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Professor Sir Bruce Keogh: ‘Only those in the system can change it’


16 February 2017

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As the highest-ranking doctor in NHS England, Professor Sir Bruce Keogh is keen to ‘inject some hope’ into the bleak narrative surrounding the NHS. Listing a string of medical breakthroughs since the discovery that malaria is transmitted by mosquitos in 1897, through to the invention of the CT scanner in 1972, Sir Bruce is adamant: ‘We can have the best healthcare system in the world and it’s a stone’s throw away.’

As the highest-ranking doctor in NHS England, Professor Sir Bruce Keogh is keen to ‘inject some hope’ into the bleak narrative surrounding the NHS. Listing a string of medical breakthroughs since the discovery that malaria is transmitted by mosquitos in 1897, through to the invention of the CT scanner in 1972, Sir Bruce is adamant: ‘We can have the best healthcare system in the world and it’s a stone’s throw away.’

But with 185,017 people waiting at least 12 hours on trolleys in overcrowded and understaffed A&Es across the country last year, the stone is heavy. While he acknowledges that the NHS is facing ‘some pretty big problems’, he insists they can be solved.

What lessons can healthcare leaders take from the unprecedented amount of pressures that A&Es have faced this winter?

Winter is really difficult for the NHS. It’s become more difficult over the last few years because demand is just relentlessly rising.

The reason that I’m so keen that we crack on with implementing the recommendations of the urgent emergency care review, published in 2013, is that there’s a growing sense that there’s no end in sight for the difficult winters. Morale among managerial and clinical staff around winter is low, and at wintertime we need everybody to go the extra mile. What we’ve seen in previous winters are people doing that out of professionalism and goodwill. This winter, as a consequence of some of the unrest during the year, much of the goodwill has evaporated.

We’re hearing a lot of five-year plans. How are things going to change for next winter? What’s going to change imminently?

What I’ll say is we’ll be fleshing that out before the end of March, but broadly speaking, we’re looking to see a more interactive NHS 111, with much greater clinical input than we’re seeing at the moment.

We are keen to see a much clearer understanding about what A&E offers, what primary care offers and what the array of minor injuries units, walk-in centres and urgent care centres offer.

We’re keen to see an increasing general practice presence co-located with A&E departments; we’re keen to see a big focus on how we can improve flow through the hospital, so when you look at the four-hour target, that’s a barometer of how the whole of the healthcare system is working. It’s not just a barometer of the emergency department.

It seems to be a regular occurrence that the four-hour waiting time target is missed. Should we expect that to be the new normal?

I don’t think we should expect it to be the new normal, but I don’t think we should expect it to turn around very quickly, and the reason I say that is if we can get into place the things that I’ve alluded to, the four-hour target will slowly start to improve again.

But I do think we need to give considerable thought to the four-hour target, because it’s a simple arithmetical calculation of how many people get assessed, treated and dealt with within four hours. There are different influences, which can make you do well or less well on the four-hour target. In an extreme example, if you have a lot of minor cases coming in and out of your A&E, you can turn them around very quickly, but it doesn’t necessarily mean you’re turning around the very sick people quickly. It is one of the problems with simple arithmetic measures.

There’s been quite a negative reaction to the sustainability and transformation plans (STPs). How do you feel the process has gone?

Some of the negative perceptions have been perfectly fair, but you can see how they arose. The process was conducted at breakneck speed – that’s the first thing. The second thing is that you’ve got to have discussions in order to develop documentation or proposals to put in front of people. So in any kind of planning process some people have to sit in the room and develop the first draft for discussion, but given the combination of the breakneck speed, the financial climate and the novelty of STPs, there was a level of suspicion.

How will the lack of clinical involvement impact the STP implementation process?

Those people who are engaging with patients on a day-by-day basis share the aspirations, the fears, and the anxieties of their patients and are doing their best to help them. They see themselves as advocates for the patient. So when you’re trying to change services, there are people who can comment, but it’s only people who work in the system who can actually change it. It’s really important to have the clinicians on board because they see themselves as the advocates and the defenders of good services. Without having them on board it’s a precarious position to be in.

Can STPs implement their plans in the time available – by 2021?

I think it’s really ambitious. There will be some STPs that will achieve a lot by 2021, but as with all things, when you start something new with different groups of people, about a third do things really well and are ahead of the pack, about a third are pretty middling, and about a third have got a long way to go. I think that distribution holds for the STPs as well.

What are you hoping will come out of the Chancellor’s budget in March?

I hope that we would see some recognition in that budget of the impact of reduced social care funding on the NHS.

What’s the biggest factor in creating a sustainable NHS other than financial investment?

The first thing is political will. The second thing is a deep understanding of the value that the NHS has to the citizens.

Is the NHS fit for the future? Do we have the right funding model?

With the advent of genomics and a deeper understanding of disease, we can now get to a point where we can identify people who will get certain diseases. It’ll soon emerge what our predisposition is to other common diseases. Now, the value of the NHS is that we, as a country, have decided to pool our resources, to pool our risk, so that no matter who you are, no matter what socioeconomic group you come from, how much you earn, your race, your age, your creed, makes no difference: when you need care, you get it.

We need to be very, very careful about undermining that iconic set of principles, because as it becomes increasingly possible to identify who’s at greater risk from different diseases, we don’t want to be working in a health system that relies on private insurance or private payment. So, my argument is that a tax-funded NHS, free at the point of delivery, is probably better equipped than any other type of health system for the emerging science.

The NHS is very dependent on five-year plans, it seems. What will the NHS look like in 10 to 20 years, in terms of services and the structure?

Acknowledging that predictions of the future are seldom right, one thing that I can be sure about is that healthcare will change from being a delivery business, with a small amount of knowledge transfer, to being predominantly a knowledge transfer business with a smaller delivery limb.

So knowledge transfer is going to be the big change in healthcare, and that’ll change people’s behaviours; it’ll change behaviours of patients, it’ll change the behavioural and social dimensions of clinical practice in a way that’ll never go back to the old days of paternalistic practice.

It will bring immediacy of information to patients and will provide us a bunch of new opportunities for the way that we organise and deliver our services.

What do you mean by knowledge transfer? Will we be self-diagnosing? 

Yes, I think there will be more opportunity for diagnosis online. Self-diagnosis will become more of an issue.

Would that mean GPs would become obsolete?

In 10 or 20 years we will see changes in diagnostic capacity and imaging, so for example, there will be changes that will happen in other industries that will have a massive impact on healthcare that we can’t even think of.

Changes in super-conducting technology mean that within a decade we’ll probably have hand-held MRI scanners, which will start to change things.

Interventions will become increasingly minimally invasive, and we’ve already seen that with laparoscopic surgery – first of gall bladders, and after that with colorectal surgery.

So the nature of our hospitals will change, and they will become increasingly complex diagnostic centres, which offer very complex interventions, and much more will be delivered closer to people’s homes. GPs will be – I think they are now, but it will become increasingly true – the consultant physicians of the health service.

Many things will move out of hospitals into primary care closer to people’s homes. We need to be aware of that and never cling onto stuff in hospitals that can be done outside of hospitals. I hope that starts to paint a bit of a future.

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