When faced with huge challenges like providing healthcare to an ageing population, it is reasonable to assume that only huge solutions will do.
But while some healthcare activities need to take place on a large scale, health itself improves or declines at an individual level. While big buildings are sometimes the best place to treat illness, achieving health generally happens in our own homes, workplaces and communities.
Social care has been engaging with these ideas for years. It has tried with varying degrees of success to find community-based alternatives to building-based services, and to give individuals control over resources. However, the NHS is still in love with hospitals. It believes in services designed through clinical leadership with patients as consumers, rather than putting patients in control of designing and commissioning services.
NHS commissioning will be increasingly important to social care providers in the future. The relationship between NHS and social care costs and outcomes is becoming ever clearer, and NHS budgets are in some areas better protected than social care budgets, which are subject to overall council cuts.
This is making many in social care nervous; NHS commissioners talk a very different language. They demand hard evidence of success, often measured in clinical outcomes which do not necessarily sit comfortably with the holistic aims of good social care provision.
Take NICE quality standards for NHS commissioning of mental health services for example. These provide a basis for funding evidence-based short term therapies such as CBT, but not for funding holistic interventions to address the root causes of poor mental health such as isolation amongst older people.
There are, however, signs of change within the health service. The NHS Confederation recently commissioned a series of reports examining citizen empowerment, community development and micro-enterprise approaches to healthcare. A session at Confed’s annual conference on this agenda was packed with emerging NHS leaders, including GPs. All were keen to ensure the switch from PCTs to clinical commissioning groups did not result in the same old thinking and services.
One of the approaches under discussion was Shared Lives, a well-established family-based approach to support in social care. Approved Shared Lives carers are matched with adults who need support; they then share family and community life. A person with dementia may visit a Shared Lives carer in the carer’s own home, with one or two carefully matched peers, instead of visiting a large day centre. In England, 4,500 people with learning disabilities live with a Shared Lives carer and their family instead of alone or in a care home.
The Shared Lives model is making forays into NHS territory. People labelled “challenging” have moved from some of the remaining NHS-commissioned special hospitals and so-called assessment centres - which cost £3000-£5000 per week - into successful and happy Shared Lives arrangements which cost £300-£500 per week. One such arrangement has saved commissioners well over £1m over six years.
There are well-established Shared Lives services for people with mental health problems. Now, the first NHS-commissioned Shared Lives service for people in the acute phase of mental illness has just been set up in Hertfordshire. This combines the support of Shared Lives carers and their families with round-the-clock professional back up to keep people out of hospital. Shared Lives is also being developed as intermediate care for older people who need multiple hospital visits and might prefer to stay in a familiar family home each time rather than a succession of step down care homes.
Shared Lives is still small and poorly understood in social care. It accounts for 18% of live-in learning disability support in the North West, but as little as 2.5% in Eastern England. The challenges of establishing a place within NHS commissioning for Shared Lives and other values-based and community development approaches will be considerable. Typically they achieve outcomes such as reduced isolation and more active citizenship which are hard to measure. These outcomes are even harder to sell to commissioners more used to negotiating with large NHS Trusts and the private sector.
But with some of the power in the NHS moving from hospital doctors and managers to family doctors, there is a real opportunity to bring the best of social care to NHS commissioners. If we succeed, we could see a lower cost, de-institutionalised NHS which is as good as helping people to maintain their health and well-being as it is at treating illness.