New care models and new ways of working need to be informed by a psychosocial perspective if the NHS is to deliver the productivity gains it needs to make, believes Paul Burstow
With NHS providers expected to be in deficit to the tune of £2bn plus by the end of this year and the spending review asking government departments to model cuts of 25 per cent and 40 per cent, finding £22bn is going to be tough.
‘We urgently need a shared strategy and plans to get us there’
Unless the work on new models of care and new ways of working is informed by a psychosocial perspective it will not deliver the productivity gains required.
Despite all this I am an optimist. The Five Year Forward View has provided a rallying point, a shared vision about the future. Now we urgently need a shared strategy and plans to get us there.
Integration at the forefront
The forward view places integration front and centre:
- integration of physical and mental health;
- integration of primary and specialist care; and
- integration of health and social care.
This can easily become about systems when it needs to be about people and relationships. Put simply, people come with integrated minds and bodies and interdependent lives.
This is not just a theory. It is already becoming reality in some parts of the country.
In Oxford, patients with cancer have experienced improved outcomes due to an integrated care pathway where, in addition to their cancer, their anxiety and depression are also treated.
In Hackney, Tavistock and Portman Foundation Trust runs a primary care consultation and psychotherapy service, which is helping to address co-morbid mental health and medically unexplained symptoms. It has reduced GP, accident and emergency, and outpatient service use by 25 per cent among its patients and achieved recovery rates of 50 per cent.
And there is plenty of compelling evidence of what works. Evidence based parenting programmes for young children with or at risk of severe behavioural problems, such as Triple P or Incredible Years, cost £1,200 per child and generate savings of £3 for every £1 invested.
‘The forward view places integration front and centre’
Good employment is an important element of recovery for many people with severe mental illness, and people in work make less use of mental health services over time. Evidence based individual placement and support services have a one-off cost of £2,700 per client but can generate recurrent cost savings to the NHS of £3,000 a year.
How to get there?
We need a workforce that is fit for purpose, that is a psychologically minded workforce. It is good news that Health Education England is changing nurse education to ensure mental health is a core part of the first two years of the degree. But removing the ringfence from Health Education England would be a massive own goal by the government.
This drive for a psychologically minded workforce needs to be part of continuing professional development and should follow the multidisciplinary approach long pioneered by the Tavistock and Portman FT.
We need payment and incentive systems that support models of care that meet the needs of the whole person, mind and body.
‘The overarching purpose is about promoting wellbeing, of giving people a life, not a service’
Given the financial climate, the temptation is to act defensively, to defend territory and view the world from behind institutional boundaries.
That is why integration cannot be seen as just another initiative. It needs to be about a new culture and way of working for mutual benefit, collaborative, focused on relationships, grounded in a shared understanding of the needs of the communities we are there to serve.
Earlier this year in his report on NHS leadership, Lord Rose said that there was no place in the forward view vision for individualistic, separatist trusts and commissioners. He also said there was a need to articulate a common purpose that would resonate and unite across organisational boundaries. The overarching purpose is about promoting wellbeing, of giving people a life, not a service.
It means asking how people, whatever their age or health status, can live well. This approach demands not just the inclusion of the usual NHS and social care suspects. It requires housing, community and voluntary supports to be in the room too.
Real integration requires co-production with service users, staff collaboration across boundaries has to be supported by those who lead their organisations and by the way we train and educate the workforce.
So this is not just about modelling new ways of working - it is about leaders modelling new ways of leading and behaving too.
I strongly believe health and wellbeing boards are best placed to lead this charge but they lack the capacity or the authority, or even the appetite to do so.
‘The successful providers and commissioners of the future will be those who adopt collaborative strategies’
There is a need to invest in their executive capabilities.
This is not just an investment of human and financial resources; to succeed it must also include an investment or pooling of authority. And it requires service providers to work differently too.
Integration is not an initiative - it is a way of thinking and being. It challenges old ways of working.
The successful providers and commissioners of the future will be those that adopt collaborative strategies, valuing and developing their relationships, looking beyond their institutional boundaries to do the best for the populations they serve.
Unless the NHS embraces both mind and body, and a psychosocial perspective runs through everything it does, money will be wasted, productivity gains will be lost, and millions of our fellow citizens will suffer.
Rt Hon Paul Burstow was minister for mental health in the last government. He left Parliament at the general election. He has just been appointed chair designate of Tavistock and Portman Foundation Trust, a leading innovator and provider of community based psychotherapeutic and psychosocial treatment and support for all ages and multidisciplinary education and training provider, and become professor of health and social care at City University, London