NHS Long Term Plan & PROMs

7 Key Takeaways, why Patient-Reported-Outcomes Measures (PROMs) have a place in the NHS Long term plan to improve the UK’s healthcare system.

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7 Key Takeaways from the NHS Long Term Plan

1. The health of the UK population and that of wider Europe is shifting to the management of long-term chronic illness that requires interaction between multiple healthcare professionals and organisations

2. In order to face these challenges, the NHS has recently published a 10 year Long Term Plan with an emphasis on integrating different levels of care to support the needs of local populations.

3. The success of health care is currently mostly measured by survival rates following treatment as well as mortality.

4. However, these measures are not patient-centred and do not enable to make key decision for individual patients in the day to day clinical practice.

5. Measuring Patient-Reported Outcomes such as quality of life can support care teams in monitoring patients with complex healthcare needs.

6. Ongoing capture and sharing of PROMs data can enable care providers to provide tailored, effective interventions at the right time, by the right person.

7. Technology has a key role to play in supporting the collection and use of PROMs, by enabling in-clinic and home base longitudinal data capture and real-time reporting

NHS: A system under pressure

The UK healthcare system is a complex landscape. It faces major public health challenges, including an increasing financial pressure and demands for services that have to implement innovative strategies to deliver high-value services in a climate of austerity. Sadly, more are turning towards privatised healthcare services as the NHS simply cannot keep up with a 1 million patients every 36 hours. Overall, there is a 40% increase in procedures and interventions, a 28% increase in hospital admissions and an approximate 24% increased attendance at A&E departments (2005/2006 vs 2015/2016). This pressurised system is unlikely to change as Nick Ville, Director of Policy at the NHS Confederation, points out that “Levels of demand on the health service are showing no signs of slowing down, which inevitably places even more strain on an already overstretched system”.1

A population with complex healthcare needs

The population’s health needs have become more complex. With 1 in 3 patients living with 5 or more health conditions of some form, there is no fast route or an all encompassing treatment that will cure all ailments experienced by these patient.2 Considering this, patients require multidisciplinary health care support to be provided with optimal treatment. 

A recent publication revealed that 1 in 3 adults in the UK are obsese and that this development has led to obesity causing more forms of cancer than smoking.3 The fact that roughly 10% of the national healthcare budget is taken up by diabetes healthcare demands indicates that the population is not only aging, but many are suffering with chronic conditions through which an array of comorbidities stem from. But what about the younger generation – the patients of tomorrow? Approximately one in ten children suffer from some form of mental health problems, whilst an astonishing 1 in 5 children qualify as being obsese by the age of eleven due to the NHS Long Term Plan.4 The reality is that the patients of today and the patients of tomorrow have a complex mix of health problems across a wide range of ages that cannot be solely dealt with by individual institutions alone.

The NHS Long Term Plan 

In order to battle the challenges that come with a constantly evolving healthcare scene, the NHS is always evolving in an innovative way. In January 2019, the NHS Long Term Plan was published setting out an agenda for the forthcoming 10 years.4 The plan builds on the policy platform laid out in the NHS Five Year Forward View (2014 – 2019) which highlighted the need to integrate care to meet the needs of a changing population.5 Frontline healthcare staff, patient groups and field experts contributed to the formulation of the agenda, with the NHS praising the strategy as helping the service to become “fit for the future”. 

The nation is getting older, with the proportion of people ages 85 years and older expected to double over the next 25 years. Not only that, but the population is predicted to rise  to 72.9 million in mid-2041. The NHS Long Term Plan aspires to deliver increased support in the areas of maternal, perinatal and paediatric medicine; chronic diseases as well as geriatric medicine and care. These areas are of vital importance when accounting for a growing, aging population with chronic illnesses. 

At the heart of the NHS Long Term Plan lie Integrated Care Systems (ICSs) as the disease areas require coordinated intervention from various healthcare professionals. An ICS is an emerging type of collaboration, whereby NHS organisations, in partnership with local councils take collective responsibility for managing resources and delivering NHS services tailored to the population they serve (NHS England). This means that many stakeholders need to collaborate with each other, share information, make joint decisions and build towards the bigger picture: is the patient getting better? Has their quality of life improved? And so, introducing a system of integrated healthcare with a focus on patient feedback and enhanced communication seems like a remedy to assist with the current health trends. Furthermore, it could ensure that an ease of access, coordinated healthcare system works for and benefits the patients using it. 

The NHS and Patient Reported Outcome Measurements (PROMs)

As outlined in the NHS Long Term Plan, the NHS aspire to make better use of data and digital technology.4 In recent years, the power of harnessing and utilising data to make more informed decisions in science and medicine has been acknowledged. Data is quickly becoming as powerful as drugs, as “personalising” medicine to the individual is becoming essential for better treatment and care. Data can come in the form of Patient Reported Outcome Measurements (PROMs). PROMs asses the quality of care and quality of life following treatment directly from the patient who experienced it. PROMs questionnaires inquire about the patient’s perceived levels of mobility, pain, sleep, mental health status etc. For example, a typical question may be “Do you have difficulty with self-care (bathing, dressing yourself)?” Interestingly, the NHS has an established national PROMs programme (NHS England) as of 2009, whereby four surgical procedures were initially chosen to derive PROMs from to better determine the quality of treatment (total hip and knee replacement PROMs collection still ongoing).6

As part of the current orthopaedic-centred programme, patients are asked to participate in a questionnaire before their procedure to establish a baseline from which to measure outcomes. Following the operation, the patient is sent follow-up questionnaires before discharge and 3/6 months following their hospital stay. From this information, clinicians can determine how much the patient’s condition has improved or deteriorated, known as the “health gain”. In the current programme, questionnaires collect information that feed into commonly used condition-specific and overall measures of health improvement, which the NHS include in their publications.7

However, in the initial stages of the NHS PROMs programme a review by the London School of Hygiene and Tropical Medicine found that PROMs had not driven the expected improvements and determined that there were no grounds to suggest that they should start reducing the number of surgeries being carried out.8 The programme suffered some criticism due to the paper-based method of collecting PROMS, which may have contributed to the programmes lack of satisfactory results at this time.9

Results from a finalised PROMs publication on patients undergoing elective surgery for hip and knee replacements between April 2016 to March 2017 were as follows:

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Figure 1: The chart displays the average pre- and post-operative scores by gender, for the Oxford Hip Score (OHS) and Oxford Knee Score (OKS).

Some of the findings show that the Oxford Hip Score (OHS) and Oxford Knee Score (OKS) (well-established PROMs sets for these procedures) greatly improved following the respective surgeries. Patients reported that on average their quality of life had improved after the interventions. Those undergoing hip replacements reported average health gains on the Oxford Hip Score of 21.1 for males and 21.7 for females. On the Oxford Knee Score, these were 15.9 for males and 16.9 for females.10

Putting the patient perspective at the heart of the NHS Long Term Plan

PROMs are regarded as an important indicator of the quality of treatment and how cost effective certain procedures are. In 2017, the Organisation for Economic Co-operation and Development  (OECD), published a report on the outlook of health statistics and promoted the broader adoption and utilisation of PROM usage in clinical practice, quality improvement and performance measurements.11

The success of health care is most commonly measured by survival rates following treatment as well as mortality. However, by measuring outcomes reported by patients such as their perceived quality of life, vital information regarding effectiveness of treatment and healthcare services can serve as performance measures to compare and improve clinician or organisational quality of care – goals in the NHS’s Long Term Plan12 Establishing a feedback loop of knowledge can help patients and their doctors share the management of long term medical conditions, which is what the majority of the British patients are currently suffering with.13 With chronic conditions, PROs become essential indicators of what treatment strategies work for the individual. By utilising PROMs in these long-term cases, patients’ results are better due to the enhanced focus on what really matters to the patient as they manage their illness.

PROMs can be used to inform clinical decision making, assist in shared decision making especially in the more integrated way of delivering healthcare which is part of the NHS Long Term Plan and facilitate the tailoring of care to the patient. If a patient receives a form of care that best suits them, the complication rates will likely decrease thus reducing the overall expenditure per patient.14

Let’s take a 2017 publication investigating the overall survival results of a trial assessing PROMs for symptom monitoring vs standard scheduled imaging to detect symptomatic recurrence in patients with lung cancer following initial treatment. The results revealed a significant survival benefit (19-month survival in the PRO group vs 12 months in the control group).15

In the field of orthopaedics, evidence shows that  PROMs informs surgeons which kind of prosthesis provides patients with the most postoperative satisfaction following a knee replacement.16

Making PROMs part of the clinical everyday

There are practical challenges with the integration of PROMs in routine clinical practice, especially when considering a large population. Barriers include the lack of on-the-ground clinician leadership for PROMs adoption. Additionally, a reluctance to avail of PROMs collection can hinder its potential. Integrating a PROMs tool into pre-existing medical record systems is challenging, especially when considering nation-wide healthcare settings. An awareness of the factors that drive everyday PROMs use is paramount and as we elaborate in greater detail in our article “Improve Patient Engagement for PROMs”.

For PROMs to be as effective and informative as possible it requires an integrated digital system through which information can flow. This flow allows all healthcare providers to be aware of the outcomes collected for a particular patient. Research in breast cancer from Germany noted that in an age group between 40 – 50 years, 90.1% of patients who agreed to an electronic PROM follow up participated in the questionnaires.17

One of the enablers of PROMs is the adaption of its digital entity. With more people accessing the NHS and with hospital admission rates increasing year on year, all of these interactions generate some form of electronic record or footprint. With 200 different data collection systems across the NHS health care network.18, the need to combine services to use PROMs platforms for volume clinical management and provider monitoring is paramount for it to succeed on a widespread scale. The electronic capture of PROMs in clinics and between appointments allows real time monitoring of symptoms, early detection of problems, and prompt clinical intervention.19 Furthermore, regular remote PROM monitoring could be used to support not only patients at high risk of emergency admission but also the millions of people who have multiple long term health conditions to reduce unnecessary outpatient appointments, promote treatment compliance, and tailor care to individuals’ needs.14 This is especially relevant in the UK with many older people with comorbidities living in small, often rural communities.

A digital platform to support integrated care

Despite the obstacles that PROMs collection may have, the investment in PROMs implementation will prove invaluable. The value in collecting the right information at the right time, consistently can pave the way for more efficient delivery of care. 

Heartbeat ONE is a PROMs enabler by providing an easy to use data collection platform that frees up care teams. Heartbeat’s solution is an automated, intuitive and interoperable tool that permits healthcare staff to focus on their patients by reducing administrative duty thus, using their time and resources more efficiently. The system aims to integrate into the workflow of the clinic or hospital by collecting and documenting clinical data dynamically, automatically and according to international standards. By gathering PROs before a consultation/surgery and at defined time intervals afterwards to track the patient’s wellbeing, our system captures the right data at the right time with minimal intervention. Through the feedback supplied by patients, Heartbeat allows this safe data to become actionable to support the day to day decision making in clinical practice. 

The future of healthcare is integrated with an emphasis on outcomes and data. Heartbeat can help it get there!

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written by
Katie O’Keeffe

Medicine and healthcare writer, responsible for international healthcare research at heartbeat.

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  14. https://www.bmj.com/content/364/bmj.k5267 (Accessed July 30th 2019)
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