So many trends – an ageing population, sedentary and isolated lifestyles, increases in chronic disease, a de-motivated workforce and a suspicious public – appear to be system-buckling challenges which cannot be addressed simply by increasing spending, even if this were affordable.
Last month saw the final publication of the Policy Futures for UK Health series commissioned by the Nuffield Trust, Engaging With Care: a vision for the health and care workforce of England.
After another recent report highlighted just how much of our care is provided informally by friends, relatives and neighbours, Engaging With Care defined workforce to include these informal carers and the ‘self-care’ work we all undertake, alongside the obvious work of paid employees of the public and private health systems.
The report provides an in-depth review of trends and concepts at the heart of relationships involving patients and all the other people in the formal and informal health workforce.
Concepts of self-care, informal care, clinician-patient relationship, governance, responsibility and accountability are not new, but this report goes deeper. it provides a well-researched analytical base on which to show that working together, patient, carer, clinician, policy-maker, manager and educator could create a better future than is often assumed.
The expert panels we worked with agreed with Sir Derek Wanless that engagement is the crucial lever for change, but then the question was: whose engagement? Three possible scenarios around the engaged consumer, the engaged worker, and the engaged citizen were created.
While these three scenarios emphasised different axes of engagement, with different and often conflicting values, we asked if they were reconcilable. Certainly they shared common assumptions about the need to:
refocus policy on health and well-being to address their social determinants;
continue innovation of systems and cultures in the health and care system;
give relentless regard to the disadvantaged and socially isolated;
develop leadership at every level in the system and in the community.
We found we could seek to maximise the positive attributes of each scenario while minimising the drawbacks, and crafted a broad vision of a society fully engaged in its health and care.
This vision included the carefully regulated opening of health and care provision to competition from public, social and privately owned enterprises. We also envisaged that services could only become responsive to the public when the culture of health and care services evolved to reflect their most important preferences.
It was also important that the self-image of a health professional went beyond an acute intervention role to that of a ‘guide’ for people with long-term chronic care needs; and that health and care workers contributed to the funding of their own training.
Individuals, families and communities need to feel empowered to take control of their health and care. This means community development and real local democracy.
Political central control must be disengaged from local solutions and local governance. The public and the workforce need to feel that change is not being done to them, but that they are part of a social movement creating change. For example, that they can participate in designing their health and care plans, not just choose from a menu of options.
Also, key parts of system change must be supported and rewarded, with changes in education and training so that clinical, social and political skills can be developed by patients and carers as well as clinicians and managers.
A basic insurance package for the 21st century must be defined, to provide an economically viable underpinning to the social systemic changes proposed.
What is now needed is not more reform but a re-engagement with consumers, health workers and citizens. The report highlights the necessity of two critical but seemingly conflicting themes: those of leadership and vision on the one hand and partnership with engaged care workers and the public on the other.
It states that the effective delivery of these changes ‘demands that health and social care leaders re-engage with the public and workforce to create services fit for the future’.
‘While engaging at all levels may slow reforms, it is the only way to achieve lasting change. This does not mean that reform must move at the pace of the slowest; it requires bold vision and leadership, beyond the time limits or political constraints of governments.’
‘Such visionary leadership must provide the motivation for reformulating professional values and stimulating a public re-imagining of health, care and well-being in the 21st century,’ it says.
‘We can hope to replace the health and care system led from the centre with one based around a focus on patients and communities, connections – professional and organisational – rather than boundaries, and an emphasis on local rather than national solutions. In this new world it is the workforce itself, embodying core values and inherently responsive to patient and community need, that will lead much of the way.’
The report identifies what needs to follow for each of the key players: policy-makers, health and care leaders, educators, workers and members of the public, and shows that without mutual respect and listening to the others, the challenges posed by demography, disease, alienation and fragmentation
will remain untouched. Whereas under the banner of a broadly based social movement for health and well-being in a fully engaged society, the future can be crafted differently.
Sandra Dawson is KPMG professor of management studies at Judge Business School, Cambridge. Will Erickson is research assistant for Policy Futures UK Health at Judge Business School; Pam Garside is a co-director of the international health leadership programme at Judge Business School; Graham Lister is a visiting professor of health and social care at South Bank University. Read the report at www.nuffieldtrust.org.uk.
The 10 background papers can be found at www.jbs.cam.ac.uk/research/health/polfutures/publications.html