Scotland’s independent think tank
Scotland’s independent think tank

Transforming healthcare: putting people first could improve the NHS and reduce costs – Clare Cable

The Queen’s Nursing Institute Scotland works with community nurses and midwives to help them build a fairer, kinder, healthier Scotland. We now have over 150 contemporary Queen’s Nurses who work in many different roles across health and social care, including care home nursing, mental health nursing, and learning disability nursing.

What we are hearing from the nurses and midwives that we work with is that many of their colleagues are feeling stressed and abandoned, that staffing and resource pressures are making it challenging to deliver person centred care. Yes, more appropriately qualified staff cannot be argued with, but that will take time and investment. QNIS believes that we need to prioritise building a healthcare system that is designed with people and communities, and that utilises nursing expertise in prevention. Community nurses and midwives are an untapped resource and the current system undervalues their contribution.

The challenges faced by the NHS in Scotland are well documented. Audit Scotland’s report ‘NHS in Scotland 2023‘, published in February this year, states that “Significant service transformation is required to ensure the financial sustainability of Scotland’s health service. Rising demand, operational challenges and increasing costs have added to the financial pressures on the NHS and, without reform, its longer-term affordability.”

There are many factors contributing to the rising costs of running the NHS, including increasingly sophisticated technology and an increasing pool of people likely to benefit; staffing costs; increasing demand; an ageing population and greater prevalence of chronic disease; an increasing reliance on drugs; and burgeoning infrastructure requirements. However, rising costs are not the only challenge facing the NHS.

Conditions influenced by lifestyle and cultural factors encompass a range of health issues such as obesity, diabetes, cardiovascular disease, and mental ill-health. Scotland, like many other countries, is seeing an increase in conditions that are influenced by socio-economic and cultural factors.

Obesity rates, for example, have been rising in Scotland, leading to higher rates of related health conditions such as type 2 diabetes, cardiovascular disease, and certain cancers. Factors contributing to this trend include poverty, the dominance of cheap ultra-processed products over wholesome food, decreased physical activity levels, and psychological factors.

Likewise, mental health, which is strongly influenced by cultural and social factors, has also been a growing concern in Scotland. Issues such as social isolation, economic inequality, stigma surrounding mental illness, and access to mental health services all play a role in the prevalence of mental illness and distress.

It is becoming increasingly urgent for the NHS to adapt to recognise the influence of lifestyle, cultural, and socio-economic factors on health outcomes. Currently care is seen as clinical, organised around body parts and specialisms, and designed around those providing the care rather than those seeking help.

But what if we built a system that had a more compassionate and patient-centred approach to healthcare delivery. Margaret Hannah’s ‘Humanising Healthcare‘ advocates for just such a system. She emphasises the importance of empathy, communication, and understanding in improving patient outcomes and satisfaction. This involves a shift towards holistic care that considers people’s emotional, social, and psychological needs alongside their medical conditions. She highlights the role of healthcare professionals in building trusting relationships with individuals and communities, and creating environments that promote dignity and respect. Ultimately, Humanising Healthcare calls for a cultural transformation within healthcare systems to prioritise empathy, compassion, and human connection in all aspects of care delivery.

Margaret Hannah believes that our healthcare system could be better and cost less. She points to the Nuka System of Care which has garnered attention for its success in improving health outcomes, patient satisfaction, and cost-effectiveness. It is a healthcare delivery model developed by the Southcentral Foundation (SCF) in Alaska. It serves as a model for person-centred care that prioritises cultural responsiveness, collaboration, and innovation.

Before the development of the Nuka System of Care, Alaska faced several challenges in its healthcare system, including geographic barriers, health inequalities, cultural insensitivity, fragmented care delivery, workforce challenges, and funding and resource constraints.

Key features of the Nuka System include:

  • Primary Care serves as the central point for coordinating all aspects of a person’s care.
  • People are assigned to interdisciplinary Family Wellness Teams that typically consist of a primary care provider, nurse case manager, behavioural health consultant, and administrative support staff. This team-based approach allows for holistic and coordinated care.
  • Building strong relationships between people and their care teams is a core principle of the Nuka System. This focus on trust and communication helps improve engagement and outcomes.
  • SCF places a strong emphasis on collecting and analysing data to measure performance and identify areas for improvement. This commitment to continuous learning and quality improvement drives innovation and efficiency within the system.
  • SCF actively engages the community in healthcare planning and decision-making through advisory boards, focus groups, and other participatory mechanisms.

Overall, the Nuka System of Care integrates self-care (of communities and of its staff) and compassion into its healthcare delivery model by empowering citizens, creating supportive relationships, addressing cultural needs, and promoting holistic wellbeing. These principles contribute to a person-centred approach that prioritises the dignity, autonomy, and wellbeing of individuals within the healthcare setting. Nuka restores hope, meaning and connection in people’s lives. 

It is becoming increasingly apparent that the levers traditionally used to control healthcare spend are not sustainable. There is little evidence to suggest that finding efficiencies, reducing demand, and implementing staffing policies such as pay freezes and not filling vacancies, make any significant dent on rising spend and therefore do not provide a long term solution to the challenges facing the NHS in Scotland.

With the right support structures and policy framework, Scotland could deliver better healthcare at a lower cost, and whilst it may seem like a mammoth task to transform our National Health Service, there are already examples of a more compassionate way of providing care taking shape on smaller scales within communities across Scotland.

QNIS has worked with community nurses and midwives to support a number of projects including mental health nurses providing trauma-informed access to cervical screening for those who have experienced sexual violence; parish nurses providing health promotion, education, and support services to those experiencing homelessness and addiction; family nurses developing a local peer support network to encourage and support breastfeeding among teenage mums; and a dementia nurse consultant providing a programme to improve the psychological wellbeing of family carers.

Integrating compassion and supportive relationships is also a focus of QNIS’s work. We recently delivered a programme of online workshops for community nurses and midwives in primary care working in some of the least affluent areas in Scotland. We know that populations in these areas have much greater rates of adverse childhood experiences. This matters for later relationships, including relationships with health and social care providers. Recognising the impact of adversity means adapting clinical practice, and adapting the organisation of services, to account for the ambivalence felt by traumatised people when they access healthcare.

Inspired by the work of Scotland’s Deep End GPs, the workshops focused on the importance of the relationship between the person receiving care and the person providing it. By drawing on contemporary psychodynamic ideas, the workshops aimed to deepen participants’ abilities to understand how this relationship works, make sense of all the things that influence it, figure out how to respond in ways that strengthen it, and promote therapeutic optimism. Initial evaluation of these workshops has been very positive and we hope to be able to continue this work in the future.

There are already parallels between the Nuka system and Scottish Government’s health policy in terms of the emphasis on person-centred care, community engagement, and integrated service delivery. By recognising the influence of real life on our health and shifting our approach to how we treat illness, Scotland has the potential to create a radically new and improved National Health Service that truly puts people at its heart.

Clare Cable is the Chief Executive and Nurse Director at the Queen’s Nursing Institute Scotland

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