A bold set of really sensible, refreshingly flexible and well-informed announcements came from NHS England Board meeting in the dark days of the end of November as we continue to battle with Covid 19. Proposals to develop Integrated Care Systems was published at a key moment for health and care as we have seen some remarkable transformation during CV19.
This work was the culmination of many months of active, systematic listening to the system and re-imagining what a future NHS could look like. Primary care, acute clinicians, leaders, local government and STP leads were invited to paint their picture of the future. The result was a set of proposals which require a mature interpretation of how they will work on the ground in each of our different localities in England. Cities, Towns, villages are able to debate the options and work out how their bespoke partnerships can be shaped to focus on a new relationship with the people they are designed to serve. It’s a very welcome focus on the primacy of place rather than organisation, of person rather than individual service.
Back in 2014, NHSE set out the Five Year Forward View. My favourite part was Chapter 2. What will the future look like? A new relationship with patients and communities. The themes were:
- Getting serious about prevention
- Empowering patients
- New care models
- How we will support local co-design and implementation.
Many of us were inspired by the ambition to break away from the “factory” model of care and repair and the increasing focus on prevention and a new relationship with people. The creation of Health and Well-Being Boards who would focus on issues such as employment, housing, mental health support groups, community projects, treatment services, workplace health and social isolation and loneliness as well as traditional reactive health and care services in the locality.
Some systems really embraced a different way of working, started working around neighbourhoods and having different conversations with communities and each other. A brilliant example of this is the work undertaken by the West Yorkshire and Harrogate STP who have taken a long term whole population approach to prevention with all partners in CCGs, Acute and community and mental health providers as well housing and community and voluntary groups.
The NHS was described as a social movement rather a factory.
But how do we actually make all this happen on the ground?
Why was there not a scaled-up delivery of the place based ambition set out in Chapter Two over the last six years?
Social movements start in places, fired by good relationships and a common purpose. It is great to see this ambition revisited in the Integrated Care System Guidance. But we should already be doing this everywhere.
Several factors have hindered the successful delivery of Chapter two with its visionary focus on prevention, patient empowerment and co-design. They include:
- Differential motivation and incentives, both financial and reputational to transform around the patient between local government and the NHS.
- A continued focus on organisational performance through CQC inspection rather than total system performance.
- Heroic, macho (even from women) leadership from some system players whose intention is to “win” rather than to collaborate.
- Health and well-being boards becoming information sharing meetings rather than deep-rooted transformers of services around the person and the place.
- The lack of a systematic way of measuring the successful implementation of Chapter two within organisations.
But there is light at the end of the tunnel and a chance for NHS organisations not just to think about the re-organising of the organisational deck chairs on board the ship, but to completely rebuild the ship. It isn’t the deckchairs we need – it’s a new type of vessel.
Integrating care systems becoming enshrined in legislation from April 2022 will help everyone make them happen but it isn’t the governance structures that will reform services – it’s new patient centred pathways, empowered people and communities and a focus on early intervention and prevention. The report sets out four key areas of policy:
- Stronger partnerships in local places between the NHS, local government and others and a more central role for primary care.
- Provider organisations being asked to step forward in formal collaborative arrangements to allow them to operate at scale.
- Developing strategic commissioning through systems with a focus on population health outcomes.
- The use of digital and date to drive system working improving outcomes and putting the citizen at the centre of their own care.
I believe that delivered in partnership with local communities, breaking away from the artificial split between commissioners and providers this will help us to focus on the people we serve not silo sovereignty and ultimately take us closer to the NHS vision – of the people, by the people and for the people.
Professor Donna Hall, CBE – Chair New Local and Bolton NHS Foundation Trust