NHS international intelligence scanning service

Introduction

The front door and ‘crown jewel’ within the NHS has long been its web of innovative primary care providers that help support patients in their homes and communities. Primary care providers are unique within the NHS landscape, as they regularly increase activity levels amid growing demand and falling public satisfaction. When primary care comes into contact with different pathways and services, it almost always delivers efficiency and good outcomes, while managing high levels of risk in the community.  However, one fundamental flaw in our model of healthcare delivery is the disconnect between primary care providers and the rest of the health system. The current model of general practice premises can be a real barrier to integration and often drive fantastic clinicians away from becoming GP partners, by putting enormous responsibility on individual GPs to either buy or lease their building at a great deal of personal expense and risk. Another critical challenge is the lack of integration and continuity of care between in-hours and out-of-hours services, disconnecting in-hours primary care services from their patients. This blog will explore two countries that have adopted approaches that tackle some of the challenges outlined above.   

Estates

The need for investment in the primary care estate has been evident for a long time. It has been the feature of numerous research reports, think pieces and new articles. The ‘8am rush’ has become the cultural touch stone used to describe the NHS’ insufficient and crumbling infrastructure. It is no surprise then to have seen the primary care estate feature in the Labour party’s manifesto and why it has been an encouragement to our primary care members to see SoS, Wes Streeting, proactively engage with the sector so soon into his tenure. Faced with such a mountainous task, knowing where to focus the government’s limited resources is no small task.  

We can look to reform of the Italian primary care system as a source of inspiration. Many will remember the scenes of Italian hospitals pushed to the brink in the early days of the the covid-19 pandemic. It was a shock to a nation that took pride in the quality of its hospital sector, but it has since given rise to a once radical reorientation of the health system in one northern region that chose to prioritise the integrated and co-location of services at the local level.  

Beginning in the region of Emilia-Romagna in 2013, it is a model of care that has been proven to work for the needs of Italians under the most stressful of conditions and has been backed up by new government legislation.  Known as Casa della Salute or Health Homes, the Italian model has established a network of community health centres serving populations of 50,000 providing primary care, prevention, maternity care, laboratory services, basic diagnostics and even some specialist services. This co-housing of services means that an ageing population with growing need to manage long-term conditions can access numerous service providers with a greater ease and consistency that is possible when services are found in large centralised hospitals.

The rapid proliferation of the Italian health homes would not have been possible without the development of new physical infrastructure. Italian GPs have often operated in single practitioner surgeries, almost never utilising an multi-disciplinary team approach. To achieve this shift to co-location, the Italian government made use of a £7 billion grant from the European Union’s pandemic recovery and resilience fund, an investment without which Italian colleagues acknowledge they would not have been able to find the necessary financial resources to make the investment.  

Commissioning

Of course, fixing the estates is only one component of reforming the primary care system. To be successful we must also look to the commissioning processes that underpin the activities that are carried out within the four walls.  

In the NHS Confederation’s October 2023 paper ‘supporting general practice at scale’ we called for “flexibility through contracts so primary care can deliver for local people based on local needs...” and the use of “contractual and non-contractual levers to make it easier for primary care to work with the rest of the system within a local community.” These calls are reflective of the often-convoluted nature that governs the funding primary care receives.  

The Italian reforms which have enabled the building of the health homes network have also sought to overcome some associated commissioning limitations. Similarly to the English NHS, Italy has seen a decline in the number of newly qualified GPs wanting to take on the risks of being an independent contractor. As a result, newly qualified GPs are required by law to commit a number of hours inversely proportional to the size of their patient lists. A GP not wishing to take on any of their own patients would commit all hours to the new health centers, while a GP not wishing to commit any time to the health homes would be required to maintain a list of patients at their practice. Crucially, this provides a phased approach for patients and existing GPs alike.

We might also look to the Netherlands for inspiration. Despite having an insurance-based system that can sometimes be characterised as making provision and planning less integrated as well as more administratively onerous, over the past 25 years the Dutch have successfully developed an efficient system for the provision of out of hours primary care services (OoHS) that should be the envy of the UK.  

The OoHS provides emergency access to patients who cannot wait for core operating hours (08:00 – 17:00) through GP led multi-disciplinary partnerships known as Huisartsenposten (HAP). In operation since 2000, there are roughly 110 HAPs across the Netherlands, each serving 100,000 to 500,000 people and comprising roughly 70 GPs. Through a well-established triage system, HAPs are able to provide access to phone and in-person consultations with GPs, access to a night pharmacy, and if needed, referral onto hospital services and emergency care.  

GPs are required to contribute a minimum number of shifts to the HAPs as part of their registration and share this responsibility with the other independent GPs within the HAP, thus ensuring that responsibility is equitably shared.  

The vast majority of the HAP's >4 million patient contacts are for the 0-4 and over 85 age groups. This existing support for vulnerable citizens made the HAPs an invaluable resource during the covid-19 pandemic, able to step up the provision of coordinated services. An evaluation in the region of Oost Brabant comprising 7 HAPs identified that it provided more than 140k appointments in 2023 for the regions one million plus population. If each of these patients were required to attend hospital, as they are in the UK, we could rightly assume that the cost would far exceed the £500k annual operating costs for Oost Brabant, in a combination of financial cost, patient experience and patient outcomes.   

Conclusion

The examples from both the Dutch and Italian Health Systems provide no silver bullet or magic answers to our challenges regarding premises and out-of-hours services. Whilst our premises and out-of-hours system present stark challenges, there are also great opportunities to learn from successful models of care and reform that have worked well in other countries. We know from our members that General Practice provides incredible care, productivity and value for money. The Government should reflect on how it can empower and connect the General Practitioner to other services . This isn’t about polyclinics or GP co-operatives, but thinking about the sensible, practical and deliverable opportunities to better integrate our primary and community estate and out-of-hours model.  

International analysts with only a passing understanding of the NHS could be forgiven for thinking the challenges facing the service don’t apply to the mental health sector. After all, based on OECD statistics, the UK has some of the lowest instances of depression and deaths by suicide, and while instances of anxiety are higher than our peers, there appears to have been an encouraging decline in instances of all three since their Covid-induced peak in 2020.  

As is so often the case though, these headline statistics hide that whilst progress has been made in recent years, there is still a significant treatment gap in the UK, with 1.5m people waiting for community mental health services, and 10% of children, young people and adults waiting over 2 years to access treatment.  That's why we were pleased to see several of our key asks to government including reform of the Mental Health Act, increased numbers of the mental health workforce and mental health support in every school featured in the recent King’s Speech. Throughout this though we must be careful not to over medicalise our policy approach, balancing clinical interventions with humanising engagement that comes from designing services with communities.  

The intersection between the clinical and the community is perhaps where we can best learn from our international counterparts. In the NHS we know there is a real need to improve how we work with communities to ensure health and care services are culturally appropriate and meet individual’s needs. While we share many of the same global challenges, the diversity of our respective local communities and system structures means that unique approaches to community engagement are abundant and hold lessons for an NHS seeking to improve. To that end, the Mental Health Network (MHN) team recently participated in the Global Leadership Exchange in Utrecht, Netherlands, hosted the Equally Well match in London and attended the 5th International Zero Suicide Summit, in Liverpool. Through these events, we connected with the leaders from around the world working in mental health, disability and substance use who have the ideas, knowledge and experience to inform improvements in our domestic approaches. 

For Sylvia Mah, MHN’s Programme Officer, “Despite the stark statistic that globally over half of deaths by suicide are by people without a mental health diagnosis, thus unknown to the system, being embedded in the mechanisms of the NHS, has made it easy to be siloed into thinking about mental health in an extremely local and singular context. The Zero Suicide International Summit provided an opportunity to combine a greater appreciation for global challenges, with an understanding of how these relate to the national, local and cultural drivers which exist within our own healthcare systems. The event helped me to break out of my silo by opening up discussions with multidisciplinary colleagues about successes, challenges, and future directions in suicide prevention globally as they design preventative interventions that are adaptable and sensitive to different cultural contexts and resource limitations, as well as being wide-reaching to populations outside of the healthcare system.”  

The GLE Summit built on this knowledge and learning exchange, with MHN Vice Chair and Service User Representative, Marsha McAdam praising how this commitment to community engagement was embedded in the design and delivery of the GLE Summit :  

“The voice of lived experience was authentically included in the exchange, and the vulnerability and transparency of the speakers and presentations made it very powerful. It was an incredible learning opportunity connect with so many leaders from around the world, and it was so positive to see how we approach different challenges and opportunities, whilst all aiming to improve the lives of the people we work with and for.  

The summit began powerfully with a session delivered by people with lived experience of disability, mental illness and addiction. And, as is often the case with international conferences, the big calls for renewed and reimagined focus can be matched by a simple line that make you think. An individual claiming the term ‘mental variation’, rather than mental illness, was thought provoking for how we support individuals to recover and thrive.  

A standout example from the summit included the Healing of the Canoe programme; a community driven, culturally relevant, substance abuse and mental health intervention program for tribal youth in the USA that is based on the knowledge that the most effective way to prevent youth from being impacted by substance abuse is to establish strong connections to tribal traditions, culture and values. The curriculum was first implemented in the Suquamish & Port Gamble S’Klallam tribal communities, and a generic version of the curriculum was then created for Native American tribes across the country to adapt and implement in their communities. Shared by Miriam Delphin-Rittmon, Healing the Canoe reflects the importance of ensuring communities drive solutions relevant to them, and that there is room for combining connection, healing and hope in mental health interventions.  

As we work to improve community engagement, we must consider the combination of methods we use to reach communities, whether that’s ‘on the ground’, or online. Following MHNs recent work exploring how we can maximise the potential of digital in mental health services, we are exploring further how we can embed international learning in national strategies, and support the significant activity being led by NICE and MHRA in England. Learning how the National Safety and Quality Digital Mental Health Standards have been developed by the Australian Commission on Safety and Quality in Healthcare was valuable and has provided a blueprint for how other nations can consider the use of digital in mental health services to meet need, whilst protecting individuals privacy, safety and not diluting the quality of services.  

In the UK, we know a country-wide, cross-government approach is needed to support the mental health needs of the population. Operating in a very different context, but with significant areas for learning and reflection, is the ‘How are you?’ campaign, an all-Ukranian mental health programme to provide psychological help and support to the population as they experience the trauma, uncertainty and distress associated with war.  It is a multi-level eco-system delivered in partnership with NGOs, which aims to build both personal resolve and resilience during the conflict but also ensuring people know when to get extra help and support. They have identified children and people in the military as key groups needing additional support, and have designed a programme to meet these population’s needs.  

‘Flourishing communities and wellbeing for all citizens’, the mantra for the GLE summit in 2024, is an important goal for countries looking to move towards prevention, early intervention and community-based care. The new government has made significant commitments to stabilise the NHS, prioritise long term planning and improve outcomes, but has the unenviable task of delivering this with few resources and a public increasingly despondent about the state of care. There has never been a more important time to work with communities to answer these unenviable questions. Connecting with colleagues from around the globe who have been here before and, shamelessly, copying their successful approaches will make this all the easier.  

As the general election campaigning enters its final week, it shouldn’t have come as a surprise to anybody that the discourse around the NHS has focused on the big-ticket items of the elective waiting list, the NHS estate and the 8am scramble for GP appointments that consume much debate around the performance of the service. However, this does not diminish the significance of interventions and innovations that do not capture the headlines quite so easily. In this spirit, the June edition of the international scanning service focuses on three examples of innovative practice that feature less prominently in the manifestos and campaign trails of the major parties that any incoming government would rightly seek to emulate to deliver on their pledges. 

The Conservatives

The Conservative Party has committed to ensuring: “...that procurement opportunities are focused on SMEs in their local economies where possible and practical.”

In this instance, the Conservatives can look to the Australian state of Victoria where the state government is financially backing a new training programme that will see more assistive health tech designed and manufactured locally, which ranges from mobility aids to voice controlled home appliances. The training programme, which is led collaboratively by Swinburne University, Bendigo Kangan Institute of Technical and Further Education and organisations from the health and manufacturing industries is intended to reverse Australia’s dependence on imported technology that is less readily available and fit for purpose for individuals. The initiative plans to combine increasing the availability of a growing market of high-quality jobs while delivering better outcomes for those who rely on assistive health tech.  

Labour

Meanwhile, while it does not feature explicitly in the Manifesto, Labour’s previously stated ‘Missions’ have explicitly referenced the importance of virtual wards for shifting resources into primary care and community services: “NHS to expand ‘hospital at home’ services, like virtual wards, (which) are also vital for delivering the healthcare of the future by bringing hospital standard care into the home using technology.”

This Canadian review on the use of virtual wards for supported early discharge, is the first of its kind in Canada to comprehensively examine the use of virtual wards across numerous countries and will likely hold key insights for their further use in the NHS. The review considers virtual wards' ability to reduce mortality, length of stay, hospital readmission and costs to health care providers. Overall, the review identifies that virtual ward programmes can improve comfort and satisfaction for patients, but the high technological use does risk placing additional burden on patients and care givers at the risk of excluding some.  

Liberal Democrats

The Liberal Democrats have made a link between air pollution and health as part of their commitments to improving public health: “Tackling air pollution and poor air quality in public buildings with a Clean Air Act”.

The NHS contributes 40% of public sector carbon emission, 5% of the nation’s total carbon emissions and will find itself at the sharp end of managing the negative impacts climate change has on the health of the population. Action is needed therefore, but climate change is not contained to a single nation and therefore global, coordinated action is required. To that end, the NHS Confederation hosted a session at our recent NHS ConfedExpo that explored the various forms of international engagement that can support the NHS to achieve environmental sustainability and how local and national organisations can act as global leaders to support other systems to achieve this too.

Featuring Chris Gormley, Chief Sustainability Officer at NHS England, Sonia Roschnik, Executive Director at the Geneva Sustainability Centre, and Alex Giles, Head of Innovation at Gloucestershire Hospitals NHS FT, the need for NHS led collaboration and leadership was brought into stark context by Sonia Roschnik when she revealed that the vast majority of health systems supported by the Geneva Sustainability Centre (part of the International Hospitals Federation) haven’t begun taking any action towards environmental sustainability. 

Chris Gormley painted a more positive picture though when he discussed how the Greener NHS team’s collaboration with the WHO meant that the NHS was able to support the 30 other countries that have set similar NetZero commitments for their healthcare systems, encouraging others to make a similar commitment, and crucially learn from the best practice of other systems.

Alex Giles discussed the tripartite approach that Gloucestershire Hospitals has taken in their role as a local organisation by combining the trust's commitment to environmental action with a focus on Artificial Intelligence development across the trust and international partnerships that are led by objectives for commercial development that expand trust revenues. For NHS trusts facing significant fiscal constraints, the ability to align their NetZero commitments with revenue generating activity can potentially alleviate cost pressures that could slow further action.

Cross-party

Looking at cross-party commitments, all three parties have outlined some form of commitment to address the consumption of vapes, and they would be wise to look to a new Bill set to be passed by the Australian Senate on the 1st July that will prohibit the sale of all vapes in any location other than pharmacies. The move means that anybody wishing to purchase a vape will need to do so for therapeutic purposes and will need a GP’s prescription before purchasing one from their local pharmacy. 

Given the prominence voters give to the NHS, it will never come as a surprise that all parties have made a variety of commitments to the service and wider public health; however, as NHS Confederation CEO, Matthew Taylor, discusses in the latest episode of Health on the Line, there is a dearth of detail on how these commitments will be funded. In these instances, the next government will need to look to tried and tested approaches to derisk their interventions in such a fiscally-constrained operating environment. 
 

Wednesday (22 May) brought to an end months of speculation about when the next general election would be held. Soon to fill the void among the health policy profession is not if, but to what extent, the NHS will become a political football.  

Manifestos will of course be launched imminently, making each party’s plans much clearer, but for now we are able to get a sense of their commitments based on the extensive public debate into the policy the NHS needs that has already occurred. Therefore, in this month’s international scanning service, we’ll be looking at the commitments the major parties have already made and the international examples each could include further in their thinking.  

Starting with the incumbents, the Conservative government has pledged to cut waiting times and has implemented various policies while in government in an attempt to address the NHS’s issues.  

Further lessons can be found in Italy for addressing the the growing backlog of elective care, now at ~8 million. Based on OECD data, Italy has a comparably strong performance on elective waiting times, but domestically waiting times are a point of long-term political debate. In 2015, the region of Emilia-Romagna implemented a plan for reducing waiting times for elective procedures. The plan took a demand and supply approach to reducing waits, including reducing requests for services that didn’t require an elective intervention and non-presentation among patients, as well as removing perverse incentives for some procedures among some providers.  

In the first four years of the plan's implementation, the ambition for 90% of specialist consultations to be undertaken within 30-days, and 60 days for diagnostic tests was exceeded. Despite this, Emilia-Romagna remained an outlier in Italy’s regional approach to health system devolution and in 2019 this resulted in the establishment of the National Observatory on waiting times.  

The Labour party's mission to ‘Get the NHS back on its feet’ also includes commitments to reduce the elective waiting list, as well as improving waiting times for cancer patients, improving access to primary care and dentistry, and improving access to community mental healthcare.  

If they’re not already, the Labour Party will want to keep an eye on Australia, where this week Cancer Australia, the national agency for cancer control, has announced the launch of the Australian Comprehensive Cancer Network (ACCN). Australia is recognised by the OECD as having a particularly strong performance on 5-year survival rates, despite the higher-than-average instances among the OECD; however, inequalities in access and outcomes pervade across the country, especially in rural and remote regions and among Aboriginal and Torres Strait Islander communities. The ACCN will build upon commitments made in the 2023 10-year Australian Cancer Plan by linking cancer services across the country. Participants in the ACCN will work together to a set of standards focused on comprehensive cancer care, equitable access, research excellence, data collection, and workforce development. The ACCN will benefit from the announcement of $1.8bn in new investment into health and medical research in Australia, that includes $1.4bn for research into the reduction of health system disparities and incidences of low survival rates among cancer patients.  

Meanwhile, the Liberal Democrats have committed to guaranteeing everyone the right to see their GP within seven days or 24 hours if it is deemed urgent. They, and other parties, are probably right to focus on their retail offer on primary care. While data from NHS Digital indicates that a significant proportion of patients are already seen with 1 week of booking an appointment, last year's British Social Attitudes survey showed waiting times for GP appointments is a significant factor in the declining satisfaction with the NHS.

All political parties can look to the work of the European Observatory on Health Systems and Policies and their new report Implementing the Primary care Approach for inspiration on this topic. At 504 pages, the report is a comprehensive compendium of the levers that can be exerted in primary care including governance, estates, and digital health and data that draws upon the insights of over 70 experts and the experiences of over 50 health systems.  

Of particular interest will be the approach taken by Spain, where just 0.2% of the population report unmet needs as a result of waiting times, and 86% of appointments for non-emergency cases take place within two days of the request. Much of this is the result of reforms in the early 2000’s that decentralised planning and fiscal responsibility of the national health system and placed an emphasis on services being developed around primary care. Primary care centers have been developed across the country that act as the primary contact point for a range of services including general practice and nursing, paediatrics and social services.  

Wherever they look, each party can find excellent practice from a wide range of health care systems. Common across all systems, though, is a long-term approach that recognises the multifaceted nature of the problems facing services and the need for multi stakeholder collaboration and devolution of decision-making to the local level.