Networks blog: Neighbourhood Health – reflecting on policy and involving citizens
Reflecting on policy and involving citizens
Initially our secretary of state for health and care was highly critical of general practice, Lord Darzi’s first report of 2008 barely referenced primary care and whatever happened to the Fuller report? Now a near volte face in the recent Neighbourhood Health Guidelines – ‘There is an urgent need to transform the health and care system. We need to move to a neighbourhood health service that will deliver more care at home or closer to home, improve people’s access, experience and outcomes, and ensure the sustainability of health and social care delivery. More people are living with multiple and more complex problems, and as highlighted by Lord Darzi, the absolute and relative proportion of our lives spent in ill-health has increased’. As I have said previously, I welcome converts. In reality, the guidelines are a rehash of former policy but now with the weight of health ministers behind them. Over the years many good policies for primary care fade inexplicably – let’s hope not again.
The former policy I refer to originated with my concept of the Primary Care Home (PCH) in 2009. ‘The ‘primary care home’ as a provider can deliver on all the above as it was predicated on extending the vision and scope of the existing ‘GP home’. It aimed to be an integrated population-based provider organisation, a home not only for general medical practitioners and their teams but for all primary care independent contractors (pharmacists, dentists, optometrists) and their staff, community health services and social care professionals. And potentially a home for many currently working in hospitals particularly those who have a responsibility for long term conditions care, for rehabilitation and for the surgeons who specialise in ‘office based’ procedures.’ With modern technology such procedures are on the increase. This concept was brilliantly developed by the National Association of Primary Care and the pilot sites were so successful not least in enthusing the participants – an NHS rarity – that it was adopted by NHS England and launched as primary care networks (PCNs). Arguably the PCNs have not fulfilled the promise of PCH but they must be the vehicle for implementing the new policy rather than more new organisational structures. They have the potential to deliver the government vision.
- from hospital to community
- from treatment to prevention
- from analogue to digital
I have previously described a primary care triple aim already delivered by some practices and certainly by the PCH 200+ pilot sites
- Increase the range and scope of primary and community services
- To reshape hospital services preferably enabled by local budgets
- To have a lead role in health and wellbeing
Primary care is the only NHS service that can achieve the entire aim by combining personal care with population responsibility enhanced by being the most computerised service. PCNs have only patchily delivered on this potential, a comprehensive developmental programme to achieve the triple aim seems essential.
But we need to go further. A nationalised service such as the NHS tends to focus on the provider and very little on the public. The Darzi report used the weak ‘engagement’, the government aim is connecting people only it seems to services. Patients and public need to be participants not passive receivers. The provider only focus is simply inadequate to deliver on the increasing workload of the NHS. Let me introduce Community-Oriented Integration Networks (COIN). The government’s plan to develop neighbourhoods presents an opportunity for high-quality, low-cost care – through collaboration, as equal partners, between health workers, care workers and everyday citizens. Achieving this at scale requires the application of the science of community development – developing trusted relationships across boundaries and coordinated actions that build community cohesion. The difficulty of achieving integration is well known. COIN is a network of people with extensive experience of doing this. Previous inattention to processes of co-adaptation has obstructed collaboration. Neighbourhoods could play a key part in changing this, by promoting shared developmental spaces (e.g. schools & faith groups, music and exercise clubs, sports events and festivals) where people learn to appreciate others and collaborate for the greater good. The homes where carers live are particularly valuable developmental spaces because they are shared by patients and carers, health and social care practitioners, families, friends and many others who are often more prepared than usual to collaborate for health and care across boundaries. Start small and build to gain experience and instil confidence. COIN has begun with care of the dying.
Evaluation is through repeated stakeholder reflection on different kinds of data in the light of their lived experiences. For example, data of hospital admissions and place of death, amalgamated by neighbourhood areas, could help local people to discuss the value of different strategies for carer support. Ongoing, facilitated debate between case studies, e.g. neighbourhoods or cities, informed by different kinds of data, could be a winning strategy. It is relatively easy to organise. It witnesses, tangible outcomes from collective efforts. It emboldens people to lead multiple micro-changes to improve quality and cost-effectiveness. It develops facilitation skills in local populations that build trusted relationships and compassionate communities. All this may sound esoteric but is in fact built on an everlasting premise. To reiterate, equal partnership between health workers, care workers and citizens require trusting relationships. Achieve that with a local focus, veritable mountains can be surmounted.
Professor David Colin-Thomé, is chair of PCC. Contact enquiries@pcc-cic.org.uk to discuss how we can help your neighbourhoods develop and flourish.