For much of the 20th century, the biomedical model of care constructed around hospitals served us well. It was ideal for a time when a paternalistic approach to disease was deemed as the right way to go. But in a world of Web 2.0, with an ageing demographic and where multiple conditions are becoming the norm, it is no longer appropriate to suggest that "doctor knows best".
In the report, A promise to learn – a commitment to act, Don Berwick, the legendary patient safety guru, set out four guiding principles. One of these is to engage, empower and hear patients and carers throughout the entire system and at all times.
The point made was that engaging and hearing patients will lead us to understand how current experience suggests poor co-ordination between healthcare and community support. It also hints that poor engagement results in individuals not admitting when and with what they need help – and this cannot be good for patients or the professionals trying to help them.
Yet, the solution must lie in the system and not within the walls of an institution. Integration is a term much bandied about in healthcare and could become a weasel word in the healthcare lexicon if the many pilots we have at present are not effectively implemented; if they don't begin to provide more care at home and in the community, and if they don't ensure a more seamless experience.
It's against this background that KPMG recently conducted a survey of 1000 patients, asking them about the future of the NHS. It revealed – surprisingly – that only 36% were comfortable with the idea of using technology, with 54% also arguing that taxes should rise to pay for healthcare.
So the public are ready to have a much more mature and sophisticated dialogue – but we need to support their informed choice so that the hospital and the A&E department are not seen as the inevitable solution.
While news of an additional £500m to A&E departments may defer some of the pain of demand over the winter, the sticking plaster approach is not going to yield the sustainable change required. The best integrated systems in the world have sustained leadership, an effective clinical leadership and engagement and have usually invested considerable sums in their IT infrastructure.
Two examples speak volumes. To begin with, take Virginia Mason in Seattle – where Gary Kaplan, the medically qualified CEO, has been in post for 15 years and where Toyota and Six Sigma approaches to clinical practice are a way of life. He says that "you don't have to be a champion, but you can't be a burier". There's also Kaiser Permanente, where almost 50% of the 9 million population can access their healthcare records online.
Yet despite these great examples of care being made fit for the 21st century, KPMG's latest report, called An Uncertain Age: re-imagining long-term care in the 21st century, suggests that few, if any societies, are facing up to the long-term care problem. Commissioned by the Lien Foundation – a Singapore philanthropic foundation – it makes the point that an ageing population coupled with changing demographics, where people move away from their home base, means the threat of less family support is becoming a reality. Add to this the growing cost of healthcare and the dwindling available funding and we need to redraw the way we provide care and the way we engage the population in that change.
As our report suggests, person-centred care is a must, institutional boundaries must be redrawn or erased and technology must play a part. Perhaps this is Berwick's most important guiding principle as, without that engagement, empowerment and listening we will not be able to make the seismic shift required to a holistic view of the system. In other words, we will not be able to move beyond the walls of the hospital, where patients and the public expect increased autonomy in return for greater responsibility for their health.