A Community-Powered NHS
As the NHS faces ever-rising demand, its founding principles of being free and universal are under threat.
But there is a solution: a radical shift towards a healthcare system focused as much on preventing illness as treating it. Working collaboratively with communities as equal partners in the design and delivery of healthcare.
By moving towards community-powered health, we can make prevention a reality, protect the NHS’s future and improve health for all.
The NHS at risk
The National Health Service was founded on a single principle: healthcare would be universal and free at the point of care. Today that principle is under threat as never before.
Demand for healthcare has grown for many years leading to unsustainable pressures on NHS services. The elective care backlog was 6.48 million in April 2022, but had already reached 4.4 million people before the pandemic. Many other areas of healthcare face significant demand challenges, including primary care, mental health and social care. Put simply, there is far too much ill-health for the NHS to treat in anything like a timely and safe fashion with its current level of resource.
This demand crisis is now threatening the founding principle of the NHS. As a proportion of GDP, Britons now pay almost as much as Americans on out-of-pocket healthcare spending while the poorest 20 per cent of households have increased their spend on hospital costs by over 100 per cent in the last decade.
This move away from free healthcare is compounded by growing fiscal strain. Analysis based on projections from the Office of Budget Responsibility (OBR) suggests that health spending could increase from 7.3 per cent of GDP pre-pandemic to 9 per cent of GDP by the end of this decade. This risks becoming politically unsustainable as other parts of state spending lose out or extra pressure is placed on taxpayers already struggling with a troubled economy.
Sooner or later, policymakers will have to seek a way out of this fiscal quagmire and without a radical shift in how we approach healthcare, there is a real risk that will mean rationing provision or the phasing in of charging for treatment.
The limits of traditional public service paradigms
It is very widely accepted that the only sustainable solution to the demand crisis is to move away from the NHS’s very strong focus on treating illness when it arises to a focus on preventing illness from developing in the first place. But since its foundation, the NHS has been shaped by two paradigms that strongly reinforce the former acute response rather than a prevention approach. These are the state paradigm and the market paradigm.
Neither reckoned with the growth in demand. Nevertheless, they maintain their firm grip on how healthcare is delivered, reinforcing an organisational culture and set of practices that treats acute response as the overwhelmingly central aspect of the NHS’s role while marginalising efforts to prevent demand occurring in the first place.
Enabling a meaningful shift to prevention that can reduce demand over the long-term in a humane and sustainable fashion will require a shift to a new community paradigm.
A new community paradigm
The community paradigm is based on the principle that communities themselves have valuable insights into their own circumstances and what they need to thrive. Communities should therefore be able to exercise genuine influence and where possible direct control, over the decisions, resource and services that support their lives.
Proper prevention is impossible without active, participating individuals and communities. This is because prevention is not something that can be done to people in the traditional service delivery sense, rather it must be achieved with them. This means health institutions need to be capable of working alongside communities, responding to their insights, and investing in them so they can actively participate in shaping better places and services.
This much more outward-facing, community-led approach enables three profound shifts we identify as needed to move from today’s acute response approach to prevention.
The first is the shift towards healthcare which is much more capable of understanding a person’s context beyond the specific condition they present with. As one evidence submission to this report reflected this is about the workforce being able to “look at individuals holistically and understand that they are not defined by ill health”.
Only in this way can healthcare bodies work with individuals and their wider networks of support to keep them healthy rather than just treat their illness.
The second shift is towards recognising the individual as an active participant in their own health outcomes. A very great deal of the work of prevention must be conducted by individuals themselves in the absence of the healthcare professional. This means a far greater emphasis on empowering individuals within the context of wider communities of support.
Thirdly, there needs to be a shift in the role healthcare bodies play in addressing the social determinants of health. The evidence is strong that stressful personal circumstances, isolation, poor housing and poverty are major causes of ill-health. Equally, the local environment within which someone lives also has a major bearing. Air pollution, lack of green space, high incidence of violent crime, unsafe roads and a host of other environmental factors will clearly increase the likelihood of ill health very considerably for those who live in those areas. Addressing these factors requires healthcare bodies to work directly with the communities affected by these social and environmental conditions.
All three of these shifts require a fundamentally different mindset and set of practices for health institutions and the professionals working within them – away from mostly treating ill individuals within the hospital or clinic and towards working outside the healthcare institution with communities and partners to address the underlying causes of ill health.
The community power paradigm in practice
The features of a community-powered approach cannot be reduced to a single rigid model. The organisations already adopting community power are making it their own – rooting it in the unique aspirations and priorities of their communities. Nevertheless, it is possible to discern three broad principles that underpin the adoption of community-powered approaches.
Principle One: Community participation in decision-making
Engaging communities more deeply in the strategic decisions that affect their lives is a trend of growing importance across the world as well as in the UK. A key feature of this engagement is that it is deliberative and consensus-building, based on techniques such as citizens’ assemblies but incorporating a range of other more or less formal approaches. This now needs to become a core part of how Integrated Care Systems (ICSs) make decisions as systems.
There are two reasons for this. First, it cannot be said in any meaningful fashion that healthcare institutions are really handing more influence to communities if the big strategic decisions that shape our healthcare are still taken deep within institutions by groups of officials or clinicians. Secondly, such engagement can also play a more specific role in the move to a preventative approach. It has the power to generate exceptionally useful knowledge from within communities when designing and implementing prevention strategies.
Principle Two: Mobilising community assets
It is self-evident, given the role of active communities in prevention that a genuinely prevention-focused NHS would understand that it had a central role in mobilising community assets. Community assets vary widely in nature from place to place but broadly include the detailed local understanding of people within communities; voluntary activity and grassroots action; pre-existing and potential networks of peer support and information-sharing such as faith communities, sports clubs and hobby groups; and buildings, space and local institutions such as schools, parks, pubs or community centres that are used and trusted by communities. Involving communities in this way is highly context specific. It is thus difficult to generalise about what that involvement might look like, but extensive case studies are presented in the report.
Principle Three: Growing a community-focused organisational culture
Organisational culture change is particularly important for a shift to a community-powered approach because of the diversity and unpredictability of solutions and challenges that the approach tends to generate. This means that community-powered organisations need to act and think in ways that can respond positively to such creative opportunities.
In addition, the evidence from bodies moving to a community-powered approach is that the biggest obstacle by far to change is existing organisational culture which tends to favour hierarchy, risk-aversion, wariness of engagement with communities and a very strong focus on professionalised acute response.
Recommendations: Creating a community-powered NHS
There are many inspiring initiatives to move towards a community-powered approach in the NHS. However, these currently operate on the edges of the system outside the prevailing state and market logic. As Integrated Care Systems take shape, there is an opportunity to embed a community paradigm throughout the system, but this cannot be guaranteed given the power of previous paradigms. There will need to be a series of steps taken at both national and local level to enable the shift to a truly community-powered NHS.
1. The role of national bodies: from command and control to permission and adaptation
1.1. Government and NHS national leadership should commit to a ten-year moratorium on any further imposed structural reform within Integrated Care Systems to let community-focused relationships and culture embed.
1.2. Government an NHS national bodies should commit to stop initiating short-term pilots as a method of change, and instead focus on developing continuous improvement mindsets and supporting peer learning exchange around community-powered prevention.
1.3. National bodies should reduce their over-reliance on single-service performance targets as ICSs collectively define place-specific objectives with the help of their local communities.
1.4. The Government should set out a clear cross-Whitehall plan to shift the centre of gravity of our health system towards prevention and address the wider determinants of health across all policy areas.
2. The role of systems, places and neighbourhoods: From separate organisations to mission-driven collaboration for community power
2.1. Proactively build in the voice and representation of communities to decision-making.
2.2. Give parity to the value of community expertise alongside clinical and professional expertise in strategic planning and service design.
2.3. Ensure that equity, diversity and inclusion strategies are not an add-on, but are core to ensuring that both leadership and the wider workforce embodies the lived experience of communities.
2.4. ICSs should be a starting point for an equal relationship between health partners and local government, with the role and assets of councils recognised as essential for effective prevention.
2.5. Recognise culture as a key enabler that can shift institutional behaviour, and ensure it is a strategic priority for leaders to actively foster a culture conducive to collaboration with communities.
2.6. A strong system-wide vision and an active workforce development plan should focus on building the behaviours and skills required to work with communities as equals.
2.7. Recognise the potential of primary care networks to catalyse the shift from deficit-based to asset-led working with communities.
2.8. Improve data standards to recognise the value of qualitative data alongside quantitative metrics to inform service design.
2.9. Use data to mobilise communities around the challenge of health inequalities.
2.10. Use the fourth ICS ambition which sees a role for the NHS to support broader social and economic development as an opportunity to reduce health inequalities by addressing the wider determinants of health outcomes.
2.11. Integrated Care Boards should commit to shifting a proportion of budgets from acute care to community-led prevention at system and place level, and grow this over time as collaboration matures.
2.12. Create a level playing field for VCS and service user groups in the procurement of healthcare services while requiring those groups to
The report features dozens of examples of community-powered health around the world. Here are a few of them.
Community Health Workers – from Brazil to Pimlico
Community members have transformed health outcomes in Brazil, in a model that is now being pioneered in the UK.
It’s a simple premise – people are trained to become Community Health Workers (CHWs). They are responsible for around 200 households each, where they regularly check in on health and wellbeing.
Crucially, they are integrated into primary care and linked with other statutory services – so they can refer to what is needed – from social groups, to immunisation clinics, to housing providers.
In Brazil CHWs now cover 70% of the population. The model has been linked to outcomes including:
- 31% lower mortality for stroke
- 36% lower mortality for heart disease
- Lower infant mortality
- Higher immunisation
- Higher breastfeeding uptake
Starting in Pimlico, London – UK practitioners are now starting to adopt the CHW model, hoping for the similarly impressive outcomes.
Canada’s community-minded GPs
In much of Canada, primary care physicians don’t work alone. Instead, they are part of multi-disciplinary teams that cover social work, psychology and psychiatry, in addition to health promotion and illness prevention.
These Community Health Centres (CHCs) have an explicit mission to address the systemic social, economic and environmental factors that negatively determine health outcomes. Each CHC is governed by community members who set priorities and help determine programmes and partnerships.
Programmes might include youth clubs and gardening clubs while partnerships might be with legal aid and local food banks.
CHCs are able to focus their attention on specific local communities and their health disparities. For example, Taibu CHC, whose patients are 59 per cent black and 85 per cent foreign-born, is “grounded in Afrocentric values”. Through ‘deep listening’, it changed its approach to cancer screening outreach, and saw breast screenings rise from 17 to 72 per cent between 2011 and 2018; colorectal screening increase from 18 to 67 per cent and cervical from 59 to 70.
Mutual support for mental health in Doncaster
In Doncaster, former social worker Kelly Hicks responded the disillusion she felt with the mental health system by setting up a community of mutual support: People First Group (PFG).
Today, the 600+ members not only connect to support each other, but organise day trips, football tournaments and other activities.
The initiative has been so successful that an estimated 90 per cent of cases group members no longer contact the local crisis team.
A recent evaluation put the group’s social value at £3.2 million, and calculated that by spending £1, statutory services have seen £69 of value created.
At the end of 2019 the NHS commissioned PFG to help run a new service providing out-of-hours support for people experiencing mental health crises. They made 1000 referrals in 2020.
And now, a new partnership with the Yorkshire Ambulance Service see PFG providing a dedicated crew to divert from A&E seven days a week.
From Covid partnership to PCN budget handover
This year, Heeley Plus Primary Care Network (PCN) in Sheffield committed to transferring a quarter of its additional roles budget – potentially rising to 25% of its overall budget – to a local community group.
The pandemic was a real catalyst for this decision. While community anchor Heeley Trust had been collaborating with local GPs for years, during the vaccination roll-out it officially partnered with the PCN, providing management, staff and volunteers.
A formal MOU now means Heeley Trust is now the PCN’s ‘official partner’ – working on social prescribing and linking up with the wider local VCS.
Health coaches are already reporting significant improvements in people’s weight, blood pressure and measures of confidence. There have been increased referrals to link workers from a wider range of practitioners.
Connecting people with HIV and clinical help
George House Trust in Manchester started as a helpline at the peak of the AIDS epidemic. Forty years on, it provides 29 different services, from one-to-one counseling to peer support group work, to social activities.
Their HIV Intensive Support service works with people who are having difficulty accessing clinical services – for reasons that could range from homelessness to addiction to poor mental health.
George House Trust key workers are embedded in the NHS on honourary contracts, and work closely with these individuals to help them meet medical appointments and manage their HIV, as well as supporting with wider needs. The ultimate goal is to put each individual in charge of their treatment.
By the end of March 2022:
- 96% of the service users had improved their engagement with clinic
- 79% had achieved an undetectable viral load
- 79% reported an improvement in their emotional wellbeing
- 85% had been stepped down to another service. An initial cost benefit analysis of the programme showed that every £1 invested returned £53 of benefit.
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