Prof Andy Brooks
NAPC Clinical Chair
Oliver Heaviside (1850-1925) was a mathematician and electrical engineer. He invented some clever bits of calculus and apparently patented the coaxial cable. He leaned towards the practical side of science, wanting to do things and learn on the go, rather than spend his time finding absolute certainty before acting. He criticised those who spoke of the need to ‘formulate rigorous demonstrations’ and said:
Am I to refuse to eat because I do not fully understand the mechanism of digestion?
I love this quote and first came across it as a student, probably when I should have been learning about digestion! However, it is a good job that I didn’t wait until after my first lecture on gastric function before I ever ate.
What do you feel about neighbourhood? Is there a need to ‘formulate rigorous demonstrations’ or get on with it acknowledging it is the right thing to do? Are integration, left shift, neighbourhood, population health more NHS buzzwords from another reorganisation that will not really make a difference or is it something we need to dine on?
Neighbourhood means organising health, care and community support around the lives of local people, rather than around organisational boundaries. Focusing on preventing ill-health as much as treating it. Recognising that the determinants of ill-health are multiple and lie beyond the scope of medical intervention. Teams solving problems together, coordinating around people, with earlier and proactive support. Focusing on lives and outcomes. People and staff having agency. Neighbourhood is much more than a new service and in fact considering it this way is part of the problem.
We know the current 20th Century model of how care is organised isn’t delivering the outcomes we would like. We aren’t providing what the population needs and deserves. If we are honest, it also wasn’t subject to any rigorous testing process before being put into place.
There are examples of when we see how neighbourhoods are already functioning. In fact the term ‘neighbourhood’ has grown out of what already works. Yes, it is patchy, variable and intermittent, but it is happening.
- When a community health and wellbeing worker, who is part of a local community, takes time to know a family well and this results in increased childhood immunisation rates, cancer screening and reduces urgent appointments at general practice – that is neighbourhood.
- When refuse collectors attach public health messages to bins, targeting certain streets by combining public health, local authority and health data – that is neighbourhood.
- When those who frequently call 999 for chronic pain receive psychological support instead of more analgesia and hospital appointments, and so are better able to manage their needs at home – that is neighbourhood.
There are plenty of other examples, but they are snacks and we need to turn them into the main meal.
We know not every neighbourhood project succeeds. Real success depends on relationships, trust and continuity with structures alone achieving little (although change to the latter is required). It is not magic. It is disciplined coordination, partnership and integration around real human need. Neighbourhood can be mistaken for structural change first, it is really mindset and operational change. It is not about reporting lines, governance diagrams and committee structures, it is about the relationship structure. It is about how teams work together, how decisions are made, how risk is shared and how communities participate. And for those after some rigour these can be measured.
Mathematics is an experimental science, and definitions do not come first, but later on. They make themselves, when the nature of the subject has developed itself
– Oliver Heaviside
The case for change is well stated, however we must not get stuck in using the wrong methods to solve it and expecting evidence of success from something that hasn’t fully happened. The health and care system cannot solve 21st century complexity using isolated organisations designed for 20th century illness. However, there is a need to increase the credibility of neighbourhood, recognising it takes time to build trust, avoid superficial branding, overstating benefits and hoping that neighbourhood is the panacea for all.
You do not have to believe every reform slogan to recognise a simple truth: people experience life locally. Their care should work that way too. At NAPC we support neighbourhoods to do just that, implementing and innovating, bringing population health to life.
If neighbourhood succeeds, it will not be because of a national policy document. The test of neighbourhood is not whether organisations feel integrated. It will be because local teams, communities and services are organised around the realities of people’s lives rather than the convenience of institutions. Hungry for this? Let’s eat.
PS
For those who like ‘rigorous demonstrations’, the examples above translate into activated staff, integrating care and activated citizens. These can realise £3,500 productivity savings per staff member, £514 saving per ‘rising risk’ patient and £154 saving per activated citizen per year. Apply this to the relevant sections of a population and the cashable savings even with conservative estimates are significant.
Interested? Contact NAPC for an indicative summary for your population and more importantly how to activate staff and patients and integrate care.
