The White Paper Integration and Innovation: working together to improve health and social care for all, published last week, sets out four purposes for the proposed changes.
At the moment, the NHS focuses almost exclusively on one of these: enhancing productivity and value for money. The others relate to population health, inequality and economic development. Whilst the NHS is perhaps not the natural home for these, they are the more important for its future.
Currently the measure of NHS performance which grabs most attention is waiting times. If you are waiting for hip or knee replacement for instance, this is of course important. But for the NHS, wanting to hit those targets at all costs, drives some unhelpful decision making.
What if the NHS was judged, not on system metrics, but on population health? If the big headlines were about how many people are in significant pain, have diabetes, anxiety, depression? How might that change decision making?
This is not a new idea, of course, but with a few rare exceptions, population health measures never get the priority needed to change the way we think about health services.
Let’s take musculoskeletal health and pain. We know that chronic pain is more prevalent in women, black people, and those who live in the most deprived areas. If we made the number one priority of each ICS to reduce the levels of pain in their local populations, what decisions might that drive?
First ICS would make sure that everyone with treatable pain conditions had rapid access. That would mean an end to the current commissioning policies such as arbitrary BMI thresholds which are against NICE guidelines. Next ICS would commission preventive programmes for those with less severe joint pain. Programmes such as ESCAPE-pain and good boost, which have been shown to reduce people’s need for surgery and increase their ability to manage their pain. They would make sure that everyone who experienced chronic pain had rapid access to support in the community, including peer support, to prevent them getting worse.
Next ICS would take a more fundamental look at the cause of the pain. They would ask why their population was overweight and inactive. They would recognise that the population most affected have easy access to fast food outlets, poor access to affordable fresh food and don’t feel safe exercising outside. They might start thinking about how to tackle the level of harassment that women experience when they exercise outside or in gyms, and the barriers disabled people face to being more active.
ICS would realise that pain is about place. Not place as a geographic boundary for health services, but place as community, run by local government, voluntary organisations and people. Instead of the NHS in the driving seat those who control place would lead. If you want to see what this approach can achieve, look at the Wigan Deal which achieved an increase in healthy life expectancy at a time when the rest of England was heading in the opposite direction. It was driven by the local authority, not by the NHS. We need to empower (and fund) local authorities and communities to drive population health improvement.
The White Paper could be an opportunity to move in this direction if ICS Health and Care Partnerships are led by local authorities. The White Paper talks about a focus on population health and outcomes when commissioning. Taking this seriously could fundamentally change the way the NHS thinks about its role in health. A change that could be uncomfortable, but one that is needed if the NHS is ever to get off the treadmill of trying to patch up patients as fast and efficiently as possible to keep up with an ever-increasing need.
