What does it mean to go from new models of care to new cultures of care? The NHS Five Year Forward View asserts that reform requires “a new relationship with patients and communities”. A new culture of care means responding to the full and radical implications of that insight.
However good the intentions, NHS reform always starts from the point of view of the people running the system. Even the phrase “a new relationship with patients and communities” is a system viewpoint.
Very often the system asks; “We are the NHS, what kind of relationship do we need with our users?” Not “We are the people, what kind of health service do we need?” Therefore, increasing productivity and reducing activity always seem to trump improving health and wellbeing.
The People and Communities Board that I chair – a group helping to keep the focus on chapter 2 of the Five Year Forward View - launched six principles to help frame the thinking here. What would a new NHS culture look like set against these principles?
Principle 1 is that care and support is person centred. The New Labour government promised more patient choice and a care plan for everyone with a long term condition. Andrew Lansley promised “no decision about me without me”. Yet in 2016, nearly half of patients still report that they are not as fully involved as they want to be in decisions about their care and treatment. Personalised care planning remains a minority pastime. Commissioners remain reluctant to invest in self- management programmes. A new culture of care would ensure that people’s experience of involvement, and of being supported to self-manage would be treated as key measures of success for the NHS.
Principle 2 is that services are created in partnership with citizens and communities. The most forward looking parts of the NHS are getting there: patients involved in recruitment and contracting; in experience-led service design; in clinical education. Some services even have patient directors. But the NHS still struggles with this. In a new culture, citizens would feel meaningfully involved in the 44 sustainability and transformation plans. And it’s not just about being invited onto official turf. We need to set our own agenda as citizens. In the words of one patient: “I don’t want a service, I want a life”.
Principle 3 is a focus on equality and narrowing inequality. Theresa May launched her new government with stirring words about the appalling mortality gap between rich and poor. A new NHS culture would be energised by this injustice. That would include thinking differently about ‘hard to reach’ groups. As one NHS manager recently put it: “people from communities you call hard to reach are working in your trust”.
Principle 4 is that carers should be identified, supported and involved. Despite much policy and strategizing, carers remain an after-thought. In a new NHS culture, staff would be inquisitive about the significant others in a patient’s life.
Principles 5 and 6 are about the power of the voluntary and community sector and of volunteering and social action. It is what David Cameron once called the “Big Society”. It is what people in the NHS are increasingly recognising as the potential of social prescribing, peer support, and other asset based community approaches.
But it’s also about recognising the importance of community-based activities that are not always associated with ‘health and care’. Volunteer befrienders and peer supporters provide a valuable service, but so do local libraries, shops, pubs and clubs. And so, critically, do jobs. Unfortunately just as people are starting to get what the “Big Society” really means, it is getting a lot smaller, as austerity bites into communities and the voluntary sector. In a new NHS culture people would be thinking a lot more laterally and creatively about how to connect with and support the health making forces in communities.
New models of care should not just be old wine in new bottles. In a new NHS culture, staff would be working with citizens, understanding what keeps them well; and figuring out how to deploy the vast NHS resources to reinforce the creation of health and wellbeing.