NHS: a health service or an illness service? An interview with Dr Paula Crick

Dr. Paula CrickTHOUGHT LEADERS SERIES...insight from the world’s leading experts

At a recent House of Commons Reception hosted by the University of Derby you described the current NHS as an ‘illness service’ rather than a ‘health service’. Please can you expand upon your thoughts on the status quo?

I've been a nurse for almost 32 years and one of the things that has always been difficult for me to comprehend is that all too often we treat people who are sick, having missed opportunities to prevent, screen or intervene. That is why I made the comment that I think we're more of an illness service than a health service.

Dr Paula Crick speaking at the House of Commons

In my view, we do not invest enough in prevention and health promotion and as a consequence we end up treating illness. If we look at some of the major killers, many of these are linked to unhealthy behaviors. Our investment in supporting and promoting healthy behaviors could be greater, including use of policy and legislation.

When I was doing my Nurse training in the 1980’s, I recall seeing a cartoon in a text book depicting nurses pulling people out of a raging river and the caption underneath said:

Nurses and doctors are so busy rescuing people that they don't have time to go round the other side of the mountain and find out who is throwing people into the water."

For me that metaphor was powerful and led to a long term belief that if we put a lot more into health promotion and prevention then, maybe, we would have a chance of being more than an illness service. This is not a criticism of the excellent public health and health promotion services we have, or the impact of health policy, but a belief that we need to invest so much more.

I have worked within mental health for many years, and there is so much we could be doing better to support mental health and well-being across the lifespan. If health promotion is seen as being under-invested in, then mental health is equally so. I am a strong advocate for parity of esteem for mental health.

Why is the transition to a health service important?

It’s obvious really. Take the public health initiatives on smoking for example. We invested a lot of time and energy, including development of legislation and policy, trying to support people to give up smoking, and the impact has been so positive. Smoking rates have declined and far fewer young people start to smoke now which is a fantastic result. We can see that morbidity that's related to smoking is coming down too.

When I was nursing in the mid-80s, if a patient who could not get out of bed (as she/he was on traction) wanted to smoke you used to put a fire blanket on their chest and they’d smoke in bed! Also, we would wheel patients with mobility problems into the day room on the ward to have a cigarette, and nurses smoked in the staff rooms on wards.  

When student nurses today hear this they are horrified. The culture shift from the 1980s through to today, with regards to smoking, has been massive, when you consider that now you can't smoke inside a pub or in a public building. This example causes me to consider other health behaviors such as diet and alcohol and think, is there the potential of a cultural shift in these areas that could have the same impact?

Alcohol use and obesity are a concern to me and to most health care professionals. Both are issues that cost our health service and, more importantly, the health and wellbeing of many people so heavily. Although, we are investing in prevention for both, I think, there's a lot more work that still needs to be done.

Ever since the big shift we made in smoking, I'm always hopeful that we can also get to a place where we have alcohol use and diet under healthier control.

What do you think needs to be done in order to enable this transition?

Every single healthcare professional should make it their business to consistently offer health and lifestyle support, offering education and advice around health behaviors, so that people feel informed.

For example, if you're a district nurse who's dressing a wound and you’re aware that the wound isn’t healing we would not just continue dressing that wound every day, we would step back and have conversations with the patient about health behaviors that may be contributing to poor healing such as nutrition, smoking or alcohol use.

It's not just giving an intervention, it's making sure you consider lifestyle factors that may contribute to impeding recovery, and those that will promote wellbeing and prevent problems in future.

Please can you outline the Five Year Forward View first put forward in October 2014?

The Five Year Forward View was set out by Simon Stevens in October, 2014. He proposed changes to the NHS which we need to make going forward. We know we've got increasing demand on the NHS and we all know we've got a challenging financial climate; yet we still want a health service with free care at the point of delivery.

The Five Year Forward View has many aspects, which includes the proposition that the population need to take more control of their own health, and essentially there needs to be a radical improvement in prevention and public health.

We need providers of health and social care to be a lot more integrated. At the moment health and social care often don’t feel joined up, with health care being primarily within the NHS and social care sitting largely with the local authority. What we need are integrated services so that those people who are receiving health and social care feel like it's seamless.

We've got some great initiatives up and down the country, particularly in vanguard sites, that are demonstrating the ability of health and social care services to work together. These need to grow so that people receive services in a way that feels joined-up, with staff working together within integrated systems to offer effective, holistic health and care to our service users.

Another aspect of the Five Year Forward View is delivering care closer to home, preventing people from going into hospital, and supporting the home as the default place of care, particularly for older and frailer people.

This requires a transformation of services because there's been such a reliance on care being delivered within acute hospitals. In order for acute care to take place in community settings we need to ensure our workforce is well educated and trained to offer increasingly complex interventions and care within the home.  

Dementia is a good example of an issue that we've got to approach in a way that's not just reliant on the NHS. There needs to be a cultural shift, where all of us, as citizens, take responsibility. The Dementia Friends initiative is a great example; they are encouraging all of us to be cognizant and respectful of the needs of those with dementia in everyday life.

How has healthcare in the UK progressed since 2014?

There has been a lot of work on both the transformation of the workforce and transformation of services. In terms of transformation of services, there has been a big focus on trying to get a joined up approach between all health and care services and systems, and from the workforce point of view a focus on working together as integrated teams.  

From an educational point of view we're working hard to respond to what that transformed world of health and care needs to deliver. We are focused on developing education and training at all levels to meet the Five Year Forward View. This starts with health and care support workers and pre-registration nurses and allied health professionals. Health and care support workers are one of the biggest parts of the workforce who deliver care, but there has not been a significant investment in their education to date.

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What we've been doing at the University of Derby to contribute to education and training of health and care support staff is facilitating them to develop their care certificate. We've also developed Foundation degrees and higher apprenticeships to support their career progression.

This is work-based learning, so we're not taking them out of their workplace, but we're equipping them with knowledge, skills, and competencies to be able, as a healthcare support worker, to work at a higher and better informed level. It has been incredibly successful.

Our programs can be quite bespoke. We consider the employer and the workplace the healthcare support workers are in, and the competencies and skill they need to carry out their role. So if we have health care support workers from a nursing home, for example, then their learning will support development of knowledge and competencies aimed at best practice in the care of older people.

What we've also done is map our Foundation degree into our registrant courses so that somebody who's done a foundation degree can progress to a registered nurse program, for example, should they wish to. We're working to establish and enable career pathways for people that come into health and social care, including those that start as support workers.

What are the main challenges that will need to be overcome?

One of the potential challenges going forward is maintaining interest from new applicants to join healthcare professions within the changing financial landscape. At the moment, we attract a lot of people into healthcare professions such as nursing, diagnostic radiography, occupational therapy and so forth. For example, we get around 10 -15 applicants for every nursing place.

We select students through value based recruitment so people are selected on their values and behaviors as well as academic requirements. The process is led by academic staff, patients, carers, and clinical staff, and all who support this process are committed to the principle that those who enter the health professions are compassionate, resilient and committed to caring for others.

In the recent Government Comprehensive Spending Review it was announced that education of nurses and allied health professionals will no longer be supported by bursaries, but will have to be funded via student loans.  We have so many people that are passionate about coming into the health professions that we should still be able to attract people but, I think, there is a challenge in trying to make sure we continue to attract the wide, diverse range of people that we currently do in nursing.

The average age of a student nurse at our University is around 27, so I’m a little concerned about how we maintain mature students who can be more ‘loan averse’. We are working closely with Health Education England and others to ensure we continue to attract more diverse students in terms of age, ethnicity and background into Nursing and Allied Health professions, and I am confident a solution will be found. To me, it is imperative that our health and care professions reflect the diversity of the service users they care for.

Another challenge is that there are more demands on the health service than ever before and our expectations of the healthcare service are greater than ever. We've got a population that's aging and the number of people living with long term conditions and co-morbidities is rising. It's difficult to see how the health service will be able to financially deal with the increasing demand.

What role do you see universities playing in transforming healthcare workforces?

I think universities play an important role in providing education and training for the workforce at all levels to ensure that they are fit to deliver and develop our current and future health and care services.

At the University of Derby, our curricula are developed alongside service providers and service users and carers to ensure their currency and relevance to the changing requirements of services and those that use them.

We have excellent working relationships with all of our NHS partner Trusts, a range of private, voluntary, and independent sector providers, local authorities and our commissioners, and work with them all in both the development and delivery of our education.

We are very embedded within our region and beyond. We listen, we hear what is required, and we respond to that by making sure that what we're producing in terms of our health and care education is not only what the workforce requires, but also contributes to enhancing the quality of health and care that our service users receive.

How important do you think Massive Open Online Courses (MOOCs) will be in the future of healthcare?

I think MOOCs are great way of distributing education for free. The dementia MOOC we developed was a good example of a MOOC that was just as appealing to a carer of somebody with dementia as it was to a health professional.

It would be good if we could see similar MOOCs around other long term conditions, for example, diabetes or high blood pressure, and also develop MOOCs to promote health in areas such as healthy eating and sensible drinking.

If we can produce MOOCs that are free, accessible and fun, it exposes people to contemporary health issues, but also to the world of education. For those people who haven't engaged in education for a while, it can be a positive experience that helps them develop confidence in their ability. With education around an issue like dementia the learning can be very relevant and applied, and in some cases make a real difference to people's lives.

MOOCs obviously take some investment to develop but I think going forward working collaboratively with health and care providers and commissioners to make sure that we put MOOCs together that are going to be beneficial to service users, carers, health and care professionals and the wider population is a win - win for all.

Where can readers find more information?

For more information on the Five Year Forward View you can go to the Department of Health website.

More information on our MOOCs can be found on our website.

About Dr Paula CrickDr Paula Crick

Currently Dean, College of Health and Social Care at University of Derby

Paula started her career as a General Nurse, specializing in acute medicine, then a mental health nurse working in acute psychiatry and care of older people with mental illness.

She served as an Army officer for 8 years heading up mental health services for Forces personnel and their families in UK and Germany, and served on operational tours of Bosnia in 1993/4 and 1997.

On her return to the NHS she led a drug and alcohol team, mentally disordered offender services, and a mandated drug treatment program for offenders. She moved into Higher Education 14 years ago, and holds a Doctorate in education.


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