The Future NHS and Care System – PCNs as Building Blocks

I recently wrote a blog about reimagining health and care in this apocalyptic moment. In this post, I want to put a bit more flesh on the bones of what that might actually look in the context of the NHS, here in the UK and particularly, England.

 

Let me just make a few statements about where I’m at when thinking about future health and care:

I believe in a publicly funded and provided national health and care service, paid for through fair taxation.

I believe that health and care should be available to all people, equally, regardless of ability to pay.

I believe in locally led health and care systems, embedded in local communities.

I believe prevention is better than cure and we need to get up stream and stop people falling in the river in the first place.

I believe creating great working cultures enables teams to flourish and brings out the best in people. I know right now that our health and care workforce is feeling burnt out and overwhelmed. We can’t keep working under the huge burdens of constantly changing goal posts, key performance indicators and heavily mandated targets. The wellbeing of those who work in this sector has been overlooked for too long and the stress levels caused by the sheer pace and volume of work are not acceptable.

I believe there is systemic and ingrained racism in our communities and within the NHS and even though I consider myself to be ‘woke’ about this, as a privileged, white, male, there is still so much work for me and us to do, both internally and externally in order to break the curse of white supremacy. It is simply not enough to say ‘black lives matter’ – our words are cheap unless we do not confront internalised narratives and change society together, from the inside-out through truth and action.

I believe our economic system is no longer fit for the 21st century and am so grateful for the reimagining of what economics is for.

I believe the role of government needs to radically change to be much more empowering of local communities, with appropriate frameworks to support this. We are seeing the mess of centralised control, with unchecked and wasteful investment in the private sector, rather than local community empowerment in this current Covid-19 pandemic.

I believe communities are able to self-organise phenomenally well, as we have seen throughout this pandemic and should be supported to do so more through a much more participatory and relational politics.

I believe that any health and care service should promote overall wellbeing by paying extra special attention to:

 

  • instating women fully and equally
  • prioritising children
  • advocating for the poor and breaking down health inequalities especially through challenging stigma (Very grateful to Imogen Tyler for her great work on this)
  • welcoming ‘strangers’ (by this I particularly mean the way we treat staff from overseas and how we care for refugees and asylum seekers)
  • reintegrating humanity with the environment (e.g. by getting back to basics of nutrition and sustainable food)
  • restoring justice to prisoners (metaphorical and real)
  • healing the sick – through both slow and fast medicine
  • ensure the honouring the elderly In how they are cared for

 

So……(!)……How do we take the best thinking around health and care systems and make it real and practicable in the NHS and Care System? Firstly, I suggest that we need to take the hierarchical, pyramidal system and simply flip it upside down. Let’s begin at the local level, as the foundations stones of a reimagined health and care system and build from there. With this we need to take seriously what Simon Parker is calling for in a rethink of what government exists for.

 

Within the health and care system though, we don’t another fresh reorganisation. We have some good things we can play around with. We just need to stretch our thinking a bit more and permission some creative, entrepreneurial experiments and we can see something really exciting emerge. Primary Care Networks are a good basic building block, which take the best of clinical leadership, and when done properly, combine it with local communities to build local health and wellbeing. They cause General Practice to work together more collaboratively, use the best of available data to map the issues a population are facing and have the flexibility to begin working differently. They are not perfect, and in my opinion, need some adaptation, if they are going to enable the tackling of health inequalities, social injustice and true community empowerment.

 

Firstly, they need more time. The phrase ‘at pace and scale’, used all too often in various management discussions In the health sector, is the antithesis of what the NHS needs right now. PCNs need time to build stronger relationships with their local communities, really listen to what their community are experiencing and build local solutions WITH their communities through co-design and co-creation. The constant onslaught of new targets, new measurement tools, new initiatives, all to be delivered by, well, yesterday, are completely counterproductive to the transition and revolution that community medicine needs to make. The current work load in General Practice is unsafe and unsustainable and is a byproduct of the consumerist attitude we have taken towards healthcare as a commodity. PCNs need time and will fail otherwise! This must be created for them.

 

Secondly, PCNs need to look at alternative and more sustainable models for the future. Currently, PCNs are very much built around General Practice at the core, and this makes alot of sense in many ways. However, here in Morecambe Bay, we have a building block called ‘Integrated Care Communities’ (ICCs), which pre-date PCNs by some five years. I believe we need to see a melding of the best bits of both, with a much wider and more integrated team within and around the PCN model. The traditional GP partnership model, though highly successful and desirable in so many ways, continues to build a model with the GP, primarily as the leader. I am a GP Partner myself – there are some huge benefits to such a model, especially often through great altruism and genuine community care. One of the difficulties facing primary care, as it stands though, is that few ‘future GPs’ want to become partners, preferring a ‘salaried’ approach and the issues facing primary care may, perhaps require a different kind of (and perhaps more socially just) economic model. I suggest that PCNs may want to explore the highly effective and entrepreneurial model of Social Cooperatives. Such models have proved highly successful in places like The Netherlands and New Zealand, provide greater sustainability, better collaborative working and more exciting opportunities. Drawing on the work of the economists, Spencer Thompson, Kate Raworth, Mariana Mazzucato, Katherine Trebeck (and others) I can see that a social co-operative model of PCNs, given trust and freedom to experiment, by either government or commissioners, could really remodel health and care at a local level, around genuine community need, as set out by Hilary Cottam in Radical Help. We could see the creation of locally led (and owned) community health and care services (perhaps even including care homes, who are still very poorly treated as we have seen through this crisis), creating healthy communities from pre-conception to death through asset based community development and participatory, democratic processes. A social cooperative model allows all people working together in a geography to be part of the same ‘system‘, rather than the current clumsiness of multiple ‘sovereign organisations’ tripping over each other, whilst creating similar community roles, bespoke to each employer’s whim. However, a cooperative model may not work for all organisations, like the police and fire-service (I’m happy to be convinced otherwise) and so building relationships, sharing milk and working having regular check-ins and multidisciplinary team meetings will continue to be important.

 

The possibilities at the local level are endless. PCNs would be able to prioritise a much more proactive, preventative model of health and care, employing smaller but more relational and therefore more effective and sustainable teams, embedded in local communities. They would form fantastic partnerships with local schools, co-designing a curriculum that creates positive mental and physical health, connecting young people more into their community and environment whilst being trauma-informed and compassionate in their leadership. Midwives, health visitors, social workers, community Paediatricians and mental health practitioners could form part of the core team and all work from the same geographical space with IT systems that actually talk to each other. Community care of the elderly would be more joined up, with care of the elderly physicians leading their own care of nursing home patients, supported by specialist nurse practitioners, along with, of course the incredible 3rd sector. It might be that some consultants, e.g. Rheumatologists, Dermatologists and Psychiatrists could belong to a cohort of PCNs, even employed by them, and therefore create a greater sense of belonging to a particular set of communities and they would also be able to work with communities more proactively through workshops, group consultations and education settings. Teams could flex and grow to suit the needs of a community, with the economic model set up to enable rather than constrain the flourishing of such initiatives. The social cooperatives could also form community land trusts which could begin to tackle various wider social determinants of poor health, including issues like housing, homelessness and access to green spaces. These cooperatives could ensure a living wage and persuade local businesses to get more involved in the area of health and wellbeing and even invest in the kind of initiatives that would create work in the green sector for local people. Why shouldn’t local health communities be involved in social change, when these issues affect the health of their communities so vastly?

 

I see local leadership teams (what we call Integrated Care Partnerships or ICPs), made up of PCN Directors, Local Government Officials, CVFS CEOs, The Police, Fire Service and Hospital Chiefs continuing to take the role of looking at a wider Population, made up of a group of PCNs and support them in tackling health inequalities, taking a servant leadership approach to empower them to succeed as much as possible. Primarily this group would be about permissioning, enabling, encouraging, holding space for learning and development, holding true to values and using data to facilitate excellence in practice. Relationships and trust will be the core ‘operating framework’ to enable PCNs to fully flourish.

 

The Integrated Care System (ICS) Leaders then need to take a similar approach with each ICP in their domain, giving as much power away as possible and taking a collaborative approach across a wider geography to learn from each other and encourage best practice and through the sharing of stories and success. It’s this kind of nurturing and facilitative leadership that will enable each ICP and PCN to flourish. Hospitals will naturally become more focused on acute care, and areas, like Oncolgy, as consultants become more aligned to the PCNs with which they primarily work (obviously this does not apply to all specialities, which is why an ICS can take more of an overall look at the hospital requirements for the population it serves). The role of the national NHS England and NHS Improvement teams then becomes the servant of all, the enabler and the holder of core values. Rather than a central command and control structure, it gives itself to a love-poured out model, creating cultures of joy right through the health and care system. Yes, it sets some priorities, but does so by listening to what communities around the nation are saying. So right now that would include asking PCNs to prioritise tackling systemic and ingrained racism, health inequalities and childhood trauma, in collaboration with their communities. They will take the best of international experience and learning, share that widely and reimagine the NHS as global trend-setter for how we create deep peace and wellbeing in our communities, enabling us to become good ancestors of the future. A radical, revolutionary but entirely practical refocusing of the NHS and Care System from the bottom-up is entirely possible. There is almost no remodelling needed, simply a change in focus and culture. It requires PCNs and the communities they serve to get on an do it together, disregarding that which prevents them. If they do this, they will find that everything they need will follow them and their light will shine brightly.

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The Art of Connecting Communities – Why Bother Connecting? (Day 1)

Over the last few years, ‘The Art of Hosting’ has been transformative to my thinking and practice as a Doctor, as a Commissioner and as a Director of Population Health. Part of the core theory that undergirds this way of working is the 4-fold practice. It involves learning to:

 

  • Host Yourself
  • Be Hosted
  • Host Others
  • Host with Others

 

Hosting yourself means doing the inner work, and tending to your own needs. It is important, if I am to give my best-self to those around me. As a type-7 personality, for me this has meant learning to embrace disciplines like silence and fasting. It has also meant learning to rest, learning some healthy boundaries, to take care of my physical needs, embrace pain rather than running from it and become more aware of my emotions, resisting the need to rationalise everything. In being hosted, it’s about letting go of control, embracing humility and receiving the gift of others. In hosting others, it’s about learning to hold space for someone else, to deeply listen and to resist the need to fix things, but rather to respond and to coach, where this is welcomed (perhaps the very art of the classic GP consultation!). Hosting with others, is about learning to collaborate, to play to each other’s strengths, to enjoy the dynamic of relationship and to create a space together which opens up exponential potential!

 

We have now hosted 5 different trainings across Morecambe Bay in the last 2 years, and hosted many more conversations. Our latest training, in the City of Lancaster (our first without the incredible Linda Joy Mitchell), was an amalgamation of some of the ‘art of hosting’ practices with our own developing practices, here in the Bay. We called this training, “The Art of Connecting Communities” and together we explored some of the theory and practice under the question: “Why Bother Connecting?”

 

We began with the amazing, Yak Patel, CEO of the CVS in Lancaster District welcoming everyone and framing our 2 days together. Yak has become a good friend and is one of the best connectors of people I have ever met. He is deeply humble, kind and compassionate. He has lived and worked in this area all his life and has taken the time to build really wonderful relationships across many communities, which means he is trusted. So when someone, like Yak, puts out a call across the area to invite people to come and learn together about how we connect communities, people respond very eagerly. there has, perhaps, never been a more important time to connect together. Isolation and loneliness is literally killing us, and our walls of division and suspicion are leading us into dangerous territory. Bringing people and communities together is an art form and one which is worthy of serious collaborative learning.

 

To welcome everyone in, we did a ‘check-in’ using circle practice. Circle is an ancient practice, and is great for breaking down hierarchies, welcoming everyone into a space and ensuring that every voice is heard and every person knows that they matter. It can be quite simple and straightforward, though my experience is that it tends to go quite deep, quite quickly. For us, in Morecambe Bay, this has always been helped by having members of ‘The Well’ communities with us. People from The Well know how to be community at a level you won’t encounter in many other places. They know how to be vulnerable, with such a natural humility and so when they open up, it gives permission to the rest of the room to also go deeper. When this happens, we find people meet at a very human level and relationships form within the group easily. in this circle, we gave people pipe cleaners and asked them to make something which represented them. We than asked them to share this with the circle. Our harvest from the circle was very rich and the amazing Jon Dorsett, a truly brilliant host and one of the best graphic harvesters around, transformed it into a stunning piece of spoken word.

 

 

After a short break, the team hosted a world-café. Hosting a good café, depends on taking time to set the room well, explain the process and have a really good couple of questions. Our café took an appreciative enquiry approach. Our first question was: “What gives the Lancaster District It’s Heart and Soul?” – after two rounds of incredibly rich conversation, we than asked: “Where and How do you Experience This?”

The beauty of a world café is the ability to find great connection and synergy in a room. The sense of positivity this conversation brought about the assets we have in this district was palpable and it created a dynamic in which everyone felt like a real participant and collaborator in the process.

 

Sue Mitchell, one of our team, a seasoned, wise and excellent coach and host did a teach-piece on ‘Deep Listening’, which we could also call ‘Transformative Listening’. Listening is an art form and one that many of us never really learn – at least not to the deepest levels. Sue, expertly took us through those levels and helped us develop a framework to challenge ourselves about how well we really listen. Level 1 ‘My Turn’ is when we’re not really listening at all and we’re just waiting to jump in with whatever it is we want to say. Level 2 is when something the speaker says sparks a memory in us and we start contributing about our own (perhaps) similar experience – oh yeah – ‘me too’! It’s about us trying to sense make and find connection, but can mean we really miss what is actually being said! Level 3 ‘My Fix’ is about the listener stepping in and trying to fix the problem. It’s a level at which we don’t really want to connect too deeply, so we try and sort it and move on! Level 4 is where it begins to be about real listening – ‘I WITH you’ – it’s quite a sacred space. It’s where we allow ourselves to feel real empathy, to be with someone in their moment and experience, putting our own thoughts and experiences aside and creating a space for them. Level 5 is where ‘we begin to hear’. It is the art of self-awareness, it’s where we allow ourselves to be changed by the encounter and have our previously held perspectives and understandings changed. If we are to really connect within and across communities, we need to learn this art of listening.

 

Having learned about the art of real listening, we practiced it, using one of my favourite practices – Triads! The concept is pretty simple – three people, together – one is the speaker, one is the listener and one is the witness. The three people take it in turns to be each role, and each time, the same question or theme is explored. The theme we worked with was: “Share a story of a connection you made that changed your life. What was the impact?” – The listener asks the question, the speaker has 10 minutes to speak, with perhaps a few questions of clarification. At the end of the time, the listener sums up what they have heard and then the witness can give any feedback on what they have seen, things which have perhaps remained unspoken or anything else they have noticed. It is a very powerful experience to be listened to and to really hear another human being.

 

Learning to harvest is one of the most important aspects of hosting well. We harvested the learning from the triads, by bringing two triads together and asking this question: “What do we know about what builds connection?” – We then asked the 6 people together to come up with one sentence that reflected this knowledge and learning. Our harvesters then cleverly weaved a web of the learning.

We finished the day by checking out, again in a circle, simply speaking words of gratitude for the day and how we left feeling ahead of Day 2. As always happens on these days, people left feeling encouraged, hopeful and connected. I love it, because it is in the spaces formed between us that creativity is catalysed, ideas are formed and new things begin to emerge.

 

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Speed

Tweet Here is a beautiful piece of prose that I have found really helpful over the last year – well worth a read and some time to reflect:   SPEED   Speed has compensations.  Speed gets noticed.  Speed is praised by others. Speed is self-important.  Speed absolves us.  Speed means we don’t really belong to [Continue Reading …]

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Reconnecting Clinicians to Healing

Tweet In the USA, doctors have the highest rate of suicide of any profession. In the UK, a similar picture unfolds. Why is it, that 69% of all physicians suffer with depression at least one time in their career? It could be because of the high workload, high stress, high demand, an increased sense of professional [Continue Reading …]

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Making Meetings Better

Tweet I’m not a great meetings person. I just generally find them tedious. I lose concentration easily, I get distracted, I end up thinking about a whole lot of things that maybe I shouldn’t be thinking about or eat far too many biscuits and then feel bloated and guilty at the same time! Meetings and [Continue Reading …]

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