England’s health and social care crisis is not only financial – it is a challenge to politics and society too. It represents a crisis of confidence about doing what needs to be done for citizens over the long term – asking tough questions and imagining a different course of action. Debates about austerity and now Brexit might dominate national headlines, but our collective failure to shift our health system towards one that supports good health and longevity is in many ways more intractable.
The long term challenge for health and social care is to adapt to the rapidly changing nature of society: increasingly complex needs, rising patient demand, and sustained pressure on a traditional hospital-dominated service model that has served us well, but is now stretched to breaking point. Symptoms of the deep inadequacy of a system that reacts to ill-health rather than promotes good health are witnessed in daily crises- overstretched A&E units, lack of hospital beds and insufficient elderly care. Yet each is tackled in isolation, rather than build the case for a fundamentally different approach.
We argue that the core route out of this stalemate is not to start at the national level, but to start locally- in places. Over decades, successive waves of Whitehall-initiated structural reform have attempted to mandate behaviour at the frontline or legislate for relationships. This has not embedded the right change. It has disempowered professionals, led to organisational fatigue and created a complex set of services that work to their own logic. As a consequence, our health and care system is an atomised set of organisations individually well-intentioned but collectively incapable of understanding whole person needs.
We need to create a more collaborate system which promotes people’s wellbeing and independence, and that can only be crafted locally. From commissioning to delivery, there is a pressing need to create pooled budgets with shared incentives and risk across the system which needs to work on behalf of people and places. Sustainability and Transformation Plans (STPs) explicitly acknowledge this problem. But many are still locked in traditional pitched battles within and between the NHS and local government. This has to change.
Collaborate and the NLGN convened the Place Based Health Commission which reported last spring to examine the constituent parts of a more radical approach. Chaired by Lord Victor Adebowale and involving senior health experts like Stephen Dorrell and Dame Julie Moore, its mandate was to start with place: the people, relationships, networks and institutions that constitute a health and care system from the ground up. What, we asked, would it look like if place – rather than service – was the unit of currency?
Focusing on place led to a number of insights, from financial model to the front line. We argued that a much-needed financial settlement must cross health and social care boundaries. We welcomed the Five Year Forward View’s focus on purchaser-provider collaboration but argue that for a system shift we needed to adopt the lens of a 30 year forward view. And most fundamentally, we argued that the voice and energy of citizens must play a stronger role in the design and delivery of services, especially outside of hospital settings. For the system to effectively support the Marmot wider determinants of health outcomes then a wider range of resources and assets in places themselves need to be activated: housing associations, developers, employers and educational settings, for example.
In many ways though, the analysis is the easy bit- winning the argument is nothing without a concomitant shift in practice. Even Greater Manchester – further ahead than many – is only in the foothills, with much heralded devolution plans more akin to delegation in practice. This is why one year on from our original Commission report we are re-convening participants in the Place-Based Health Commission this week as part of a major conference that will ask: what will it take to turn emerging plans into real change that we can feel?
For it is those working day-in, day out in places who will ultimately need to lead change. The national system needs to address the funding challenge, but it also needs to do something in many ways harder: to step back. National policy needs to focus on enabling rather than mandating behaviour and relationships- the initiative needs to come from places themselves, attuned to needs and opportunities of people and communities. Already there is ample evidence that unleashing initiative bears fruit: examples from Buurtzog to Troubled Families to Oldham’s Focused Care Model show that front-line collaboration based on building trust and going beyond clinical need is critical.
The challenge is that while we have one single National Health Service, what our modern society requires is actually the opposite: a series of local wellbeing systems. Are our politicians, professionals, and crucially the public, going to be up for this shift in practice?