Focus less on systems and structures, more on relationships and trust

“The NHS needs a more fundamental shift in how we work alongside patients and individuals to deliver more person-centred care, recognising – as National Voices has championed – the importance of ‘what matters to someone’ is not just ‘what’s the matter with someone’.”

So says the NHS Long Term Plan, published earlier this month. A few days later Quality Watch (an initiative of the Nuffield Trust and The Health Foundation) released data illustrating why such a fundamental shift might be needed.

Examining a basket of measures routinely tracked in NHS and other surveys, Quality Watch asked “are patients benefitting from better integrated care?”. The blunt answer is no.

Some key indicators

Did people feel supported to manage their long term condition? The trend was getting worse over time. Were people being involved in decisions about their care? The trend was not improving. Were people able to see or speak to their preferred GP? What was happening to informal carers’ quality of life? Both trends were getting worse.

The study examined some key “system” measures. Were potentially preventable emergency admissions to hospital being prevented? Were delayed transfers of care being reduced? Neither were improving.

Indeed, only one of the measures in the report showed an improvement trend: people dying in their usual place of residence.

These data provide a partial and discouraging update to earlier National Voices analysis. In Person-centred care in 2017 [INTERNAL LINK] we found a mixed picture, but with an overall story of flat-lining performance on a variety of measures of how well services meet people’s needs.

The NHS Five Year Forward View, published in 2014, committed to “transforming the relationship with patients and communities” and had a whole chapter on the theme. Why hasn’t this worked? Here are three reasons:

Person-centred care has never had sufficient priority.

Consider accountability in the NHS. Bosses can lose their jobs if they fail to control the money or meet key targets. By contrast, it is not clear that there are any consequences for poor performance on patient experience or person-centred care. This is reinforced by a tendency not to measure the things that most matter to people. The irony of the Quality Watch study is that it contains no measure of the extent to which people experience a joined up service, because no such national measure exists. In our 2017 report, National Voices called for better metrics. It is welcome that the NHS Long Term Plan signals the intention to develop an “integration index”.

Neglect of primary and community services.

A second reason for poor progress is the relative neglect of and disinvestment in some of the essential underpinnings of person-centred care: primary, community and social care services, public health and a holistic governmental approach to “health in all policy”.

The NHS struggles to turn policy into practice.

Not knowing what levers to pull, it tries a bit of everything. In this mix, there is perennial over-optimism about unproven management vehicles (STPs, integrated care systems) and insufficient interest in the cultural and behavioural factors that notoriously “eat strategy for breakfast”.

Will things be different this time round?

The NHS Long Term Plan contains some excellent commitments. For example, it wants to increase the share of the NHS budget that goes outside hospitals, to make care more personalised and integrated and to do more to tackle health inequalities. But the obstacles to the NHS Five Year Forward View vision of “transforming the relationship with patients and communities” have not disappeared and could scupper the new Plan, as we warned in an earlier blog [INTERNAL LINK].

If the NHS is to truly make a fundamental shift in the way it works with citizens, it must obsess less about structures, systems and technocratic levers, and more about people, relationships and trust. It must reach out more to the communities it serves and to the voluntary organisations that sit between the communities and the services. And there is reason for optimism. The Plan sets out a new comprehensive model of personalised care, which will be accompanied by a delivery plan for implementation, set to be published this week. This goes further than previous commitments made in the personalisation space. National Voices will be doing our bit to challenge and support the NHS to make these commitments real, and to really shift the dial, when it comes to being person-centred.