Why do we need to do things differently?
The NHS has a good history of improving the quality of care through programmatic approaches. Most STPs could identify where these would help them with specific issues in their area. Most have developed plans of action, usually at increasing cost, that target these issues. There is a good chance that these will be successful.
When it comes to reducing cost and balancing finance there is less record of success. Attending to increasing demand and complexity comes at a cost and there is no widespread belief that the target the NHS has set itself for savings and financial control is achievable.
Most STPs turn to the third element of the planning structure to provide the narrative for achieving this. By investing in preventative approaches and new models of care the NHS will reduce demand on its more expensive acute services.
This is a flawed argument in many ways. High levels of screening and easier access to primary services will over time result in people being pointed towards activity that redirects them from acute provision but will also collect a larger number of people that require those more expensive treatments. Once those larger numbers of people are in the system, they are picked up for other assessments and treatment as complex, but at times low level, complaints are explored diagnosed, often re-diagnosed and treated.
Furthermore, hidden behind the rhetoric of ‘support for comprehensive hard-hitting and broad-based national action on prevention’ is a fundamental mind-set of large-scale programmatic approaches that do things ‘to’ people rather than ‘with’ them. The guidance on ‘when to consult’ shamelessly explores when it is necessary to ask the public about changing a service suggesting that the issue is one of how you get sufficient support for the plans you have made, not how you develop a shift in the way people live their lives or use health services.
There is good research to show that such approaches to intervention in living systems have exactly the opposite impact to the intended approach. The current approach to health and well-being will increase service dependence. Despite best intentions, legislation and inspection hold more weight than the opinions and needs of local people and their locally elected politicians. We need to challenge accepted truths about the way health systems, organisations and communities work.
How do we build a movement for change?
For this work to flourish, it is necessary to build a large network of individuals and organisations/programmes that identify with the work. There are many, many potential contacts.
How do we rapidly grow the number of people connected to this work so that we build a movement for change?
This is a leadership development challenge. It addresses a ‘wicked’ or ‘complex’ or ‘system’ issue, namely; how do I, as a leader, work more effectively with others in the furtherance of our collective endeavour. It addresses a belief that surfaced in this year’s workshop session that at the heart lie questions of compassion and ethics. In recent tragic events such as the Grenfell fire or earlier events such as Mid-Staffs, we have seen how the ‘squeezed middle’ of organisations often knows its actions lack compassion yet they feel powerless to effect change. When the inquiry that follows such events reports, inevitably the follow up will involve tighter regulation and compliance, the unintended consequences of which is often to reduce the space for compassion and ultimately to encourage unethical activity.
What would it really take to make your city a healthier city?
It cannot be about control. Control creates dependency. Be generous, invite others in, and allow space for them to explore. Have some humility; acknowledge other’s perspectives and points of view.
Think Biology instead of Mechanics. Design approaches that allow for things to grow and flourish as well as whither and die. Most seeds never find the sunlight. A healthy eco-system is self-sustaining.
It begins with ethnography. People do not use services and pathways as we design them. Our interests are not theirs. Understand how services fit in people’s lives if you want to design approaches that really work.
It is a whole system approach. ‘No top down reorganisation’ is a political slogan that has some validity. But bottom up reorganisation is not the answer either. This requires change all across the system, at the same time, learning together.
Change is co-designed. The boundary of the ‘system’ is rarely clear. If you want a healthier London you will need to work with residents businesses and other agencies in designing new approaches not invite them into your internally created plans.
Follow the energy. There are an infinite number of ways that you might proceed so find the ones where the energy is strongest. Follow that existing pull and use it to draw increasing numbers into the fold.