People are living longer with long-term conditions. The NHS needs to reimagine how it can support them by working with a range of partners and citizens.
The Health and Care Act 2022 put integrated care systems on a statutory footing, creating a framework for the delivery of more integrated services. The success of this depends on local organisations and leaders working well together.
Medical services contribute to 20% of a person's health and wellbeing, while the remaining 80% is down to health behaviours, social economic status and the physical environment. Spending £151bn on the NHS and only £3.4bn on public health therefore is unlikely to significantly improve population health.
What must we do differently if we are to achieve sustained improvement in population health across the neighbourhoods of Hampshire?
This is the question we have been asking ourselves in the Hampshire New Frontiers group – the first of three pilot projects supported by National Association of Primary Care (NAPC) and NHS Providers to improve the way primary and secondary care services work together.
We are delivering change on the ground and seeking new 'frontiers' for innovation and transformation – a 'team of rebels', as author Matthew Syed would describe it. We were chosen not because of our positions of authority but because of our values, ideas and energy.
Our learning so far suggests that to successfully integrate primary and secondary care services, we must do the following:
Focus on health creation – not just prevention
We need to accept that wellness and illness co-exist, and this requires a change in behaviour. This means developing a greater understanding of the context of how people live their lives, incorporating the cultural, social, psychological and environmental issues that might be relevant. By creating improved health through confident, empowered, capable people, families, and communities, we would also reduce incidence of diabetes, cardiovascular disease and chronic obstructive pulmonary disease.
Key to our success in the Hampshire system is how to get to the heart of each community/neighbourhood and how we create neighbourhood movements for change.Chief Strategy and Population Health Officer
This is a fundamental shift in the power base – away from statutory institutions, towards local neighbourhoods and communities. Key to our success in the Hampshire system is how to get to the heart of each community/neighbourhood and how we create neighbourhood movements for change.
We have started in small steps, adopting evidence-based interventions, to understand our role as linchpin, supporter, contributor, integrator and facilitator.
Change how we shape our services
Giving people agency is key. Our responses need to evolve from being specialists to being a person-centric, multidisciplinary service. Service provision should be seamless for the person, even if it’s not always perfectly logical or seamless from the provider perspective.
We have started to understand 'unmet needs', working together between hospitals, primary care, mental health and community providers, local authorities and people. Health is an outcome of our social determinants as well as our genetics. We need to recognise that even if we joined all the statutory services together and worked in perfect harmony, it would never be enough to address all inequalities.
Act on data… and intelligence
We have started to work with others to develop a rich picture of each community to proactively target health creation opportunities. Using data on social determinants, theographs of service usage and maps of community assets, we plan to start conversations with communities and their leaders about what matters to them. This will enable us to offer a completely new perspective on priorities for providers which may start to shift us towards a health creation world.
As this is such a big transition from where we are currently, we have started small – learning and evolving as we go. We also need to take some of the fear and perceived threats out of this new approach.
Resource efforts to address population health
We want to strike the right balance between doing the 'day job' – tackling backlog and waiting lists – and focusing on improving population health for focused cohorts of our communities. The pressure is understandably on tackling the backlog, but if we don't carve out time, and repurpose a proportion of collective resources and budgets on health improvement to invest in communities to strengthen themselves, we will simply be trying to empty the bath water while the tap is still flowing.
We have started to reallocate some of our resource and funding to prove that evidence-based interventions will work for our neighbourhoods.
Embrace digital innovation
In many ways, digital solutions and technology have become the cornerstone of working in this 'living with COVID-19' era. They have enhanced and enabled virtual and focused/targeted face-to-face care.
If we use digitalisation wisely, we can safely break down the siloed healthcare working environments that have become the norm.Chief Strategy and Population Health Officer
Digitalisation is one of many answers, but it is not the sole solution. Rapid normalisation of digitalisation has given us the ability to share data and educate across platforms that did not exist a decade ago. This innovation can allow us to identify populations and the people most vulnerable. If we use digitalisation wisely, we can safely break down the siloed healthcare working environments that have become the norm. The norm is ironically becoming antiquated. Focused safe digitalisation will facilitate real-time coordination across all sectors of the community. The potential is staggering when you consider fragmentation of care has left many groups of people disenfranchised and uncared for.
Imagine if we are able to enable and enhance patient experience and safety; data driven clinical decision-making; effective care team workflow, equipment, consumables and medicines; and collaboration and patient partnership.
Allow people to experiment, fail, learn and succeed
It's important to develop curiosity and courage to challenge the status quo, and avoid colluding with activities and processes that are unlikely to lead to health improvement. We also need to accept that change will never be perfect.
Governance to support this approach is very different and not the same as our monthly assurance of performance. We have started by taking small steps, working with targeted cohorts of the population and going where there is energy, to help address the fear and resistance in order to build momentum.
Align key system measures with driving improvements in population health
Imagine if we had a set of 'wellbeing' as well as 'illness' measures that were monitored regularly. Our systems are well trained in focusing on what gets measured. If we want to shift focus and effort towards creating and supporting communities that have agency to improve their own population health, then we must look to measure the right things. For example, measuring the connections that people have in a community could indicate the level of social support that exists.
Provide education and knowledge
Population health encourages a genuine system-wide approach which has the potential to significantly reduce the demand curve in the health system. Adaptive change in whole systems require significant 'change management' to implement new ways of working: shifting processes, roles and responsibilities, changing the power dynamics, realigning funding and starting on new learning.
Appropriate guidance, expertise, education and knowledge sharing is required to maintain short-term results while new models are established for the long run.
In January 2023, look out for our paper on our initial efforts to learn about fostering and delivering health improvement for our population entitled: "What must we do differently if we are to achieve a sustained improvement in Population Health across the neighbourhoods of Hampshire?"
This blog was co-authored with the following:
- Jessica Berry, senior transformation manager, Hampshire and Isle of Wight Integrated Care Board
- Carl Brookes, consultant cardiologist, Hampshire Hospitals NHS Foundation Trust
- Helen Bruce, GP, Hampshire Hospitals NHS Foundations Trust
- David Cruttenden-Wood – general and colorectal surgeon, clinical director for Virtual Healthcare Hampshire Hospital NHS Foundation Trust
- Laura Dannahy, divisional director of psychological professions – Mid and North Hampshire, Southern Health NHS Foundation Trust
- Charlotte Hutchings, GP, clinical director North and Mid Hampshire, Hampshire and Isle of Wight Integrated Care Board
- James Lawrence-Parr, associate director population health, Hampshire and Isle of Wight Integrated Care Board
- Nicky MacDonald, divisional director of operations – Mid and North Hampshire, Southern Health NHS Foundation Trust
- James Moody, head of strategy and innovation, Test Valley Borough Council
- Jon Rumsey, health intelligence analyst, Hampshire and Isle of Wight Integrated Care Board
- Howard Simpson, consultant emergency physician, Hampshire Hospitals NHS Foundation Trust
- Ali Young, associate director – health improvement and place (North & Mid Hampshire), Hampshire and Isle of Wight Integrated Care Board.
Facilitated in partnership with Hampshire Integrated Care System by the National Association of Primary Care and NHS Providers.