal social service needs. The services and resources available within the primary care setting have the potential to prevent the development of conditions which might later require hospitalisation.

Whilst for secondary care it described a more ‘revolutionary’ view, because of acute setting long term pressures. It also mentioned the importance of public and patient involvement, and guidance has been issued by the Assembly Government on how best to involve public and patients. Previous to this ‘ Access and Excellence (NHS Wales 2000) described the long term pressures on acute hospital provision, and it called for a new vision for acute care, delivered as part of an integrated system of health and social care, based on new ways of planning and developing services.

A more recent development has been the UK wide review by Wanless ‘Securing Our Future Health (Wanless 2002)’which identified several drivers.

Existing commitments
Medical technological advances
Changing and increasing public expectations of the health service
The need to integrate services
The impact of PH initiatives
Changing health needs of the population
Prices for health services resources
Improvements in productivity levels
Levels of capital investment
Capacity shortfalls and short-termism created by erratic spend levels.

Derek Wanless was also commissioned by the Welsh Assembly Government to examine how resources should be translated into reform and improved performance (Wanless 2003). This report makes a number of recommendations, including, the need to pay more attention to ill-health and promoting good health, a radical re-design of health and social care services, improved workforce planning, development and utilization, and better information systems. Coulter (1995) notes that health care systems dominated bysecondary, tertiary, and emergency care tend to equate with costly, disjointed and sporadic services.

Other key policy drivers are the existence of the local ‘Health, Social Care Well Being’ documents, which aim to embrace a partnership strategy using an integrated and multi-disciplinary approach to NHS and Local Authority planning, again highlighting the need for preventative and health promoting services. In terms of public and patient involvement Signposts 1 and 2 (NAfW andOPM 2001, WAG 2003) are key policy documents driving forward on the patient involvement agenda, with an aim to achieving better practice and performance. The concept of choice is now well established in the UK health service.

The most recent policy document is Designed for Life (WAG 2005), encapsulating the Welsh Assembly Governments whole approach to improving health in Wales. It builds upon Improving Health in Wales, highlighting the importance of transforming services through active planning and practical modelling, leading to better quality of life. Other health care systems, such as Kaiser-Permanente and the Veterans Health Administration in the United States, the Canadian health care system and, increasingly, the NHS in England, have already faced up to the implications of these broad demographic and epidemiological shifts by developing more proactive, preventive and community based approaches (NHS Scotland 2005).

The Audit Commission in Wales (2004) produced an overview diagram (Figure 1) illustrating the required reconfiguration of health care services, in order to develop a whole-system approach, which is characterized by greater emphasis on health prevention and promotion, the development of self-care, and the need for having highly developed clinical partnerships and care pathways with services based around the user. Coulter and Cleary (2001) argue that modern health care services falls short of the ideal, calling for ongoing cultural shifts rather than cosmetic services changes alone.

Figure 1: Reconfiguring health care services - adapted from Audit Commission 2004

Horizon Scanning

The Nuffield Futures Report (Nuffield Trust 2000) 'scanned' the environment of UK health towards 2015, and described developments in six different key areas:

Disease

There is a shifting burden of disease from young to old and from communicable to chronic disease.

Society

Developments in society reflect increasing wealth and opportunities resulting from economic developments and changing work and family structures, although these sit alongside increasing inequalities and relative deprivation. There is clearly an increasing health gap between the best and worst off in society.

Environment

Positive environmental developments have taken place, such as those in air quality from reductions in the major sources of pollution, whilst at the same time there is increasing public concern about food safety. Factors such as globalisation of trade and travel, global warming and social trends will ensure that new infectious diseases will emerge and re-emerge.

Governance

There is an increasingly global aspect to health issues and European Union institutions are increasing their impact on health policy, whilst devolution has led to diversifying health policy.

Economics

There is increasing demand pressure on health financing due to technology and rising public expectations. Pharmaceutical expenditure is increasing. An ageing population along with an increasing older dependency ratio will also place pressure on future NHS financing.

Industry

Developments in industry include the human genome project, drug discoveries, new screening opportunitiesand treatment in the area of molecular genetics, developments in bioengineering and biotechnology and the growth within the pharmaceutical and private health care sector.

The report goes further identifying six key issues for policy-makers towards 2015. These are:

Version 3 / Date: 19.9.05 / Status: FINAL
Author: Teresa Ann Owen / Page 1 of 18
National Public Health Service for Wales / DRIVERS TO SERVICES
TAO/DR/Designed for Life 2005/Drivers to Services – v 3 / FINAL

Rising public expectations
The ageing population
Assessing new technologies

Information and communications technology and information management
Workforce education and training
System performance and quality

These headings have been adapted based on the evidence review, to identify the key drivers into both secondary and alternative care settings. These are discussed individually.

1. Rising public expectations

Expectations of health continue to rise amongst the population, and therefore clinical practice and the organization of healthcare must change too if a public funded healthcare system is to survive (Coulter 2002). In general, there has been an increased awareness of quality failures in the health system, and medical errors, an increase of information leading to comparisons at both regional, national and international level, and an increasing trend in the medicalisation of normal life (e.g. childbirth, ageing etc), all of which are fuelled by societal changes and media, medical and commercial influences.

It is recognized that the patient of the future will be better informed, less deferential and less willing to tolerate poor quality of care. Coulter (2002) suggests that the media and commercial activities can help shape attitudes to healthcare, and this may foster demands for wider availability of expensive treatments. She and others such as Kendall (2001)go further describing the patient of the future as a ‘…decision maker, care manager and co-producer of health, an evaluator, a potential change agent, a taxpayer and an active citizen’

‘At the most basic level people expect to feel safe and secure. People have expectations about how long they are going to live, and also the quality of their lives. They have a range of expectations about the type of care they receive when they interact individually with health services, which might include whether they are able to be treated, when they are treated, who carries out the care and how they are communicated with, what alternatives to treatment are offered, how successful their treatment is, whether they have to contribute financially in any way, and how well they recover their health’(Nuffield Trust 2000).

Some of the implications of these developments might be a greater focus on individual responsibility for health in the future, greater public involvement in health care decisions, and increased choice about the provision of health care.

Drivers into secondary care

The medicalisation of normal life events will mean a continued move towards specialist care, which has traditionally been centred on the hospital. If the trend continues, then traditional health care services will remain the dominant force in shaping health service. Another key driver into secondary care is the slow uptake and development of health services in the light of good practice guidance– be this in clinical, estate, workforce or research aspects of the NHS..

Drivers into care outside the acute sector

The key drivers are detailed planning and forecasting and effective communications, between professionals and patients, and between professionals and between patients, whilst the ‘patient choice’ movement continues to be a popular concept, now mainstreamed into the political agenda (Appleby 2005). Other drivers include the need to enhance self efficacy, while the evidence suggests that self management of chronic diseasecan reduce hospitalization and accident and emergency attendances (Newman et al 2004). The role of NHS Direct has also changed the NHS, while appropriate care choices in the community, improved prescribing availability (e.g. greater and improved prescribing by various staff groups), specialist services, and intermediate care are key in driving services out of the acute sector. Back in 2000, ‘Access to Excellence’, (NHS 2000) highlighted the potential of intermediate care to deliver both substitute services and to support complex patient care.

2. Demographics and Epidemiology

The patterns of illness and diseases have changed significantly. The main killer 50 years ago were infectious diseases and childhood illnesses. These are now replaced by today’s killers of cancer, coronary heart disease, strokes, and accidents. Obesity now rivals smoking as a contributor to ill health. Indeed the burden of disease on society is now substantial and new health problems may yet emerge.For instance, healthcare associated infection (HAI) is now regarded as an issue of major national importance. Failure to address increasing in avoidable ill health will put huge pressure on NHS (Coote 2004). Palmer (1999) summarises the main global environmental challenges affecting health, including new and re-emerging diseases, the effects of climate change such as increased flooding, and changes in agricultural production, increased urbanisation and exposure to chemical hazards.

Medical advances have now provided new possibilities for the diagnosis and treatment of illnesses and chronic diseases which were previously life threatening or fatal. Up to 80% of primary consultations and 75% of emergency hospital admissions in Britain involve people with long term conditions (HSMC 2005). In Wales, the prevalence of limiting long term illness is higher than in all but one of the UK regions, and an estimated 800,000 adults report having at least one chronic condition, while in the over 65 year age group, two thirds have at least one chronic condition and a third have multiple chronic conditions (NPHS 2005). These chronic conditions have largely been unrecognized, and cannot be cured, and as a result the people with these conditions are often frequent users of health services. This situation has been hampered by traditional care often being episodic, reactive and unplanned (DoH 2005). However these people can be helped to live a longer and richer life than previouslypossible and the evidence clearly shows that the most effective care is delivered when resources and services are integrated and focused on empowering the patient to provide appropriate self-care. A healthy lifestyle may help persons to delay the effects of old age, and it should be noted, that a 70 year old today, is likely to be healthier and more independent than a 70 year old 30 years ago (NPHS 2004).

The UK population structure is also changing and this change will continue, with the most significant element being the ageing of the population, and an associated increase in disability and illness, particularly in the chronic conditions associated with ageing. This trend has an immediate effect on demand for healthcare, since older people are the most frequent and costly users of healthcare resources. In the future however, this burden of illness may change as the older people may be fitter, healthier and they may have managed their conditions better. However we need to bear in mind

that age for age older people have been getting healthier. So, while we can expect anincreasing burden on health care from an ageing population it is not straightforward. A 20% increase in the number of older people does not necessarily mean a 20% increase in the demand for health care (NHS Scotland 2005).