It’s the power of communities, not fancy slogans, that will help save our NHS
Building a community-powered NHS that is capable of supporting good health in neighbourhoods and reducing demand pressures on hospitals has never been more needed. But it goes against all the instincts of our top-down system of managing healthcare, writes Jessica Studdert.
What is it about health secretaries and alphabetised lists? Sajid Javid had his four ‘P’s, prevention, personalisation, performance and people. But the latest health secretary Thérèse Coffey has thought up a quartet of her own, ABCD: ambulances, backlog, care, doctors and dentists.
The problem is less the overwrought sloganeering, more the tired form of top-down statecraft they reflect. The NHS is in crisis, of that there is no doubt. But although our centralised system of healthcare delivery creates personal accountability with politician nominally in charge, they actually have a limited number of levers to hand – communications teams being one of them.
Other levers at their disposal include strategy documents, performance targets and ringfenced funding streams. In her first few weeks in post, Coffey has already reached for all three. A new plan for patients which largely contains measures already announced, a new GP appointment target and a new £500m adult social care discharge fund. They all amount to performative action but don’t actually get to the root cause of the problem facing our NHS: that of rising demand.
As the NHS crisis gets deeper, the existing system logic asserts itself all the stronger. The same failed levers get pulled again.
New Local’s Community-powered NHS report set out a case for change that recognises what the system needs isn’t some top-down reprioritisation or some witty new slogans. The system certainly needs more and secure funding, but money alone isn’t the answer. We need to bring about a real shift in culture and mission to focus beyond clinical boundaries and build community capacity to address the determinants of health outcomes at root. This would release hospital-based acute provision to focus on real emergencies and create a better system focus on reducing preventable illness.
But that is not yet happening at scale. As the NHS crisis gets deeper, the existing system logic asserts itself all the stronger. The same failed levers get pulled again. The bigger the problem, the more micromanaged the solution. The more complex the challenge, the narrower the targets become. This business-as-usual instinct hoards more power and initiative centrally, when there is increasing evidence that a better approach would be the reverse: to push out power to localities and communities themselves to shape more effective responses.
There was an irony in Coffey’s use of ‘ABCD’, an acronym that is better known to practitioners inspired by the principles of asset-based community development. This recognises community strengths and assets first and foremost, which can be mobilised and driven by communities themselves. Strengths-based principles inform a range of approaches from Health Creation to local area coordination which are disrupting the traditional divides – for example between “professional” and “patient” – to give communities more power and say over the support they need to thrive.
We need to bring about a real shift in culture and mission to focus beyond clinical boundaries and build community capacity to address the determinants of health outcomes at root.
In healthcare in particular, these approaches are nascent but notable. In Lancashire a GP-led approach Healthier Fleetwood is reversing the relationship whereby patients walk through the door with illness, to GPs going out into the community to support wellness: through community choirs, gardening and peer support groups. In a year they saw a drop in A&E attendance of 17% and non-elective emergency activity reduced by 6.7%.
In London, a programme of community health workers is being established, based on a model from Brazil, where links between communities and clinical settings had a range of health improvements including reducing mortality from stroke and heart disease by over 30%.
And in Sheffield, the Heeley Plus primary care network this year committed to transferring a quarter of its additional roles budget – potentially rising to 25% of its overall budget – to a local community group. This supports activity such as health coaches, who are already reporting significant improvements in people’s weight, blood pressure and measures of confidence.
These initiatives can demonstrate impact compared to a business-as-usual clinical response. To supplement this, there is exciting new evidence proving the deeper potential of a system-level shift, if local partners were given more responsibility to adapt their approaches to community priorities.
A Manchester University study found that life expectancy in Greater Manchester rose higher than expected after health devolution in 2014. In particular, the research identifies a narrowing of health inequalities, whereby the increases in life expectancy were larger in areas with high income deprivation and lower life expectancy before.
These initiatives can demonstrate impact compared to a business-as-usual clinical response.
The context for the NHS is obviously bleak. Not least trying to reach some operating normality across waves of Covid and legacy backlogs, a fatigued workforce and now the prospect of a further round of public spending cuts.
A community-powered vision offers some hope for the future, if only those in leadership roles nationally and within new ICS structures would grasp it. But it relies not on micromanagement, targets or slogans. It requires deep trust of the frontline, a culture shift throughout the system and above all recognition of the expertise that rests within communities themselves.
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