Big changes in small places

There is a shift being planned for the NHS which has the potential to be one of the biggest in its history. Certainly more long lasting and with more potential to create real change for people than the scores of restructures which the UK’s favourite public service has had to endure during its nearly 70 years of history.

It’s a shift that has often been talked about as desirable, more recently talked about as essential, but never, if we’re being honest, one which has been backed up by real system change.

It’s the shift from hospitals to communities, but it can’t just be moving familiar approaches into smaller buildings. It’s the move from formal to informal care, but it can’t be about sacking your heart surgeon and replacing her with a volunteer, which is what many people will read into that kind of change. It’s the shift from a biomedical to a social model, but we’ll have to find some plain English for that. As Anu Singh eloquently outlines in her recent blog, it can mean support to self-manage rather than rely entirely on medical professionals, peer support or group activities, and health coaching, but it has to be about more than those new programmes, it has to be a change which takes root across the whole system.

This won’t be easy. Whether we work in healthcare or not, we are all taught that health professionals know best. The expertise of our health professionals, based on years of training and incredible advances in research and medical technology is fantastic and we should never take for granted that we access that for free: it often stops suffering and saves our lives. But that attitude of ‘doctor knows best’ is less useful when we feel that we aren’t really responsible for our own health, or can’t manage our own care. And it can be lethal when the health system ignores the insight of people themselves or their families which is a lesson we never seem to learn. It is these ingrained attitudes which both people using services and those working in and managing them find so hard to shift.

We talk about them as culture change, which is often code for things we don’t really think are achievable, and our responsibility. I’ve blogged before about the changes which are achievable and are the responsibility of us all:

  • Building asset based thinking throughout the system: this means everyone being trained to think first about what people can or could do with support, then about what they must rely upon services and professionals for.
  • Passing the ‘connection test’: expecting all services to connect people and avoid disconnecting people from their family, friends and communities, and having the courage to measure both the connections and disconnections.
  • Thinking whole-person, which for most people means thinking whole-family and whole-community. Family carers are not just another group of people with support, they have expertise, are often care coordinators and they provide untold hours of support. They need training, breaks, information and access to emergency back-up: the same things that paid professionals need to care safely and well, without damaging their own health.
  • Continuing to shift power to people, not just as individuals (eg Personal Health Budgets which shift control of money from services to individuals) but also as groups (eg people with Personal Health Budgets given the opportunity to link up, pool resources and feed into planning processes).

We are excited that Shared Lives, thanks to a £1.75m grant from NHS England, is going to be one way of showing people that these cultural shifts can be practical, affordable initiatives that will help people live well, enable others to contribute their skills in a very human way, achieve better health outcomes and save money. £1m of funding and additional expert support is being made available to Clinical Commissioning Groups (CCGs) to enable:

Because Shared Lives carers are trained and paid, but not by the hour, doing much for which they expect no payment and involving their family and friends informally, Shared Lives is able to combine the best features of paid and unpaid support: the formal and informal, professional and personal. This way of working can’t be forced, but it can be facilitated: the matching process ensures that everyone involved makes a positive choice to spend time with each other, rather than being assigned or placed. As a nurse who is now a Shared Lives carer put it: “I can still use my nursing skills but there aren’t the same power structures and bureaucracy in my kitchen as there are in the hospital.”

The shift in power and the cultural change cannot be separated. The experience of doing things so very differently changes the lives and thinking of everyone involved, commissioners, people using support, managers, Shared Lives carers and even their kids. But it’s achievable, scaleable, affordable and most of all, it’s happening right now, in an ordinary-looking family home not far from you. As strategic partners of the NHS England Integrated Personal Commissioning programme, we will be spreading this new way of doing and thinking nationally with lots of NHS organisations.

Many people fear big changes in the NHS. They think of iconic hospital buildings closing. The values of the NHS being erased for the profit motive of faceless private sector multi-nationals. This change is happening in small places, but those small places are everywhere.

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2 thoughts on “Big changes in small places

  1. Pat May 23, 2016 / 9:07 am

    A snippet of ‘doctor knows best’ that is rarely noted is that of patient ‘ownership’. That’s the one where the patient and family have no rights or input because the NHS ‘owns’ the patient. Sadly this attitude is still rife in the NHS, especially in relation to patients with any form of disability. This will need to change dramatically before any other change can work effectively. The inherent danger that will otherwise result is that shared lives would become the replacement for the current options the NHS uses to bully families and patients. Instead of ATU’s and MCA abuse, the NHS will abuse the shared lives options and whisk patients off to a shared lives setting, on discharge, when they already have their own home, life and family that is actually the best option for them. Woe betide the patient/family that disagrees with a doctor!

    • Alex Fox May 24, 2016 / 9:20 am

      Hi Pat – thanks for commenting. We don’t see Shared Lives as a panacea and I agree that no single solution should be imposed on everyone. We are a very, very long way away from that being a danger for Shared Lives though! The areas making the most use of Shared Lives are only using it for less than 1.5% of social care provision, and much less than that at present for NHS provision. I also agree that the culture of ‘my patient’ needs to change, which I think requires an attitude change for us all, towards sharing responsibility for our health with professionals.
      The Shared Lives matching process guards against the scenario you are concerned about: both the (self-employed) Shared Lives carer and the individual/their family have to agree that there is a good match before any long term support arrangement is entered in to. Also, where a person’s family are willing and able to care for that person themselves, there would be no financial incentive for doctors to try to impose Shared Lives, even if they could. Our challenge as the model grows is to defend the matching process and other crucial elements of Shared Lives which keep it working well, with people who use it in the driving seat.

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