In this blog by Professor David Colin-Thomé, chair of PCC, David considers how patients and the public can engage in their healthcare to give a locus of control, be a welcomed customer and be enabled to contribute to community strengthening. David concludes that neighbourhoods are the ideal vehicle for such advancement and looks at four areas that can help the paradigm shift required.
The NHS as an archetypal nationalised ‘industry’ lacks a customer focus. The late Philip Gould identified the need ‘to bridge the schism between the person as a citizen and as a customer.’ Arguably the NHS is not so hot on the citizen element either. When the redoubtable Nye Bevan set up the NHS, he inherited the previous culture within healthcare. Despite the patient previously having to pay, the belief paying gives you leverage seemed only to apply to a privileged few. What probably set the inherited culture? The dominant professions of medicine and nursing exude an authority culture, readily adopted by other healthcare professionals. Post the significant Griffiths report of 1963 NHS managers have enhanced their authority. What’s to be done as previous attempts to redress the lack of patient influence – e.g. Choice initiative, personal budgets and the ability to change your GP/GP practice – induced only a minor impact? The stifling of change to the status quo seems endemic.
I suggest four areas worth exploring albeit briefly to address the rhetorical question posed in the title – access, responsiveness, enablement and participation. Brevity is a blog requirement, but hopefully may encourage more input from readers
Access
A universal problem certainly not confined to the UK. For the NHS increasing the numbers of clinical staff and various operational initiatives have had relatively marginal and un-sustained impact, although at least a satisfaction upsurge in the recent GP patient survey. The public require accessible and amenable information to make optimal choices about their health needs, the context being healthcare systems worldwide cannot keep pace with the rising demand for services. Information gives power. The UK government in response is investing heavily in the NHS App. ‘The plan is to transform it into the ‘’digital front door’’ to the entire NHS providing patients with a single secure record of their data and enabling direct access to various services including AI- powered advice for non urgent conditions and self- referral for certain treatments. Also including integrating primary care, mental health and specialist services by 2028, giving patients more control over their care and improving co-ordination and efficiency.’ Cynics will be ubiquitous of course but outside of the NHS, businesses and indeed international health care organisations have hugely benefited from sophisticated IT. Ridding the enormous amount of duplication and bureaucracy of clinical services certainly will improve access. I for instance have long term conditions, and with readily available personal information can markedly reduce face to face consultations. Some may well struggle with technology, but it is eye opening how many even elderly people are comfortable with it.
Responsiveness
Fundamentally traditional professional authority must be supplanted by an authority based on participatory partnerships and co-production. The meeting of experts – patient and professional – leading to shared decision making. Paradigm shifts are occurring but spread is at ‘snail pace’. A challenging opportunity for institutions educating professionals. My College the RCGP has been active over many years but changing attitudes garnered over eons will take time. Maybe cumulated feedback via the NHS App may hasten behaviour change.
Enablement
Many patients even with supportive personal clinicians require more support. Some 30 years ago ‘my’ practice informed by USA managed care organisations, employed a nurse trained by a USA based care manager to be involved with patients who had multi-morbidities and often complex needs. Their clinical measurements improved as did their confidence and hospital requirements fell significantly. The model spread culminating in the national policy of the community matron. In recent times other enabling, exciting initiatives have been developed delivered by lay workers. The adoption of community and wellbeing workers (CHWW), a model started in Brazil over 30 years ago where it is now the delivery model for primary care with over 70% of the population now having a CHWW with remarkable outcomes. They are people recruited from their communities, who are embedded in primary care teams and the community sector, to proactively assist in providing health and wellbeing services to those communities. Four key principles that make the model unique and effective when applied together- the CHUI – principle: Comprehensive, Hyperlocal, Universal, Integrated, to build trusted relationships with their households, professionals and services on the patch. (see NAPC website for more details). Lay workers focusing on the individual with more complex needs – social prescriber link workers and care navigators- complement. Efforts must be made locally to have a clear plan and review to prevent confusion and duplication of these local community assets.
Participation
Let me introduce COIN (Community-Oriented Integration Networks). The government’s plan to develop Neighbourhoods presents an opportunity for high-quality, low-cost care – through collaboration, as equal partners, between health workers, care workers and everyday citizens. Achieving this at scale requires the application of the science of community development – developing trusted relationships across boundaries and coordinated actions that build community cohesion. The difficulty of achieving integration is well known. COIN is a network of people with extensive experience of doing this. Previous inattention to processes of co-adaptation has obstructed collaboration. Neighbourhoods could play a key part in changing this, by promoting shared developmental spaces (e.g. schools and faith groups, music and exercise clubs, sports events and festivals) where people learn to appreciate others and collaborate for the greater good. The homes where carers live are particularly valuable developmental spaces because they are shared by patients and carers, health and social care practitioners, families, friends and many others who are often more prepared than usual to collaborate for health and care across boundaries. Start small and build to gain experience and instil confidence. PCC is actively supporting COIN development.
Health is far more than the absence of disease, a locus of control over one’s life and destiny is essential for health and wellbeing. If through joint concerted effort all the areas described are progressed, patients and the public will be the respected welcomed customer, the enabled citizen with agency, all contributing to community strengthening. Neighbourhoods are the ideal vehicle for such advancement
Professor David Colin-Thomé is chair of PCC, a not-for-profit social enterprise supporting primary care, the development of neighbourhoods and collaborative leadership, contact enquiries@pcc-cic.org.uk or visit www.pcc-cic.org.uk for more information.
