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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How Does Change Happen?

How does change happen? This has become an incredibly important question to me over the last few years, and I am still on a big learning journey in discovering some answers. There is so much that needs to change – so much that is currently going on in our communities that simply doesn’t work for people. So I keep asking – how does change happen?

 

I recently read a book called ‘The Moral Imagination’ by the great peace-builder and activist, John Paul Lederach. In it, he talks about the concept of ‘critical yeast’. Yeast is itself changed in a new environment (surrounded by flour) and then begins to bring about phenomenal change around it. You don’t continue to see the yeast, but you surely get to see it’s effect!

 

For me, change begins with listening, and by that I mean deep, generative listening to those who we could think of as ‘critical yeast’. The kind of listening in which you can no longer continue to see things the way you did previously. As you listen in this way and find your self changed, you can longer continue with things as they are – you realise that things around you need to change also.

 

It’s one of the reasons why I am absolutely committed to putting myself into uncomfortable surroundings or situations which challenge my neatly held world views and beliefs. I try and make sure I take the lanyard off my neck, step out of the clinical settings I know and the board rooms I sit in and spend time in and with the communities we serve. I really believe it is vital for all leaders, especially those in senior positions to regularly take time away from the boardroom and really sit with the communities they are paid to serve. If you don’t have your finger on the pulse of the pain people are experiencing, then it’s all too easy to make decisions on behalf of them which utterly lack compassion or kindness.

 

So, together with my good friend, Yak Patel, who is the CEO of the Lancaster CVFS (Community Voluntary Faith Sector) and a man of real humility who holds our communities in his heart, we went to be with some people doing amazing things across our district. Yak is great at holding me to account and ensuring that I put my money where my mouth is!

 

We started on The Ridge, the largest council estate in Lancaster. There we spent time with Lisa, who we know through ‘the art of connecting communities’. She runs the community centre, and we wanted to listen to the experiences of people living on The Ridge and understand some of what they are facing. Simple things, like a cut on their bus service (as timetables massively favour the University) is leaving people isolated and cut-off, especially elderly citizens at weekends.

 

I asked Lisa what she thought about the growing rhetoric that the problems communities like ‘The Ridge’ are facing are not to do with ‘resources’ – she rolled her eyes and retorted – “easy for people to say that, but over the summer, I couldn’t pay myself a salary for 2 months, so that I could ensure that the youth provision needed through the holidays could actually run – the funding for those kind of activities has been cut so much, it’s a joke….” Lisa, like so many other big-hearted and socially-conscious community workers, had to work 80-90 hours a week, holding down a second job, simply to be able to pay her own bills – similar to what happened at Christmas, when she worked long hours to make sure that 75 children on the estate actually had something to eat and a present to open on Christmas Day. People of good heart are feeling overwhelmed, unsupported and burnt out. I asked Lisa what she would love to happen – she wants to bring the community together, to talk about what’s strong, not what’s wrong, ask the community what it is they actually want and need, rather than assuming the providers of public services somehow magically know (!) and focus on what The Ridge could become – for the community, by the community.

 

On The Marsh, we met Debz. Debz also came to ‘the art of connecting communities’ last year. You might describe Debz as a ‘salt of the earth’ person. Down to earth, she has seen it all. I asked her what the biggest problem is for her community…..”drugs…..the place is overrun with drugs – and people are on the ropes”. The food club was happening, thanks to fareshare, when we arrived (although huge trays of strawberries were already completely mouldy)….and there were queues down the street….she shared with us some of the complexities involved for young people and the situations they find themselves in – multi-generational trauma….but what she struggles with most is that those who are supposed to care, don’t seem to want to understand. She told us of difficult encounters with the local GPs, the local hospital, social services (one family had had over 24 social workers – what’s the point in that, she asks?), police, schools and city council….although she has noticed some attitudes begin to change (perhaps because of the poverty truth commission).

 

She feels that people on ‘The Marsh’ are judged, looked down on and it’s reputation is very hard to break. But she also knows that people who live there want things to change and they want to be part of the change. That can be really tough, with the threat of violence and the very real involvement of gangs from Liverpool and Manchester, bringing intimidation. “Why would people not do drugs and get involved in selling them? It pays better than any work available”, she shrugs.  She believes the community can find some more hopeful dreams and she talks about the difference a new church in the community centre are making (a conglomeration of a few different congregations working together)….She wants to bring the community together to talk about what they want to see change, but especially how they can be part of that change….however, she doesn’t think it can happen through some kind of new found motivation alone – it’s going to take real investment. She tells me that if we want to stop seeing men dying in their 20s, from drugs, violence and suicide – we need to think altogether differently about how we work together with communities. Yak nods in agreement – he used to have Debz’s job, before he became CEO of the CVS. He tells me how many funerals of young men he has been to from this community. I feel deeply sad.

 

Then we’re on to Poulton (which has the worst health outcomes in North Lancashire), to meet our friend Joanne, who runs Home Start for Lancaster and Morecambe. What an amazing lady! And such a great charity! We sit with Joanne and one of her trustees, Sheila (who used to work in children’s services at Lancashire County Council, before she saw the decimation of her team and the unacceptable levels of stress she and her team were having to work under, which she deemed to be totally unsafe). The work they are doing for young families is extraordinary. Most of their referrals come from Health Visitors, but they are now full, and simply can’t take any more referrals unless more volunteers arrive. What I love about Joanne and her team is the collaborative-coaching approach they take. As they have worked alongside families, and discovered what they want and need, they have seen co-produced groups around issues like Domestic Violence and Autism support. What Joanne is most proud of is that they have created a culture in which you can walk into a room and no one knows who is a ‘client’, who is a volunteer and who is a member of staff – brilliant! “A community of mutuality” – she beams! Humility is the order of the day and it leads to real relationships that bring real change. As services have been cut and fragmented, increasing pressure has fallen onto the charity sector to hold things together – but resources have not followed. Despite great connections across the sector, the pressures are mounting, the cracks are showing and the risks are increasing.

 

I have no idea how much money Lisa, Debz and Joanne must be saving the public services every year, in terms of health and social care….but I do believe we could be making some far better and wiser investments with the ‘public purse’. We should be putting a whole lot more faith in community centres and workers, like them. If we do so, we will find it much easier to tackle deep-seated health and social ineqaulities right in the heart of our communities, taking an asset-based approach, being brave enough to redesign around relationships rather than transactions (as my good friend Hilary Cottam says in Radical Help) and find that communities really do want to be a part of transforming their own futures. Just like in Wigan, there needs to be a New Deal between communities and the public services to ensure that there is mutual vision and accountability for the resources that are available. What are we brave enough to stop doing, so that we can learn to do what is altogether better? Are we able to change? Not if we remain in our silos and ivory towers and continue to tell ourselves the same old stories. But might we dare to step outside the fortresses of what we know and learn to deeply listen? If we can do so, we cannot help but be changed….and as we begin to change….well…..then change begins to happen!

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