A new approach to health care

This is just the right time for Collaborate and the New Local Government Network to launch a consultation on Reimagining Place-Based Health. Inspired by this initiative, here is my (initial!) contribution…


Reimagining Place-based Health

The 20th century health service is not fit for the 21st. Changing demographics, the climate of austerity, new technologies and the ageing society have combined to create a quantity and quality of demand that no amount of extra money intended to deliver ‘more of the same’ can possibly meet. It’s clear that supply-side reforms have had their day; what Britain needs is wholesale, demand-side reform aimed at reducing calls on NHS resources.

The failure of the NHS to plan and implement IT reforms successfully and within budget calls into question our very ability to deliver a national health service in the way our forefathers envisaged it; yet it has been right to invest in reduced numbers of concentrated centres of excellence for key elements of service delivery, to avoid excellence being diluted and dulled. For years the ‘postcode lottery’ has been a term of derision but, in future, local systems to meet (restructured) local demands will demand diversity of approach – so homogeneity should not be part of the restructuring process.

Promoting public health has played but a minor role within the NHS since its inception. It’s easy to say that ‘prevention is better than cure,’ advocating investment in traditional forms of preventative measures, but as a top-down strategy this is not sustainable. There’s still a role for regulation – from iodising salt to the smoking ban and nutritional standards in school and hospital food – but it should complement demand-side reform, not replace it.

Demand comes from individuals and communities so it’s here that we must look for solutions. We should build upon the ‘expert patient’ model, utilising IT to share knowledge and resources and provide mutual support amongst people with related conditions. This principle can be extended – investing in community-based organisations promoting weight control, helping diabetics learn from each other, giving better community support for housebound people needing care, for example.

Such measures are today called ‘volunteering’ but they are truly expressions of citizenship, a set of values that helped us found the NHS but which have been lost in so many ways in the last half century. Even as ‘voluntary service’ has become synonymous with ‘second class’ or ‘amateur’ most of our major hospitals couldn’t survive without huge numbers of volunteer hours of administration, patient monitoring and care, fundraising and other more or less traditional roles. Volunteering is important for two more reasons: firstly, taking part instills within the volunteer a general sense of wellbeing which promotes their own good health (reducing demand on the NHS) and, secondly, collaborative volunteering is an effective counter to loneliness. Put another way, volunteering counters two of society’s biggest killers: middle aged stress and the loneliness of old age.

One cause of stress is financial worry; a recent study showed that the average American takes three days per year off work either to sort out financial problems or due to finance-related stress. The average is misleading and will hide a significant number of people who take a significant amount of leave for this reason. The growth of in-work poverty in Britain in recent years must have had a similar effect here and increased the demand on NHS services – not least in the link between stress and smoking and alcohol problems.

Financial problems can be resolved in the workplace, and not just by responsible employers avoiding paying stress-inducing low levels of pay. Why not deliver financial literacy on the shop floor? Invite charities to provide financial counselling and advice there? Create access to loans, through workplace-based credit unions?

After sleeping, work is the biggest usurper of our time. Over many years a Health and Safety culture has grown up in the workplace, often fostered by organised labour. Over-emphasis on the ‘Safety’ element, reduced trade union influence in the private sector and the blossoming of the atomised SME sector have all allowed ‘Health’ in the workplace to be downgraded. H&S is seen as ‘protection against bad things’ and not ‘promotion of good things’. Employers who actively encourage cycling to work are in the minority, musculoskeletal disorders continue to dominate employment-related health conditions and heaven protect the boss who removes the automatic vendors of crisps, sweets and fizzy drinks from the works canteen!

In Darlington a group of employers has come together to share employee volunteering opportunities. What distinguishes this group from others like it is their relationship with the local NHS Mental Health Trust. Together these companies are working to de-stigmatise mental health issues, identify them early, support sufferers at work and prevent problems arising. Mental health is too often the ‘also-ran’ of health services; underfunded, under esteemed and over-relied upon.

Almost all health problems are found disproportionally amongst more deprived communities who engage in high risk activity (not least smoking) more than others, lack access to the wholesome food and knowledge needed for a balanced diet and have the least well developed self-supporting community infrastructures. The measurement of community life expectancy, the bottom line in health metrics, confirms this.

Healthy communities are the route to sustainable healthy citizens. The public sector and the NHS in particular have responsibilities for this but ultimately health services are tools for society to use; new circumstances demand new uses and even new tools. Perhaps the planned devolution of NHS spending powers to Greater Manchester will open the door to community-based pro-health practices aimed at empowering patients (and potential patients) to reduce the demands they make on the NHS? It’s certainly an opportunity which shouldn’t be squandered. Such an approach could save lives and money too, over a period such as ten years – but that’s well beyond the spending horizon of any Government.

The most likely reason why none of the above might happen at scale is that the most expensive phase of any new idea is at the beginning, during transition from the old.

The death toll from austerity may yet rise still further.