The NHS Five Year Forward View acknowledges that we can only achieve better health, better care and better value by fundamentally changing our service’s relationship with patients and communities.
Empowering patients and communities is where the agendas for the NHS and local authorities really come together. The NHS Five Year Forward View acknowledges that we can only achieve better health, better care and better value by fundamentally changing our service’s relationship with patients and communities.
Local authorities have long been engaged in shaping their communities, building local assets and community resilience. They, too, know that we have to reduce people’s need for statutory services to be able to face the future demographic and financial challenges. So together, we all have the same aim: to have strong cohesive communities where people have the knowledge, support, skills and resources to manage their own lives and health to realise their own ambitions, and where partners across communities are recognised for what they offer.
For these communities to emerge and flourish we have to recognise our role as public services. Sometimes we prevent others doing more by what we do. At the very least, we have to refocus the way we work and our interactions with the places in which we work. We must become enablers and champions of self-determination and self-care, not fearful of our own irrelevance. We must take part in our local community’s conversations, not always think that they must take part in ours. We must move away from our professional focus on needs and vulnerability and be the first to celebrate people’s strengths and interests.
These changes do not need big structural reorganisations or complex multifaceted programmes. They do need a new mindset. In each and every one of us. In our colleagues and in their colleagues and in theirs. We need to reach the tipping point. It starts with us. We build on long and proud histories in many areas, of communities recognising and responding to local need. Our job then, is to be the invisible, non-invasive architecture that supports this resilience.
The Stockport approach is around transformation of the whole system, encompassing four broad areas:
From our experience of People Powered Health over the past four to five years, we have developed four tangible areas that can make a difference:
Our approach must change from ‘factory repair’ to prevention and enablement. Individual people should be at the heart of our work and must always receive a ‘nothing about me without me’ approach.
This requires vision and leadership, permission to change and sponsorship. We must shift the emphasis from clinicians taking responsibility for people’s health - which creates passivity and raises unreal expectations - to empowering patients to take control of their health (by employing nurse coaches and peer supporters, for example).
We must enable goals to be set by patients, encourage positive behaviour change and take account of what matters to people in how they want to live. This approach is all about behaviours: being positive, courageous and encouraging individual ownership of actions.
By using the concepts behind ‘Patient Activation’(1) and Self-Care, we can guide (rather than direct) patients by holding collaborative consultations. We must link patients into specialist advice and treatment but we must also think about people and networks. This can be achieved with a ‘human’, conversational approach based on their individual strengths and interests.
Workforce development then will be key to supporting collaborative consultations. For example, by using the ‘Three Conversation Approach (2) we can replace the traditional ‘assessments for services’ culture with a new behaviour, culture and practice based on three conversations:
Conversation 1 – How can I connect you to the things that will help you to get on with your life, based on your assets, strengths and that of your family and communities? What do you want to do? What can I connect you to?
Conversation 2 – If you are at risk, if your life is in melt down - what needs to change to make you safe and help you regain control? How can I help to make that happen? Furthermore, what offers do I have at my disposal, including small amounts of money and using my knowledge of the community, to support you? How can I pull these things together in an ‘emergency plan’ and stay by your side to make sure it works?
Conversation 3 – How can I make sure you are in control and feel empowered to be so? What is a fair personal budget and where do the sources of funding come from? How can I help you to use your resources to support your chosen life? What do you want to do, what matters to you, what makes your life worth living? Wigan Council offers an excellent example of a comprehensive approach to addressing workforce culture. (3)
‘Place based health’ should be the approach;(4) the concept of People Powered Health together with people shaped pieces offering a persuasive framework.
It helps to think of a borough as a number of geographical areas, localities and neighbourhoods, and ask what residents recognise their neighbourhood to be. In every neighbourhood there are community hubs, cafes, libraries, church halls, community centres.
We need to identify and help develop new community hubs (5) for locating information and advice in places people identify and will go to in their neighbourhoods, including carers. Find out what is already happening in terms of lifestyle and behaviours in a community and use resources creatively to enable new ‘assets’ to evolve.
We must ensure local GP practices are included and linked with community hubs through creative social prescribing, through connecting to targeted prevention services (use community navigators or connectors) and through patient participation and involvement.
And we should use targeted prevention tools such as the evidence-based Health and Wellbeing Checks, as used in Stockport, to identify need.
Links must be made between the formal healthcare system and informal, voluntary and community sector activities happening in local communities. Approaches described as ‘more than medicine’ can give people skills and confidence, working on the social fabric of communities to improve health and wellbeing. (6)
The new approach shifts focus from organisations to places encompassing the wider determinants of health beyond clinical symptoms.
For those unable to access the offer, we must develop a virtual, digital information service and offer enhanced and supported access to it. We should seek to use social media to enable others to be informed.
We can help prepare neighbourhoods to be dementia-friendly communities by taking on the messages of Greater Manchester’s Ambition for Ageing, for example.
We should use public health promotion services as an asset to support education, lifestyle, behaviour change, develop peer support and expert patients, develop links to targeted prevention services and the new multi-speciality community teams.
And crucially, we must ensure strong links are made between the primary care services and the new MCPs or Integrated Neighbourhood new care model teams.
Internal reorganisation won’t be enough; we need to take notice of the empowered community voice to stimulate ‘social movements for health’.
In order to do this, existing community champions and ambassadors need to be identified. By enabling and encouraging others to come forward, (7) we can creatively grow volunteering. (8)
We should ask what social movements are already happening and seek to make connections to health and care. For example, connect arts, leisure and community issues such as transport or energy to health.
Health as a social movement can tap into the inherent compassion in a community, raising awareness of isolation, loneliness and anxiety.
Loneliness is a key issue impacting significantly upon the health and wellbeing of many citizens. There is significant evidence (9) that older people are profoundly affected by loneliness in our communities, but we believe it is an issue that affects all ages, and has a high cost not only to those experiencing it, but also to wider communities who miss out on the knowledge, kinship, skills and assets of so many people.
We can generate a social movement by creating neighbourhood steering groups and identifying those who can advise and enable action. By holding community conversations, we can highlight the levels of hidden distress in the neighbourhood and ask the question ‘do you want to live in a kinder community’?
“There is no power for change greater than a community discovering what it cares about.” Margaret Wheatley
The enabling role of public services should be emphasised, and we should seek to grow a spider’s web of connections, spreading out from neighbourhoods to cover a borough. Consider using startup funding, participatory budgeting and timebanking to develop interest and incentive.
Intergenerational connections can be powerful. We should involve wider organisations in a system-wide approach - housing, VCS, fire service, public health, businesses, private providers of care and support and faith groups from all persuasions.
We must seriously question the current commissioning model and not be afraid to ask if it is fit for purpose. The Voluntary and Community Sector has a lot to offer and we could be using it more effectively.
In Stockport, we were not afraid to decommission 70 VCS organisations on the same day, in order to generate a new collaborative approach, using Alliance Contracts, working to a common vision and outcomes, in contracts which stress trust and integrity. Alliancing redefines relationships; it’s about alignment around a common vision, trust and working collaboratively to shared outcomes; together the sector is more than the sum of its parts.
Resources need to be used more efficiently; we should seek to reduce silo working and duplication. We must see decommissioning as a positive step and use recommissioning to achieve common outcomes. (10)
The approach recognises that what is needed is top-down leadership and the permission to change culture, staff to be empowered to question and change, and the encouragement and heeding of ‘outside in change’.
The barriers (e.g. cultural, policy, resources, perception of risk, who holds decision-making, investment in the current model) need to be recognised and understood. Disruption is likely needed, but not chaos.
Innovation must address both the head and the heart - to inspire and motivate through persuasive narratives and stories. In theory, change of scale happens through developing a core of passionate champions which expands to those more reticent, before finally reaching the watershed where those come on board who were resistors when they see everyone else has.
“Never doubt that a small group of thoughtful citizens can change the world, indeed it’s the only thing that ever has” Margaret Mead