Today I’m attending the launch of the New Care Models Vanguard Programme and reflecting on what I think will come to be seen as an important period in NHS history. There are real opportunities to build on the great strengths of our NHS while making important shifts which reflect a changing society. But these opportunities will not take themselves.
March saw the announcement of the Vanguard sites and the Integrated Personal Commissioning (IPC) sites. Both national programmes have been broadly welcomed as the start of bringing Simon Stevens’ Five Year Forward View to life. The next few years are likely to determine the shape of health and care services for decades to come as these initiatives point the way for the rest of the system.
My personal experience of similar programmes over the past 15 years tells me that for those of us advocating person-centred care and co-production alongside people using public services, this is a moment of great opportunity but at the same time risk. We must ensure that the opportunity is taken and the risks minimised.
There is a strong tendency for those involved in these kinds of programmes, both centrally and locally, to focus almost exclusively on making changes to organisational systems. Under great pressure to deliver, usually with very difficult timescales, programme leaders are always at risk, whatever their motivations, of focusing on the plumbing and wiring rather than the people. This is not to say, of course, that the structural and system elements – like joined up budgets and integrated organisational and professional arrangements are not vital – they are. It does, however, mean there is a tendency, right from the design stage, not to place person-centred approaches centre stage. They are always there in public pronouncements and stated goals but the link between them and the detailed strategies and plans is often weak.
There are many reasons for this. Co-production with the users of public services in designing and delivering them is still quite novel, perhaps especially in health. The reality is that, for many, it is also still quite still counter-cultural and made difficult by our systems. As professionals we feel we are already person-centred and usually try to be so, but the experience of those we serve often tells a different story. Doing this properly takes time – something that high profile programmes often feel they don’t have. This can lead to superficial engagement rather than serious co-production – itself undermining trust and even generating cynicism.
In addition, although the evidence base for achieving person-centred care is increasingly strong, these approaches have not yet gained serious traction in health. For example, only small numbers of people with long-term health conditions report having a care plan they co-developed with their health professionals. Programmes which aid self-management, shared decision making, enable peer support or link people to community supports for well-being are not routinely commissioned at the necessary scale.
So there is a potential nightmare scenario here, of merely shifting deckchairs, rather than realising a serious person-centred win-win. This win-win will require people using health and social care services, and wider communities, taking responsibility and action for their own health and well-being. It will require strong communities, local third sector organisations and universal services playing a much more significant role. This can’t be achieved just by joining up organisations or integrated teams working in a more co-ordinated way with people. It also requires the release of capacity and energy from people, families and communities, which only comes from them being at the heart of how things are done and through different, supportive uses of professional skills and system resources.
This is where the opportunity lies. We increasingly know what works in generating much more effective relationships between practitioners and people using health and social care services, and so better outcomes. Two key means are personalised care and support planning and what C4CC partner Nesta has called More than Medicine. It is therefore vital that right from the start, the localities involved in NMC and IPC do the following things:
- Co-produce the design of the local initiative with local people using public services and maintain this co-production at strategic and operational levels of decision making throughout. This requires going well beyond consultation.
- Ensure the powerful involvement of local voluntary and community sectors and re-direct resources during the period of the programmes to community based support
- Give at least as much attention (probably more) to the model of care as to the financial and organisational model.
- From the start, design key elements of person-centred care to be at the heart of the care model – including personalised care and support planning, support for shared decision making and self-management, peer support, community based support for health and well-being and help for people to connect to these.
- Design evaluation approaches with people using health and social care and incorporate outcomes that are meaningful to people, not just to the systems commissioning them.
Our early involvement with the IPC programme gives us encouragement as the selection of sites and early design of delivery support has prioritised and committed to these things. I have heard Simon Stevens say that three things he wants to see from the programme are:
- Joined up services and supports
- More powerful users of health and social care
- A very different relationship between the NHS and the voluntary and community sector
The sites will be challenged in keeping on this track, and we would advise local people and organisations to do all they can to help them maintain this focus. It will be necessary for those involved with the Vanguards programme to do the same. C4CC will offer as much advice and assistance as possible to the initiatives.
Part two of this blog, What else can we do? will be published tomorrow, Thursday 23 April 2015.