Changes in the NHS are happening at a local level. This will lead to the re-shaping of the system around new care models. To keep up the NHS must shift focus to demand, place and collaborators say Lord Victor Adebowale and colleagues
Sir Michael Marmot’s famous statistic estimating that only 20 per cent of health outcomes are based on treatment has never really been taken seriously. If it had, would we really still be talking about health, social care and public service integration rather than doing it?
‘The forward view assumes ownership of the system rests with those who run it’
For many standing outside of the NHS world, debates on the future of health and care in England feel remarkably insular. We know that health and wellbeing is influenced by broader determinants than service interventions; yet even forward looking policy like the NHS Five Year Forward View closes ranks and assumes the ownership of the system rests with those who currently run it.
This is problematic because the world in which the NHS works is changing around it. It is changing most tangibly at a local level, where pressure on budgets and a rising set of social demands will re-cast the relationship between residents, councils and other service providers between now and 2025.
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It will do this in a context of devolution: fast becoming the only game in town for local government, and a primary means through which the relationship between NHS and other public services will be renegotiated.
As the vanguard programme infers, change in the health system will happen in different ways for different places. What will make these programmes successful is not only effective delivery of new care models, but a degree of collaboration across public services and with the community that has hitherto proven very difficult.
‘There has been no lack of commissions and reviews on the future of the health system’
In September, Collaborate and the New Local Government Network are co-hosting a Commission on re-imagining place based care, which seeks to explore how a more systematic level of place based collaboration can be embedded within healthcare reform.
There has been no lack of commissions and reviews on the future of the health system in recent years. But this one hopes to be different: it takes place as the starting point, has demand as the focus, and collaboration as the mechanics.
It will ask how the system feels from the outside in, and how a whole range of actors in a place can work together over to go past the five year threshold and begin re-shaping a system around new models of care that transcend existing institutions.
Shift the focus
We think three shifts in focus will be key:
- From supply to demand – seeing the world through a service lens is an endemic problem, meaning that public agencies typically know a lot about people’s responses to service interventions, but far less about the assets, resources and networks of communities outside of this. Making large scale integration such as Greater Manchester’s health and social care devolution deal work within its financial envelope will depend on understanding and managing community demand on a far more profound level.
- From organisations to place – place based health requires the productivity of NHS services to sit within a broader set of qualities about leading place. This means that concepts like system leadership, collaborative delivery and real outcomes based commissioning quickly need to become tangible actions – something we will be testing in our four evidence sites of Sunderland, Suffolk, Sutton and the West Midlands.
- From patients to collaborators – meeting the supply and demand gap in health and local government services (estimated at £14.4bn by 2025 according to the Local Government Association and Collaborate modeling) will depend upon whether the public sector can see the resource base in a very different way - encouraging much greater collective responsibility for health outcomes, and embracing the degree of diversity in provision that is necessary to create bespoke services for individuals and communities. Yet this is not a one way street - behaviour change, now part of mainstream public health discourse, is as much about changing the perspective of professionals as nurturing the potential of collaborative citizens.
These three shifts are already part of the way in which the health system is looking to re-invent itself in changing circumstances. This is to be celebrated.
‘There is a fundamental imbalance at play’
But there is a fundamental imbalance at play, which means that, at worst, transformation in NHS services will proceed in isolation from changes in the broader system. This will undermine efforts to think holistically and act preventatively – two dynamics upon which the potential of devolution and integration are seriously dependent.
Our commission will not change the debate overnight, but we hope to offer a route in for people who want to widen the lens, and welcome your input.
Lord Victor Adebowale is chair, Dr Henry Kippin is executive director, and Sarah Billiald is managing director, all at Collaborate CIC
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New care models: To keep up, the NHS must shift focus in three ways