Unsurprisingly, most of the case studies we include in our pamphlet concern primary care. It is here that the importance of the involvement of patients and the public in their own care and health is most obvious.
People need to avoid loneliness as much as smoking, but loneliness is not something a doctor can prescribe for; only by getting out and meeting people, and in general leading a purposeful life, can people look after this aspect of their health. Clinical staff can, of course, recommend such changes, and I often think that at any time, if we were very quiet, we would hear a thousand clinicians telling a thousand patients that ‘you should get out more’.
However, without real support from the world outside the consulting room, little happens There needs to be a real partnership for that to happen.
Case study: Growing Health Together
Over the decades, there have been a number of GP practices that have moved beyond the medical model of healthcare and recognised how much the social and economic conditions and cultural lives of their patients contributed to the ill-health that they saw in their consulting rooms. Many GPs have recognised that if they simply deal with ill-health and not the building blocks of health, they are too far downstream to have the impact that they need. But until recently, the structure and organisation of GP practices as small individual businesses made it difficult to spread this different way of working.
In very recent years, the creation of primary care networks (PCNs) at the neighbourhood level and integrated care systems (ICSs) at the area level have provided the opportunity for GPs to work more cohesively. In east Surrey, this shift has led to innovative ways of working, with GPs and their partners recognising that they needed to tend to the building blocks of health rather than just medicine – to bring just as much focus to housing, social connection, cultural expression, and trust.
GPs in east Surrey had been part of an action learning set, which tried to address how people’s lives and health connected and the sources of, and barriers to, health and wellbeing in their local areas. Out of that work they created the Growing Health Together programme, which invites people who live and work in the area to come together to strengthen the conditions that allow health to improve.
From the outside, Surrey might seem like a wealthy part of the world, but a closer inspection reveals different realities. For example, the proximity of Gatwick airport means parts of east Surrey have higher than average numbers of refugees, with different health needs and challenges. Growing Health Together has three priorities:
— Health: supporting social, physical and mental health for people of all ages and backgrounds as we emerge from Covid-19.
— Equity: making access to health-giving opportunities such as physical activity fairer and more equal.
— Sustainability: reducing waste and supporting a healthy environment, and recognising that doing so is critical to human health.
The close partnership between primary care, council, schools, cultural institutions, and crucially, communities and their organisations has helped create initiatives in five PCNs, as varied as nature-based health interventions, creative art projects, group-based breast-feeding support, inclusive exercise classes, Friday night activities for young people and cultural events for African communities. Importantly, people themselves identify priorities for change, and the assets and connections they can bring to the challenge.
Progress was aided by supportive leadership at a system and PCN level and the presence of a large and proactive GP federation which wanted to spread this good practice.
Dr Gillian Orrow, one of the GPs leading this work, said: “When I began discussing these ideas with colleagues in 2019, I imagined they [would] remain on the fringe of accepted practice. After all, while common sense, they initially seemed too radical to challenge the status quo. The Covid-19 pandemic changed everything, and four years later, I could not be prouder to be working alongside so many community members and colleagues from all levels of the NHS and other statutory and nonstatutory organisations to proactively and collaboratively grow health from the ground up in our embedded neighbourhood model.”
“Growing Health Together has held engagement events with community members and frontline professionals across east Surrey, identifying the sources of and barriers to health and wellbeing in local communities, with a particular focus on groups experiencing health inequalities.”
Across the country there are other examples of GPs that have moved beyond the limitations of the medical model and are working with social and economic partners
How to spread these?
Shifting the individual encounter
We need structures that correct the power imbalances that often shape people’s encounters with the formal health system, recognising that these can be even greater where people may face additional barriers such as low literacy. We need to make it harder to ignore the outcomes people want and experience, and easier to respond to their priorities. We can do this by improving the metrics we use to assess the impact of services to focus on outcomes that matter to people. The current ‘friends and family test’ asks patients whether they would recommend the service they have just received from the NHS to friends and family. This data takes up time, but adds little to our understanding of whether a service has helped people become healthier. We need to develop new measures of the user experiences, and the health creating impacts of health intervention. This could include questions like:
- Do you understand what you yourself can do now to help your health and wellbeing?
- Do you know who is in charge of your formal care?
- Do you know what to do if things get worse?
We need to make better use of tools such as the NHS app, both as a trusted source of support and information and to capture ongoing data about the health and wellbeing impacts of services – including where they come from outside the formal health system. Data from these tools needs to be treated as a resource for service improvement and shared widely with people, communities and providers so that they can collectively use it to shape better services in future.
We also need to equip clinicians to have different conversations with their service users: identifying goals, sharing responsibility for outcomes and supporting people to overcome practical obstacles standing in the way of better health that derive from inequality, discrimination and lack of trust. Royal Colleges and universities have a critical role to play in providing appropriate training for clinicians of the future. Regulators also need to be a part of the debate, so that regulatory regimes reflect the different risks involved in sharing responsibility.
Building a community for health
No patient should leave a consultation without being clearer about what they themselves can do to support their own health, their next steps, and back-up plans for crisis or deterioration. For many patients this will involve tapping into a range of resources across the wider community. At a minimum, patients should expect to be signposted to the available support from national and local charities who may be able to support them with their condition. Again, the NHS app would be the ideal place to facilitate this integration.
Clinicians need to be meaningfully engaged as members of teams that can provide this wider holistic support. The neighbourhood teams envisaged in the 2022 Fuller stocktake are the right vehicle for this, bringing together support from across health, care and the VCSE sector, and working to build and sustain community capacity and assets.
Technology has played and will play an increasing role in assisting people to manage their health and health care. The NHS is proud of its principle of equal access to healthcare for all, free at the point of need. Now and into the future, that principle of equal access will depend upon the public’s ability to use tools and resources that will help them manage their health and healthcare. For us to put the NHS founding principle fully into practice, the NHS and other major institutions must work relentlessly to reduce and overcome the digital divide.
Integrated care systems will need to commission and run services that build on community and multi-agency partnership. They will need to create money flows that incentivise upstream, preventive intervention. They need to ensure that they understand community need, inequalities and assets and build strong mechanisms to hear from service users, community groups and the formal VCSE sector as part of any decision making.
In line with the Hewitt Review, we believe that the role of both local government and the VCSE sector needs to be strengthened in the ICS structure. This will be vital if we are to shift money and influence out of hospitals.
Systems need to be able to draw on improved data – on outcomes rather than activity, as outlined above – to hold themselves and their partners accountable for population health outcomes and for reducing inequalities. They also need to ensure that money in the system flows to those who achieve the outcomes that matter to people. This will mean significant sustainable and strategic funding for community and voluntary activity that is health-creating.
Leading from the centre
National leaders need to clearly set out that a new relationship with people and communities is both a prerequisite for a sustainable and equitable health and care system and a core part of the operating model for how health and social care will be organised.
We need clarity of purpose and communication around this shift. ‘Health creation’, with its focus on the role of community and individual action, is the right paradigm. This lens needs to shape all national decisions: we need a workforce plan that supports a massive shift towards community-based and non-medical roles.
We need funding that focuses on population health outcomes, rather than transactional activity – starting with a reversal of the decline in public health budgets.
The overall goal of all health policy and spending should be a longer healthy life expectancy. This metric should be one of the organising principles of a new government, with a cross-departmental cabinet committee in charge of progress on narrowing the healthy life expectancy gap.
So that the hegemony of the medical and professional voice is balanced at the centre, the government should appoint a ‘patient tsar’ and an NHS England ‘patient director’ to work alongside the many clinical directors it already employs. Patient and community voice needs to be formally included on the board of NHS England, the Care Quality Commission, and NICE.
The Department of Health and Social Care mandate (which is already discussed with Healthwatch, a statutory body which champions the needs of health and social care users) needs to be based on much more sustained engagement with the patient and community perspective, for example through an ongoing analysis of the priorities identified in every system’s strategy and joint strategic needs assessment.
National professional bodies need to focus on strengthening their members’ ability to engage in person- and community- centred care. Patients, communities and their organisations have a clear role to play in developing curricula and in delivering training to health professionals.