“Any intelligent fool can make things bigger and more complex… It takes a touch of genius – and a lot of courage to move in the opposite direction.” E. F. Schumacher
Integrated care boards (ICBs) are increasing in size via clustering and merging. Group models and mergers are all the rage for NHS Trusts. As the 10-year health plan for the NHS unfolds, where will neighbourhoods be positioned on the scale chart? Will the current 30-50,000 withstand the present flux? Is there a risk we are losing sight of what really matters?
Why does the NHS think that bigger is better? The increasing wish for scale in the health service has several drivers, which include arguments for efficiencies (reduced running costs and resilience), with the aim of being more effective. It is the latter point that is harder to achieve and yet for the public is the most important. Outcomes are what matters, yet most of the air time is given to organisational streamlining. The propensity to focus on efficiencies, whether back office or in direct care arises out of the transactional perspective of seeing care (or more often cure) as the result of well-defined pathways. Elective care no doubt fits this mould better than others, with waiting lists, theatre utilisation and workforce scheduling amenable to linear improvement methodologies. Don’t get me wrong, there is certainly room for this type of approach.
There are also important subtexts to the ‘big is beautiful’ mantra. Having fewer organisations means fewer organisations to manage from the top down. This applies at all levels. The Department of Health and Social Care (DHSC) and NHS England will have fewer ICBs to manage and ICBS will have fewer Trusts to strategically commission. How many primary care neighbourhoods will ICBs and Trusts wish to deal with?
Leadership is another area where concerns are raised. The oft repeated line goes that larger organisations attract better leaders, and that there aren’t enough good leaders, so we need fewer organisations.
Add all these together and the answer is clear isn’t it – we need larger organisations operating at bigger scale.
How might we consider this differently? Perhaps we might view it though two alternative lenses?
The first is from a person perspective and the second from a wider public sector position. The three shifts of ‘hospital to community’, ‘treatment to prevention’ and ‘analogue to digital’ provide a welcome platform for what actually matters to people. ‘I only want to tell my story once’, is a common message from the public. Ensuring shared digital records are a reality will facilitate this. As most interaction with care services happens outside hospital walls and in local communities, a focus on community care requires a joined-up approach from local services, rather than how joined-up the individual services are to their HQ. True leadership here is letting go, not clinging on.
Moving from treatment to prevention is equally a local endeavour. This is true about primary prevention, with education, housing, employment and leisure through secondary prevention and to caring for those at the end of life by preventing unnecessary and unwanted treatment.
Secondly, a wider public sector view helps to reframe where the focus should be. ‘Scale’ is much greater at a local level when we move away from a just an NHS view of Neighbourhood. By considering the totality of local authority services and voluntary sector provision at a local level, both the volume of activity and the number of assets is huge. The principle of neighbourhood needs to be depth (all sectors) and not spread (solely big NHS geographies).
Returning to efficiency and effectiveness. The order of these needs to be reversed: the purpose of care is to be effective. The three shifts, if done well will result in better outcomes. Neighbourhood health is much more about relational care than transactional cure, with its complexity and person-centred outcomes. Applying industrial management theory to inherently non-linear care will not have the resulting efficiencies that are desired. Primary care organisations working in partnership with community, mental health and the voluntary sector can provide better care through operational integration opportunities. Efficiencies and increased capacity will arise from intra-team working focused on care needs rather than inter-team working focused on the needs of an organisation.
Leadership in Neighbourhoods should be local and generalist, not distant and specialist. By combining the NHS, LA and Voluntary sector leadership we would have enough capacity. This could be enhanced by harnessing the under recognised and underutilised primary care leadership.
Care is complex and more so in primary than secondary care. Let’s hold that complexity close to where people live, in local neighbourhoods. Whose size should it be? Ultimately, whose size makes the most sense –the scale of community and individual need, rather than organisational scale
