Developing and using an overarching narrative.
(In my introductory piece to this series of posts “The Mechanics and Morality of Change in the NHS” I identified six themes that I believe any innovator needs to consider before, during and after the process of introducing change to the NHS. (New readers may want to read that first).
By comparison with nearly every other need for an overarching narrative for change, the recognition that one on prevention needs to face and persuade the public seems at its most straightforward.
However in the next breath, nearly every time that a health commentator mentions a need for prevention, they are likely to include the phrase that ‘prevention is better than cure’.
Never be ashamed of reaching into the great treasury of human clichés. They become clichés for a reason. A cliché is a phrase that people use over and over again until they become everyday. They become clichés for the reason that many people believe in them. They may embarrass policy makers, but they are gold dust in developing a public narrative.
So we begin this narrative with a golden phrase that works by telling the public what this story is about.
But beware, whilst many people like the cliché others, when it is used to bring about change in the NHS and do not like less resources and energy being spent on ’cures’, will resist prevention.
In all of my posts arguing for the necessity of developing an overarching popular narrative for change, I warn that one of the reasons for doing this is because the other side – those who are against the change – will mobilise a strong narrative against you.
Putting this harshly, if you fail to develop your own public-facing narrative in favour of the chang (and one that works) you will be completely squashed by the public-facing narrative against it. If your own narrative doesn’t fly, the public argument against it will flatten you like a steamroller.
Regular readers will know that very early on most mornings, I read the Telegraph comment pieces. It’s not that I ever agree with them, but they are often well mobilised public arguments against policies that the NHS needs to change.
A few weeks ago I wasn’t surprised to read a powerful attack on the way in which GP practices have developed their work to help prevent disease. Here was an argument against GPs spending time on activities such as screening.
Let me explain the argument. Janet Daley argues that GPs switching to more prevention removes resources from those who need treatment. Her point is partly a sectarian one. Older people (Telegraph readers?) are of an age which may be past prevention, and therefore moving resources from treatment to prevention is discrimination against them.
This is a great example. Never ever think that because you and all your mates think everyone you know agrees with your argument, that this means they do. There are those who believe and will argue that for some, cure is more important than prevention and they will mobilise public opinion (in this case) of older people against you.
Never be shocked by the way in which supporters of the status quo will organise arguments against you. It’s what they do. Look out for them. Take them on.
In this case the there is a clear way through this argument that has been provided by Clare Fuller in her May 2022 report.
If NHSE were to implement this report, England would have a modern primary care service that would be based on the recognition that within the current work of primary care there are three entirely different businesses. And most importantly those businesses need different skills and organisations, and different partners.
So, to argue for prevention in primary care I would develop my public narrative from the Fuller Report.
One of the reasons that over these last few years primary care has been overwhelmed by demand is because we need primary care to carry out three entirely different services – simultaneously. At the moment these three services trip over each other with GPs trying to do it all. They can’t. The demand is too great, and the services are different.
First, because as a society we have failed to put sufficient resources into the prevention of ill health too many people in their 40s 50s and 60s are acquiring long-term conditions for which they need help from primary care. There are nearly 20 million people with long-term conditions and the great burden of working with this enormous level of ill health rests with primary care.
The main business of primary care is working with mainly older people who are already sick with long-term conditions. If these patients could better manage their long-term conditions, hospitals would not be overwhelmed by the demand for emergency beds.
These patients occasionally need to meet their GPs, but more importantly to help them better self-manage their condition(s), they need more regular meetings with nurses and other health care professionals. If primary care could help them manage their conditions without going into an emergency bed in hospital, the NHS may thrive. If not it has a difficult future.
Second, GPs need to provide occasional one-off work with mainly younger, fitter people. Some of this is administrative and really does not require a GP. Patients will have a one-off emergency which, provided it is dealt with quickly, does not need longer inputs.
Thirdly GPs provide a preventive service. One that is the core of health improvement and may involve screening for serious diseases. Much of this should involve local government public health professionals alongside primary care and may not need the work of GPs themselves.
These are three entirely different outputs of primary care which need different staff and need to work with different parts of the health service and other services. Our current problem is these three services are confused between each other.
If primary care could find the resources to better carry out preventative work, it would ensure that in the future those long-term conditions would impact on patients later rather than earlier in their lives and reduce demand for primary care. If we fail to prevent disease until later in life, the danger is that primary care, and the NHS, will be overwhelmed.
To implement the Fuller stocktake and provide better primary care, preventative services will need a strong argument for change. Change won’t happen without it.