From one-sized to personalised: enabling the NHS to shift from hospital to community, analogue to digital and sickness to prevention

The Government is developing a new 10-year plan for the NHS in England to ‘build a health service fit for the future’. Joe Fraser and Josh Hutchison set out the steps needed to put personalised care at the heart of those changes.

Personalised care has the power to both transform lives and reinvigorate the NHS.

Looking at the Government’s goals for the new 10-year NHS plan, its time has come.

The aim is to shift more care from hospitals to communities, make better use of technology in health and care, and focus on preventing sickness – all of which will be enabled through personalising care.

We know it’s no good proactively targeting people with poor health if we’re only going to address their clinical issues. Everything else in their lives is a potential barrier to improving their health – it’s only by helping people manage their non-clinical challenges that we can help them get better, enable prevention and address health inequalities.

We need real culture change for personalised care to be embedded, and here’s how we can make it happen:

System leadership

? Frame the need for change and define what we want to see. To invest in prevention, we need to be really clear on future demand and capacity, why we need to change, what it will cost and the implications of doing nothing. Spell out clearly the actions we want ICBs and providers to take and develop quick tools to help them review and reflect on how personalised their services actually are.

? Co-produce a vision of a personalised NHS. This needs to incorporate the views of politicians and clinicians (of all stripes); the voluntary sector (big and small); patients (especially those who feel alienated); and the patients of the future (children and young people). The change will feel radical but will be just what is needed. Strategic alignment with health inequalities, population health management and integrated neighbourhood teams would make sense, but let’s make sure form follows function.

? Take it seriously. Treat personalised care like it’s the introduction of a new medication. We need to model the need, and the number of roles required to service it; the expectations of impact and the digital tools needed to enable it; the extra time needed in consultations and the shift in job plans; the commissioning gap, and the business case. Let’s deliver this properly.

? Follow through on the rhetoric. Make the change you want to see through contractual levers and incentives; meaningful targets with reporting that ‘Russian-doll’ up from providers all the way to DHSC; and empower ICBs to deliver it. Following Darzi, they will need regional transformation managers to support that change efficiently. NHSE has a role to play here.

? Focus on the ‘easy’ wins. Some of this work is radical and difficult, but some should be happening already. Forget ambitious strategic visions for a second, what is stopping shared decision-making happening in every provider, or each ICB actually co-producing its work? The NHS Contract already calls for personalisation, leaders just need to prioritise it, and see it as a catalyst for better quality outcomes. Some of it will be happening in pockets – let’s learn, and support spread and adoption.

? Focus on the pain points and build up the prevention case. If the system is focused on elective and emergency care issues, the initial focus for personalisation needs to be there too. Show how directly it can relieve the pressure. Simultaneously, make the case for secondary prevention with better long-term care management, so that we’re not just bailing out our overflowing bath tub more quickly, but also turning off the taps.

? Don’t expect it to scale straight away. No-one knows how this will operate at scale. We should learn from culture change in healthcare and other sectors: align delivery to a targeted cohort, strategically pilot it, learn, iterate and get it right before spreading. We must avoid a ‘Big Bang’: that’s a good way to blow something up, but not to grow a new way of working.

? Develop strategic partnerships. Charities have always worked alongside the NHS and they will be crucial to engaging their stakeholders in this change. But arguably the private sector will be too: digital, data, estates, (see below for all three), holistic support provision, and impact investment (where appropriate).

Digital and data

? Use technology already here to support personalised care. Tele-coaching, virtual peer support, access to community groups and self-management education on demand are all available already. Transparent management of personal health budgets (PHBs) can unlock further support options and efficiencies. We need to raise awareness of what’s possible and engage suppliers to better shape the market.

? The NHS app. We can use it for digital personalised care planning (it’s starting in London) to be a personalised care super-enabler. But it can also be the main referral route for further tailored support, and a two-way channel for health and wellbeing communication to revolutionise the relationship with patients.

? We can monitor wellbeing for both patients and the workforce. This can help us spot the signs of deterioration as part of a preventative approach that stops health needs from escalating, ultimately reducing hospital admissions and staff absenteeism.

? The data we need is not just clinical. The wider determinants of health informs us that people’s behaviour, their interests, and what they buy is more important to their health outcomes than which doctor they see. Having access to commercial marketing data could help the NHS to prepare for future demand, provide feedback for public health interventions, tell us the brands to partner with, and the messaging required to reach underserved populations.

Communications and expectations

? Cut out the jargon. ‘Personalised care’ and the names of its interventions mean nothing unless you are already interested. That makes it difficult to talk about, which is deeply ironic since the kind of care they offer is fundamental to a therapeutic relationship and intuitive to all patients. We need to strip out the jargon and co-produce terms so we have a common language about personalisation.

? Tell all stakeholders what to expect. We need to clarify for managers, clinicians and patients via tailored campaigns that our approach is changing. On entering a consultation, we need patients to engage in the management of their health. It’s no longer a case of patients arrive with the problem and the clinician provides the “solution”. As a model for addressing the scale of the challenges we face, it just doesn’t work. We want patients to work with us differently, and we need them to hold us to account so that change really takes place. If personalisation doesn’t work for them, it isn’t working.

? Help patients to keep us honest. Offer easy access to their care, appointments, and the order of procedures they should receive, to help the system work for everyone. Patients who understand their pathway can alert us when something’s wrong (e.g. missing a diagnostic before a consultation) and reduce wasted time and effort.

Workforce and estates

? Create a digitally-enabled personalised workforce. At the moment we don’t have enough roles that facilitate personalised care to meet demand, and c.99% of those we have sit in primary care. But demand exists across care-settings; we need more roles who are accessible everywhere via a virtual referral hub.

? Incorporate personalised care into education. Personalisation must be part of the curriculum so it becomes second nature for tomorrow’s clinicians. But we can’t expect them to deliver if their job plans and work culture remain stuck in the past. Time needs to be built into practice to better understand patients and support their wider needs.

? Make personalisation core to training and support for the workforce. Upskill the current workforce about personalisation and reinforce that learning through personalising support for the workforce themselves. Not only would that reduce absenteeism and improve wellbeing and retention, but it would provide a ‘framing’ narrative to help the workforce personalise care from the outset.

? Bring the ‘real world’ into the clinical space. Co-produce estate refurbishment with people who feel excluded from the NHS to create truly welcoming, safe spaces. It would help clinical staff to think more holistically and could offer opportunities for businesses to co-locate with health, reducing capital expenditure or providing revenue.

These are some of the steps we must take to ensure personalised care has a tangible impact on patients and the NHS. They are part of re-imagining the NHS to align more closely to the intrinsic imperative to care. To treat someone’s ailments, you really have to know the person before you, or else how can you know if you did ‘no harm’? Personalising care takes us back to the very foundations of healthcare and in doing so can make the NHS fit for the future.

Joe Fraser is Head of Healthcare Inequalities Improvement, Personalisation and Prevention for the NHSE London Region and Josh Hutchison is a Partner at Channel 3 Consulting.