Moving to a new and holistic model of healthcare

4 September 2019

By Siva Anandaciva

In this guest blog, Siva Anandaciva, Chief Analyst for Kings' Fund, shows how the health and social care system can be reformed to address the root causes of poor health.

A few months ago, I sat in a meeting and realised I was going to be obsolete. This is not because my industry is downsizing, or because my job is at risk of automation (less than a 25 per cent chance of that according to the ONS). It is because I have been trained for an old world.

That ‘old world’ is one in which the energy that drives the NHS and wider health and care system is quasi-competitive – you compete for contracts, for activity, for market share. It is based on divisions between secondary care and primary care, and between providers and commissioners. And it is based on the here and now – four hour waits in A&E and annual financial performance.

The new NHS Long-term Plan sets out a clear policy intent to change this, and move to the NHS being seen as part of a wider system of care that aims to improve the health and wellbeing of local communities. But despite this intent, the NHS still has a regulatory and financial approach based on the performance of individual organisations. Despite the policy rhetoric, the health and care system has retained many of the behaviours and incentives that will keep us tethered to the old world.

For this reason, work like the Centre for Progressive Policy’s report Beyond the NHS and The King’s Fund’s report on the Wigan Deal takes on greater meaning by offering both a glimpse of the new world and reiterating the case for changing the world we have. The CPP’s focus on investing in prevention, learning from place-based approaches to health, and coordinating the work of government on the social determinants of care may not be news to the public health lobbies. But at the same time they require a genuinely radical shift in what leaders in the NHS prioritise and how they view their roles. The meeting I was in - held in the offices of a local London charity that wants to tackle childhood obesity and improve the health of people with multiple long-term conditions – was focussed on achieving this dynamic shift.

So how do we move from the old world to the new world? I think three things are needed.

First, a recognition that there will never be a ‘good time’ to invest in prevention. Even a cursory look at the fiscal outlook suggests the next five years are unlikely to be a time of milk and honey that provides all the funding growth that will be needed for improving the NHS, prison services, schools and prevention. But if leaders wait for the NHS to ‘stabilise’ financial and operational performance before turning to investment in wider health and care services, they will be waiting a long time. Ultimately, investing in preventatives services that tackle the wider determinants of health is a choice – and every spending review or Autumn Budget that comes and goes without action is an active choice by the government to not invest in the health of the nation.

Second, picking up on another theme from the CPP report, it is time to think again about the benefits of a coherent pan-Government approach to tackling issues in society. Public Service Agreements and spearhead strategies may no longer be fashionable, but the principle remains sound: multi-agency problems surely require multi-agency solutions. Reviewing the roles of all departments in tackling social determinants of health would be a welcome first step to bring the right national players to the same table.

Third, the principle of subsidiarity in health and care has been talked about for decades. But the difference I see now is that rather than power being granted from national bodies to local or regional organisations, neighbourhoods, communities and cities are seizing the power they need to deliver change. For example, in Wigan – local leaders are building on the strengths and assets of individuals and communities to improve health outcomes and wellbeing.

Every good idea finds its time eventually. New Zealand is taking the first steps towards a wellbeing-focussed approach to national budgeting. And national leaders in the UK health and care system are beginning to frame public spending decisions around inclusive economic growth.

There are reasons to be optimistic that the new world is within our grasp. I remember a time when I would go to a local NHS strategy away day and ask boards what they wanted their organisation to be famous for, and the answers I would hear were along the lines of: ‘to be the renal centre of Europe’. Now the answers are ‘to be the best employer I can be for my staff, to be the best provider of life chances to my local community’. As an NHS chief executive once told me, once you start talking about the right things it is easier to do the right things. When I hear ‘inclusive growth’, ‘anchor institutions’, and ‘social determinants’, increasingly become part of the day-to-day discourse in the NHS, I feel like we are starting to have the right conversation.

Siva is chief analyst in the policy team at Kings' Fund, leading on projects covering NHS funding, finances, productivity and performance.Before joining the Fund in 2017, Siva was head of analysis at NHS Providers – the membership body for NHS trusts and foundation trusts – where he led a team focused on NHS finances, workforce and informatics. Previously, he was an analyst in the Department of Health working on medicines policy and urgent and emergency care. Siva has been a governor of the Homerton University NHS Foundation Trust since October 2014.