When it comes to health, it’s all about that place

The government’s new health white paper sets out steps towards what ‘joined-up care’ will really mean, finally recognising the centrality of place. Claire Kennedy finds much to celebrate, as well as big questions to be answered.

This month’s health and social care white paper contains lots of familiar words around ‘person-centred care’. However, it also contains within it some new and clear statements about the role of place.

These start to get to the heart of some of the genuine opportunity there is in mobilising the revolution in health and care that this white paper and its siblings the Health and Care Bill and the Adult Social Care Reform white paper envisage.

Three welcome steps

There is much to celebrate in a paper which sets out measures to “make integrated health and social care a universal reality”.

First, the definition of ‘place’ as being something that is “meaningful to people” is key. Successful place-based working will ultimately require co-creation of health and care outcomes within a local community – that will only work if people recognise themselves as part of that community and feel a sense of connection and community with the others contained within it. Big tick for this!

Second, the recognition of the complexity. Both in pooling budgets – so quick to say, so tortuous to achieve – and around data sharing and workforce integration. It’s good to see signs of pragmatism and support for these challenges. 

Third, the start of a national debate about local governance of place-based healthcare. It’s much better to have a national debate than every local area discovering the same problems and challenges themselves.

Four questions to answer

However, as with any radical agenda with big ambitions, some of the most eye-catching parts of the white paper are those where it provokes some big and interesting questions. Here are four of them.

1. Can new local leaders be effective?

To start with the most obvious: the creation of a local leader at place, ‘accountable’ for the delivery of outcomes.

We are familiar with the idea that with great power comes great responsibility. It might equally be argued that with great accountability needs to come great empowerment.

These leaders will need to be empowered in a way that will be, by definition, a challenge to the statutory bodies that make up the place partnership and the central bodies who are used to managing that accountability.

If this is to work, a lot of people are going to feel uncomfortable. If they don’t, it will be evidence that not much is really changing.

Big question number one is: why would anyone want to step into a role where they are accountable for the actions of others, over whom they have no influence?

2. What does accountability look like?

And number two is the ongoing question about what that accountability looks like in a sector where there are currently (at least) two forms of accountability operating in tandem: national regulatory accountability and local political accountability.

We will leave national political accountability to one side for the moment but it is, of course, the elephant in the room.

How to ensure that local people’s political voices form part of local accountability, and are seen as ‘equal’ to national regulation is a live challenge across so many local places.

It is not yet clear how the ‘place board’ will link to local political accountability.

Resolving this will be key to understanding whether local political engagement is able to operate as a keystone in this new approach.

3. How will local priorities be set?

My third question has two parts – how local priorities will be set, and what this means in practice for things that are not identified as local priorities.

Prioritising is really hard work. By definition, it means that some things that people really care about are defined as less important. Everyone struggles with priority setting in real life, let alone in an abstract setting where they are representing a particular organisation or badge.

Trust is the magic ingredient that unlocks effective priority-setting. So there will need to be hard work and time spent within local places to allow people to believe that just because something they care about is not on the initial priority list, it doesn’t mean it will never happen.

4. How will people’s voices be heard?

The white paper says that ‘people’s wishes and wellbeing’ should inform prioritisation.

But how will the system establish what people’s wishes are? People are notoriously complex. It is entirely possibly that their wishes do not form a helpfully consistent agenda, or even that they may not align with the ambitions and outcomes of the organisations within the partnership.

We need to take care that these issues don’t de-rail a new way of working in healthcare.

One reason that the health and care system has become increasingly centralised is that setting national priorities and following them creates a parent-child dynamic. This is probably the ‘easiest’ of the models available to organise services.

We now recognise the limits and drawbacks of this model. But we need to recognise the strong impulses people will have to retain it. There are always reasons something unliked remains embedded.

So, a strong and clear voice for communities is an important part of making place-based working work.

Conclusion

The white paper is an exciting step towards a new way of envisaging health and care. A step closer to a vision of co-creation of health outcomes rather than a model of wellness vs illness.

It is also a hopeful statement that builds on what we learnt about the power of local communities throughout the pandemic, and the power that comes from local connection.

But, in taking that radical step deep into place, we will have to:

• learn to understand and celebrate the diversity of perspectives that may produce
• and empower local place leaders with the time, trust, support and agency to lead differently.

New Local is currently undertaking research on how community power can help protect the future of the NHS. Join our mailing list for updates.

Photo by Chanan Greenblatt on Unsplash

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