We need to focus on the person not our own organisation to achieve real integration, writes Donna Hall
I’ve spent my entire 35 year career developing place based initiatives: The Urban Programme, City Challenge, Single Regeneration Budget, New Deal for Communities, Public Service Agreements, Total Place, Sure Start, Health Action Zones, Town Deal…and unfortunately loads more!
The one thing I’ve consistently learned is that they don’t work. None of them.
Well meaning public service professionals often descend upon a neighbourhood, set up an office, develop a vision, a shared purpose to “integrate” through a large budget and then promptly disappear after five years when the programme and the extra money come to an end. Things go back to “normal” and local people wonder what was the point of all that? Outcomes are rarely improved or sustained beyond a couple of years.
That’s why it was surprisingly refreshing to read the NHSE/I Integrated Care System Guidance released at the end of 2020. The whole tone of the document reads very differently to most NHS guidance documents. This is about long term, sustained, mature, deep rooted, system wide change within and across our health and care organisations and with local communities at the centre of the change.
There have been numerous NHS reorganisations over the years, however, this is different as it’s the NHS looking outwards to place, partnerships and people rather than inwards.
We can’t waste this precious time and opportunity arguing about sovereignty, governance structures or pooled budgets
This marks for me a real turning point not just in the history of NHS policy from its noble origins based on a 1940s style factory production line model, but for wider public service reform, for local government, department of work and pensions, the police, housing and community and voluntary organisations.
People don’t live their real lives in service silos or the boxes of need that we put them into. They aren’t “bed blockers” “frequent flyers” - they are our valuable rather than our vulnerable people. Some systems failed to protect them back in March as they were discharged to die in care homes when our slogan was “protect the NHS” protect the organisation rather than the person.
Human centred integrated services focus on the anthropology of communities and what motivation, support, challenge will work and what is a complete waste of time. This is why the various top down experiments we tried didn’t work. They weren’t rooted in human centred systems, in the reality local communities and how people live their lives.
This time we have a genuine once in a lifetime opportunity to permanently shake up how we relate to local people as public servants across commissioners, providers and local government. We don’t work for the Clinical Commissioning Group, the acute provider trust, in a GP practice or as a health visitor. We all work for the people of the place, wrapping our complex, frequently hard to navigate (let alone to access) services and support mechanisms around our communities.
It’s an excellent opportunity to focus on the person not our own organisation and to radically rethink prevention by building up and reinforcing the social scaffolding in neighbourhoods through joint investment models.
By listening harder to patients with lived experience we can take out the repeated doubling up and duplication, communication slip ups, threshold raising and simplify the steps by developing a more flexible multidisciplinary workforce across health and care.
By listening harder we will learn also about the stuff we do that actually doesn’t work. The “interventions” that we introduce because many years ago someone thought it was what people needed; it was built into a commissioning specification and goes out to tender every five years, sometimes competing with four or five similar overlapping service specifications none of which centre on the person. We need to move to a coproduction rather than purchaser provider led model of commissioning if we are to truly transform public services.
We can’t waste this precious time and opportunity arguing about sovereignty, governance structures or pooled budgets. The real heavy lifting isn’t all this distracting stuff that frequently occupies us during times of change. It’s the human centred redesign and relational working we’ve been searching for over several decades and sustaining it as the way we all work into the future, every day, forever.
This article has also run in LGC.