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Plans to put ‘place’ at the centre of healthcare are long overdue
John Copps welcomes the emphasis on ‘place’ in NHS England’s plans for health system reform, and argues that the balance of power should now be tilted towards primary, community and social care.
Repeated lockdowns over the last year have meant that many of us have not ventured far from our front door. Just as COVID-19 has taught us about who are core workers, it has also shown us what are ‘core places’.
When it comes to healthcare, for most people this means having day-to-day needs met close to the place where they live. In my case, the dentist is at one end of my street and the GP and pharmacy at the other. For those with more complex needs, this will also include local social care provision, neighbourhood community health services and district nursing.
This definition of place – ‘where I live’ – has always been a lens through which patients see their care. It is what we all recognise and understand. In short, to anyone outside the NHS it is obvious.
Yet, strategically, the NHS has taken its eye off ‘place’ as an organising principle of care. Power and influence lies disproportionately in the remote bureaucracies of Whitehall, ‘regional teams’ and acute care, which has gradually hoovered up more and more resources. This was recognised in 2019’s Long Term Plan, which set an ambition to rebalance this bias.
Place at the centre of NHS reform
At the end of last year, NHS England and NHS Improvement outlined plans for the future NHS to focus on collaboration between health and care partners. Included in its published proposals was a clearly stated goal for joined-up working at ‘place’ level, underpinned by ‘place leadership’.
Place leadership means partnership working at a local level between GPs, local authorities, community and mental health services. At neighbourhood level, this partnership will be built around the recently-established Primary Care Networks (PCNs).
Critical to the proposals are the relationship between health and social care – and therefore local councils. NHS England goes as far as to state an ‘offer’ to local government: to work ‘much more closely’ and become a ‘more effective partner in the planning, design and delivery of care’. These words received a cautious welcome from the Local Government Association, who have consistently argued that councils must be ‘essential and equal partners’.
But not all services will neatly fit into the model of place-based care. For all the benefits of local services, people with complex needs that require more specialist expertise will need care that is planned over a larger area. Hospital, specialist mental health and ambulance services will have to be organised at a greater scale – through collaborations across a wider system or multiple places. At this scale, even with top quality care we should accept that it will always struggle to feel as connected to our communities.
The emphasis on place should be warmly welcomed, but not without qualification. The plans are yet another chapter in the history of constant tinkering with NHS structures and responsibilities, set against a backdrop where the pandemic has strained resources to breaking point. The commitment to partnership with local government must be genuine, followed through in good faith, and accompanied by a sustainable solution to social care funding.
There is also a danger of over-complication and riding roughshod over existing hard-won gains – as Prof Donna Hall and GM’s Warren Heppolette have warned, the reforms must avoid being ‘a set of shiny new partnerships, sometimes with new money attached, overlaying the same old responsibilities and loyalties’.
The logic of place is that how this future reorganisation plays out should be largely down to local decisions. Delegation of responsibility must be just that, and not be subject to a narrowly-defined framework controlled by the centre.
There is much to be optimistic about in NHS England’s plans. Putting place at the centre of healthcare is long overdue. We should welcome it hold our leaders to their promises – because if people matter, then so does place.
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