Insight: setting the expectations of the patient/customer

In July 2018, the National Health Service will mark its 70th birthday. Much has changed since 1948 but it is perhaps remarkable then that the core founding principles of the NHS are unchanged:

-        that it meets the needs of everyone;

-        that it be free at the point of delivery;

-        that it be based on clinical need, not ability to pay.

Not only have these pillars stood up to time and technological advance, they have also become an integral part of our political and social fabric. 

The uncomfortable truth, however, is that times have changed. Whilst the electorate continues to demand a free health service, the definition of ‘clinical need’ has changed radically since 1948. Driven by rising living standards, changes to perceptions of entitlement and, crucially, technology, what was once desirable is now essential. We don’t just demand free medical intervention, but increasingly we want it provided at a time and place of our choosing.

Furthermore, as the breadth and quality of care delivered by the NHS has increased, so too have patients’ expectations of what can be achieved through medical intervention. Taken in the context of the current era of financial constraint, an imbalance exists between what can be done medically, what can be done financially and, indeed, what should be done in the ultimate best interests of patients individually and collectively.

The NHS is now at a pivotal, potentially existential point in its history. Changing the health service to meet every patient need may no longer be sustainable. Instead, should we be focusing on shaping the public’s expectations based on the capacity and capability of the NHS? And could this, in fact, be the cure to both the ills of the modern patient as well as the modern NHS?

There is no single measure to address these questions. They demand a fundamental shift in both health and social care policy, and an honest societal debate. This perspective does, however, outline two areas that both contribute to the status quo, and present opportunities to challenging it.

Self-care or patient care?

According to the King’s Fund, 66% of adults exercise too little, 70% has a poor diet, 21% smoke and 27% of men drink too much. Most intriguingly, 60% have a ‘fatalistic’ attitude towards their own health.[1] One in five patients misses at least one round of medication they are meant to take regularly. Medication non-adherence is estimated to cost the NHS £500m a year in waste alone. Consider, in addition, the £20,000 to treat a hip fracture resulting from not taking biophosphonates,[2] or the £1bn spent a year on patients with diabetic foot conditions, often caused by poor management of the condition with insulin.[3] Much of the cost incurred by the NHS, therefore, results from ‘failure demand’: initial intervention not being adhered to, resulting in further need for intervention.

As patients, we need to play our part in the bargain too, owning our own health and wellbeing and helping ourselves. This could happen in a number of ways; from more stark messaging around missed appointments and medication adherence, to the withholding of interventions based on lifestyle criteria (see the Vale of York’s plans to base access to hip replacement surgery on Body Mass Index and smoking behaviour). Such measures are not ends in themselves, but examples of ways in which the balance of patients’ expectations that the NHS assumes total responsibility for their healthcare could be redressed.

Waiting times: re-establishing their purpose 

Waiting times have become emblematic of the NHS. Such is the industry around measurement that their achievement can feel like the fundamental purpose of the system. Their introduction undoubtedly had a dramatic and positive influence on access to care. At the same time, our expectations of when and, through the patient choice agenda, where we receive definitive treatment, were radically heightened. These ambitions can in fact run counter to the strategic direction of the health service and, indeed, the best interests of patients. 

It is widely understood, for example, that the provision of urgent and emergency care in the community can be more clinically effective and cost efficient than via A&E. Much of healthcare policy and investment is oriented towards developing services such as 111 and extended General Practice to ‘pull’ patients into alternative settings. But the ‘push’ factor could be effective too. Leaving aside its uncertain impact on patient outcomes[4], the four-hour standard for discharge or admission in A&E remains an incentive for patients to use the acute sector for minor conditions by promising face-to-face access to a clinician more quickly than any other part of the healthcare system. If, for example, the de facto expectation of patients with minor conditions is that it may take 6 or 8 hours to receive treatment in A&E, services such as GP hubs could be more persuasively framed as the appropriate care setting. 

Shifting the mind-set

Expectations of what the NHS provides fuel our behaviours. A fundamental reset is required to sustain the health service and its founding principles. Our perceived need for medical intervention should be challenged and replaced by care provided according to the demand of the diagnosis and the best means of achieving positive outcomes. This would both require and help to generate a more mature, responsible patient and support, basing access upon true need. Remaining true to the visions of Aneurin Bevan and the sustainability of our National Health Service depend upon it.

[1] King’s Fund, ‘Health behaviours: future trends’ (2009), accessible at:

[2] Let’s Take of It, ‘The True Cost of Medical Non-adherence’ (2015).

[3] Kerr, M., ‘Foot Care in Diabetes: The Human and Financial Cost’, Insight Health Economics (2017).

[4] Jones, P. & Schimanski, K., ‘The four hour target to reduce emergency department ‘waiting time’: a systematic review of clinical outcomes’, Emergency Medicine Australasia 11:5 (2010), pp. 391-8.

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