Magazine article Renewal : a Journal of Labour Politics

Place-Based Health: Why Local Accountability Would Lead to Better Quality and Outcomes

Magazine article Renewal : a Journal of Labour Politics

Place-Based Health: Why Local Accountability Would Lead to Better Quality and Outcomes

Article excerpt

Designed in the middle of the twentieth century, the National Health Service is struggling to cope with the demands of the twenty-first. Reform of an institution held dear by the British public is inevitably subject to constrained political parameters. Yet the NHS is creaking under the weight of pressures building up due to demographic changes. Sooner or later it will need a fundamental repurposing. If it is to survive and meet our nation's health needs in the future, the NHS will need to move away from a centrally managed hospital-based model and towards a locally accountable community-centred system of support.1

The symptoms of systemic failure are presenting with increasing frequency. The NHS recorded its worst ever performance figures in the first month of 2016.2 Hospitals are experiencing unprecedented demand and missing waiting time targets for time-critical care. The pressure on hospitals is reflected in their deteriorating finances, which the Public Accounts Committee concluded is occurring 'at a severe and rapid pace.'3

This pressure in the acute end of the health service is creating more public political pressure to respond to these symptoms, at the expense of addressing the root causes. The government has committed an extra £8 billion a year by 2020 to the NHS, which came at the expense of spending on social care and public health - budgets that have been cut and whose reduction will create further burdens on health services. New funding for the NHS has been tied to £22 billion of efficiency savings to make up the remainder of the £30 billion funding gap the NHS Chief Simon Stevens identified by 2020.4

More money and more efficiency may well paper over the cracks. But short term fixes designed to ensure the system limps on until the next election will not address longer term structural pressures which need to be recognised, understood and addressed. Deeper reform should be informed not by the immediate requirements of existing institutions, but rather by the reality of the health needs of the population at large. To do this effectively, we need to take a step back.

When the NHS was established in 1948, life expectancy was sixty-eight years. Today we live an average of thirteen years longer - eighty-one years. As our population ages, more of us are living longer with one or more long-term conditions which require ongoing management. And modern lifestyle-related diseases like obesity - inconceivable as an epidemic in the late 1940s when rationing was still in place - have grown in prominence. Obesity alone is estimated to cost the NHS £5 billion a year, causing knock-on health problems like diabetes or high blood pressure.

These emerging health trends create challenges for a hospital-based model of primarily clinical services designed to treat illness. There is increasing recognition5 that only about twenty per cent of individual health outcomes are the result of clinical treatment, with the remaining eighty per cent influenced by wider factors such as lifestyle choices, the physical environment and social factors.

A place-based approach for prevention

Yet the balance of energy and resource in the system is focussed the opposite way: overwhelmingly towards providing clinical treatment only when a patient has become ill, rather than preventing admissions in the first place and providing the majority of support in communities. Crucially, our model of clinical treatment is very poor at linking up with wider local resources and services which could affect these wider determinants - such as housing, employment support and social networks - and working with people to take greater responsibility for their own health outcomes. A place-based approach would need to be designed to work with, rather than in isolation from, these local resources and assets in order to create a system that would support and promote wider wellbeing effectively.

A system that enabled greater agility in this way would necessarily end up with a greater degree of local variation to meet different needs and more effectively drive improved outcomes overall. …

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