The NHS was designed in the 1940s for brief encounters: healing us or fixing us up. We often experience it doing that astonishingly well. But now 15 million of us live with long-term conditions; three million with multiple long-term conditions, which cannot be healed or fixed. People want just enough easily-reached support to live well, and to become a patient as infrequently as possible, but instead many develop long term, increasing reliance on intensive support services which not only feels miserable, it is bankrupting our service economies. We have developed the treatments and services which people need, but we have not yet developed ways of offering them which get the best out of anyone involved.
Public service leaders behave as if their main challenge is to build the right kinds of systems and organisations. It’s not: the challenge for them and in fact, for all of us who use or will use our health and support services, is to build the right relationships between people who need support and people who offer it.
I’ve often heard people who work in the mental health system talking about the need to keep someone out of the mental health system. Those professionals, who are themselves skilled and caring, and generally believe their immediate colleagues are too, see the system that they are all part of as toxic and dehumanising. How do groups of skilled and caring people become dangerous bureaucracies?
Many people now use personal budgets to opt out of those bureaucracies and set their own rules to frame the support relationships in their lives. But that does not work for everyone. Shared Lives demonstrates you can develop a national, regulated framework in which thousands of people can develop very individual, and therefore very human relationships. That can happen consistently, safely and at lower cost. Radically devolved models like Buurtzorg and Community Catalysts’ networks of micro-enterprises do the same.
We can I believe scale down our big public service bureaucracies to behave in more human ways. That doesn’t mean reaching fewer people, it would in fact mean more money going to the front line and less to big management structures, or obscure corporate entities. The ownership model we need for public services which build fully human support relationships is the locally-owned co-operative, not the multi-national. Achieving this would not only enable many more people to live well with the long term and lifelong conditions which are the NHS’ most intractable challenge, it would free people who joined the ‘caring’ professions but find themselves in uncaring organisations.