Why the NHS urgently needs to turn to the community – and how to do it

We know the diagnosis: the NHS is at risk from ever-increasing demand – but we’re failing to come up with a cure. As we publish our major health report, Jessica Studdert delves into a new way of treating healthcare: one that puts communities – and therefore prevention – first.

Policy in a rut

For decades, there has been a growing recognition that our treatment-led, hospital-dominated model of healthcare is not fit to confront the health challenges of our ageing society and changing burden of disease. Also for decades, national policy has failed to fundamentally shift the centre of gravity of our health system away from acute response and towards more effective support of wellbeing which would better stop conditions emerging or deteriorating.

There is widespread consensus on the diagnosis: we need to shift to prevention. But there is policy inertia over the appropriate treatment route to getting there. Over the years, more of the same has been administered by different parties in government, with diminishing returns: individual service efficiency drives, ever more nationally-imposed targets and an expanding blob of arms-length bodies overseeing activity.

Of course, austerity has made the situation worse, with funding having failed to keep pace with growing demand for over 12 years. But austerity has also had the consequence of injecting further stasis to the national political response. Debates rarely go beyond an escalating arms race to be seen to be the more generous party when it comes to NHS funding. This is to the detriment of a more sophisticated discussion about how reform needs to ensure provision is fit for purpose for the 2020s and beyond.

New Local’s latest report A Community-Powered NHS argues that if we are to keep the founding principles of the NHS being universally available and free at the point of use, we need to reorient our healthcare system to be much more capable of preventing illness occurring, alongside effective treatment when needed. This requires a more honest appraisal of the current dominant public service paradigms which constrain the policy and service response, and render it incapable of recognising the assets of people, networks and communities who exist outside institutional boundaries.

The grid below sets out three paradigms for the NHS. The state, market and community paradigm column titles will be familiar to readers of New Local’s original report, The Community Paradigm. This grid applies the same core framework to the NHS, which in many ways is the archetypical manifestation of a state and market machine, but in which the beginnings of a new community paradigm are emerging that hold promise for future sustainability.

Three NHS paradigms: state, market and community

The limits of state and market paradigms

Our core contention is that both the state and market paradigms, which emerged during the second half of the previous century and dominate our model of healthcare provision to this day, were developed to solve different health challenges.

The state paradigm’s emphasis on uniformity and the primacy of the professional was a necessary response in the early days of setting up an unparalleled universal system of healthcare. Yet such a one-size-fits all approach has diminishing returns as health inequalities have progressively widened, and there is increasing need to engage with the wider social determinants that shape health outcomes.

Similarly, the market paradigm’s focus on increasing productivity and patient choice, which has been growing since the 1980s, was a response to burgeoning costs and the limits of standardisation from the patient perspective. But an approach which relies on simply increasing the efficiency of one-off service transactions is not able to effectively confront complex, inter-connected health and life issues.

Crucially, neither the state nor the market paradigm is capable of responding to the rising demand which results from an ageing population and changing burden of disease linked to life circumstances. Models which focus on administering treatment to a patient at the point they present with illness or in crisis, can essentially only respond to rising demand by increasing activity. This is neither financially sustainable nor morally desirable. Instead, we should be orienting our system towards keeping people happier and healthier for longer where they live.

The opportunity of community

To do this effectively and system-wide, means recasting the relationship between our healthcare system and communities. Where the state and market paradigms have either a non-existent or narrowly transactional relationship with activity that occurs outside the buildings of services, a community paradigm centres on community capacity, assets and networks. Far from seeing people in a deficit-laden sense as merely passive recipients of clinical treatment, it recognises their own insights and capabilities as essential to creating good health and wellbeing.

There is an overwhelming amount of evidence which supports both the clinical efficacy of community-led approaches to health, and the direct impact they have on reduced demand for services. From the GPs who see their role to build community capacity to improve general health, to new models of community health workers based in neighbourhoods, and acute providers setting up deliberative forums to gain the insights of communities. Fascinating longstanding practice from Canada, Alaska and Brazil shine light on the potential for deeper community involvement, governance and mobilisation to improve health outcomes for those facing deprivation and exclusion from traditional services.

Three routes to a community-powered NHS  

The evidence of a different approach is out there – we have taken the insights and set out three core ways in which a community-powered NHS can be made real, as the new integrated care system (ICS) landscape takes shape.

Firstly, communities need to be given more opportunities to participate in decision-making, their expertise recognised and given parity with professional and clinical judgements. The examples of Camden Health and Care Citizens’ Assembly, West Yorkshire Health and Care Partnership’s citizens panel on delays to planned care and Frimley Health and Care’s Community Panel show how this can be done. These principles now need to be hardwired throughout ICS governance and practice across systems.

Secondly, community assets need to be actively mobilised. Professionals should work with the existing energy and dynamism in communities to give them more direct power to shape provision and improve outcomes. Inspiration and proof of impact on demand can be drawn from a wide variety of existing practice, including GP-led models like Healthier Fleetwood, the successful Brazilian community health worker model now being applied in central London, and the Canadian model of Community Health Centres, which provide holistic care combined with local initiatives to address wider determinants like poor education attainment and structural racism.

Thirdly, our existing healthcare institutions need to grow a community-focused culture. Our analysis consistently finds this crucial to securing community-led outcomes. Models like the Wigan Deal, which has brought about improvements in life expectancy locally, demonstrate how a whole-workforce buy-in to a new reciprocal relationship with communities is crucial. Pioneering ICSs like that in West Yorkshire are showing how a system-wide vision and buy-in can be developed. And a  generations-old Nuka system of care in Alaska shows us the dramatic turnaround in life chances that can result from putting communities in more control – in this case for native and American Indian communities who had previously faced significant exclusion and poor outcomes.

Of course, the political times we live in are unprecedented and incredibly febrile. Yet uncertainty in Westminster makes it all-the-more necessary to build resilient local systems. A deepening cost of living crisis that will push more people into poverty means it has never been more urgent for our public infrastructure to improve its response to deepening inequality. And as our NHS remains mired in a pandemic that won’t recede, we owe it to those NHS heroes who got us through the worst of it to put the system on a sustainable footing.

Our NHS needs to be fit for the healthcare challenges of this century, and released from the limits of traditional approaches – we believe a new community-powered NHS can renew our healthcare system to be fit for the future.

Image: PFG Doncaster

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