Dr Johnny Marshall
NAPC Senior Leadership Team
There seems to be widespread consensus within the NHS, and beyond, that simply continuing to spend more on acute reactive care will not deliver more sustainable long-term NHS healthcare provision and that a “left shift” or “shift left” is a desirable NHS tactic to help meet demands for access to healthcare. This “left shift” is often defined as a shift of activity out of hospitals into the community and described as “bringing care closer to home”.
There is also widespread consensus that despite this powerful sense of common purpose, and some great local initiatives, insufficient progress has been made on realising this objective as business as usual.
Wes Streeting’s call for a transformational shift from “hospital to community” has re-ignited ambition around this topic ahead of publication of the upcoming NHS 10-year plan and very familiar solutions are once again being put forward.
Many of these solutions reflect historic attempts to “bring care closer to home” that have been focused on translocating disease focused services from the acute sector into the community or somewhat nostalgic calls to go back to “good old general practice”.
However, this perspective overlooks the very fact that the reactive biomedical approach, which may have served the NHS well in the past, is now inadequate in meeting the challenges facing health & care in the 21st century. Especially as healthcare only accounts for about 10-15% of a population’s sense of health & wellbeing.
On this basis, delivering a successful transformational shift from “hospital to community” needs to reach beyond both translocation and nostalgia. It requires a purposeful shift away from an emphasis on reactive biomedical services to building more proactive, holistic, personalised support and care offers around what matters to people and their sense of health & well-being. This should be done in partnership with residents and communities to create health, prevent ill-health, reverse or ameliorate the impact of disease/disability and avoid an inappropriate escalation of place of care.
All of this delivered by empowered people/residents/citizens better able to support their own sense of health & well-being and working in partnership with flourishing teams drawn from primary care, community services, mental health services, social care, voluntary sector and the wider health & care sector. All united around a common purpose of improved population health by addressing what matters to individual residents.
NAPC has been increasingly curious about whether the success of such a mission requires a fresh look at what the tactical approach of a “left shift” could, and perhaps should, really be.
The prevailing view on this tactical “left shift” within the NHS is perhaps unsurprisingly viewed through the lens of service provision, after all that is what the NHS does. This perception may be serving to sustain a predominantly top-down case management approach to the “left shift”. Whilst this undoubtedly delivers significant benefits to individual people at particular moments of greatest need it doesn’t impact on the health of the vast majority of the population and therefore it is unable to deliver the benefit required to support more sustainable healthcare provision on its own. The result is perhaps more of a skew left, as shown in the upper graph below.
Without action across the breadth of population health need there is a danger that simply translocating work from “hospital to community” increases the intensity of demand in the community through growing numbers of people with the high-risk intensity. This can overwhelm even the most integrated levels of support and care.
What if we were to adopt a population health perspective instead?
This would define a “left shift” as improving the health of the entire population, as shown in the lower graph above. This requires a breadth of support and interventions that create health, prevent ill-health, reverse or ameliorate the impact of disease/disability and avoid inappropriate escalation of place of care. Such a shift has the potential to deliver significantly more benefit to population health, patient experience, value for money and the experience of the workforce.
In this “left shift” the transformation from “hospital to community” is inextricably linked with both the transformation from “treatment to prevention” and “analogue to digital”, as these underpin so much of the above.
This is not to mean that the NHS is to be responsible for every single factor that contributes to our health & well-being. But it is important that the whole NHS understands how it can best contribute across the spectrum of factors that impact on the health of the population. It challenges the NHS to be an effective partner with other agencies in delivering the intended change. It is equally as important that the secondary care/specialist elements of the NHS are as clear about this as the primary care/generalist elements to maximise the value that such an approach would bring.
This transformational “left shift” will inevitably have to be built through deliberate incremental improvements, that compound over time, and requires a multi-faceted approach encompassing:
- Shared common purpose across all health & care sectors – improved population health/reduced health inequality
- Workforce activation and clinical stewardship – leading in partnership with communities to deliver local solutions
- Aligned digital solutions, metrics, investment and resources – across all sectors
- Effective team working – with flourishing “real” teams accountable for the health of a defined population
- Agency/activation of people – feeling more able to advocate for their own health & wellbeing through support in overcoming their individual challenges
Within any healthcare system the metrics of success significantly shape the culture and delivery. How long people wait to access the care they need or to address the health concerns that they have really matters to them and therefore it matters to us. But it’s not all that matters to them and understanding their health in the broadest sense by better tapping into the 90% of factors outside of health care provision that influence their sense of health & wellbeing is more likely to increase their access to the support and care that they need.
This will require us to consider how we can develop metrics that support a more coordinated approach around what is important to people, such as healthy life years, the state of our individual metabolic health or our ability to support our own health & wellbeing.
All of this leads us at NAPC to surmise that adopting a population health focused “left shift” as a tactical approach within the NHS offers potentially significant gain.
Rather than being an exclusive part of the “hospital to community” transformation agenda, a population health focused “left shift” encompasses “treatment to prevention” and “analogue to digital” in equal measure. In effect, they are interdependent in delivering the potential benefits of such an approach and require equal attention.
Each sector within the NHS should be working to this population health focused “left shift” and the whole NHS workforce should understand their individual role in delivering it. Only then will a widespread consensus be converted to a truly sustainable NHS delivering improvements in the health of our communities, a better patient experience, better value from the collective resource available and a great experience for its workforce.
As NAPC continues to explore the merits of delivering a population health focused “left shift” we invite you to join us in sharing your thoughts and practical experiences on just such a change. Please share your thoughts as reactions and comments to this post.
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