Transforming health and social care: can the chrysalis become a butterfly?

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In a new report, Transforming the delivery of health and social care, we argue that current models of care rely too much on acute hospitals and care homes, and pay too little attention to community services that support people in their own homes. Although primary care in the United Kingdom is much more firmly established than in many other countries, there are wide variations in the quality of general practice and most practices work on too small a scale to enable more care to be provided in the community instead of hospitals.

Prevention and public health have not received the same attention as treatment, and progress in fully engaging communities in adopting healthier lifestyles and behaviours has been slow, as we saw in Our Future Health Secured? report. While specific services often provide good care, fragmentation between GPs and specialists, physical and mental health care providers, and health and social care hinders the delivery of the high-quality co-ordinated care that patients and service users increasingly require and expect.

All of these factors lead us to argue that current models of care need to change fundamentally if they are to be fit for the future. The financial pressures facing public services for the foreseeable future reinforce the case for change and make it imperative that ideas that have been in good currency for some time are now taken seriously. This case is strengthened by the increasing demands of an ageing population in which long-term conditions, and especially multi-morbidity, will become much more common.

But what are the chances of this happening? Evidence shows that models of care have evolved since the modern welfare state was established and significant progress has been made in improving care in the past decade through a combination of investment and reform. But will it be possible to sustain and ideally accelerate this progress in the much more challenging climate that lies ahead?

In our report we argue that health and social care services need to learn from evolutionary processes in biology if innovation at the scale and pace needed is to occur. One of the key lessons relates to the way in which programmed cell death enables new life forms to emerge, as in the transition from the chrysalis to the butterfly (see Coiera's paper in the British Medical Journal). By extension, outmoded models of health and social care need to be decommissioned to create space for new and more appropriate ones to establish.

The example of mental health services illustrates how decommissioning has been able to bring about a transformation in care away from the former asylums. In this case, a vision of care being delivered in the community played a key role in supporting the changes that occurred. Funding arrangements enabled new services to be established as hospitals were closed, with politicians, clinicians and managers working together to lead these changes.

As well as paying more attention to decommissioning, there is a strong case for making it easier for new providers to enter the market and for there to be greater support for existing providers to develop and spread innovative service models. This means that politicians must change their attitude to risk-taking and encourage active experimentation and testing of new approaches. As Tim Harford has shown using examples from many different sectors in his book Adapt, success depends on supporting innovations, identifying those that are worthwhile, and being willing to tolerate failure as part of the process of change.

Another important ingredient is to harness the creativity and skills of staff working in health and social care. High-performing health care organisations like Intermountain Healthcare in the United States do this through investing heavily in training and development and supporting innovation to occur ‘from within’. Organisations like Intermountain create time and space for staff to review how they deliver care and provide opportunities for them to learn about models in other organisations known for their superior performance.

The other point to emphasise is that the changes needed in health and social care do not depend simply on searching for the next big idea. In our view, too much attention is paid to invention and not enough to replication. If better ways of providing services have been developed and shown to be cost-effective then they should be implemented in all organisations through the systematic adoption of best practices.

The fact that on some indicators the NHS appears to do better than other systems does not undermine our argument for fundamental change. Health and social care services in all countries need to adapt to rapidly changing population needs, regardless of how well they perform, and the United Kingdom is no exception. Unless new models of care appropriate to the needs of an ageing population and the increased prevalence of long-term conditions are developed, it will be increasingly difficult to sustain the core strengths of a system that provides the whole population with access to comprehensive services at an affordable cost.

Although the new Secretary of State for Health will inevitably be distracted by short term issues in the run up to the General Election, the real challenges are long term. We hope he will show real political leadership by supporting the case for a radical transformation in the delivery of care. Our new paper should be essential reading for him in setting out the agenda he needs to focus on – services and not structures.



Independent Pharmaceutical Consultant,
Comment date
20 February 2013
Hi Chris, I definitely would agree that health inequalities and public health influence in primary care has been put to death. The tunnel vision of stressed out finance directors and managers has reverted to old behaviour short term quick wins without an ecology check on whether this is going to make a difference or whether this is sustainable. Whilst primary care understand the need for self care and prevention, it is like like a mirage not tangible or within reach and so often evaporates. There requires a paradigm shift, to let go of the past , the professional bio power and enable an honest discussion and risk taking to co create health with communities. I am involved as a Trustee for a homeless charity, in addition to working in primary care and what I see there is an amazing mobilisation of people and resources , creativity and sharing collaboration ....making a difference. My view that we need to learn from other disciplines fields to make more sense of what and how we design health. The principles of ecological processes and systems thinking human dimension relational aspects are not embedded. The systems we operate in does not allow transformation .. Transactional rules. The competitiveness and lack if integration and collaboration between different interfaces is a real problem. The culture to support transformation needs to be there, which is values connection, trust creativity and partnership, asset based approach. I have come to the conclusion that the NHS commissioning is a rabbit staring at headlights ... Hope I am wrong !

Helen Tucker

Vice President & Researcher,
Community Hospitals Association
Comment date
15 September 2012
Excellent report Chris. Already being used and referenced. So important to stress the need for increasing community capacity. Is there any way that there can be some clarification about community hospitals? You do not mention them in the report, although we have 320 in England, and they are playing a significant role in intermediate care, local diagnostics etc. and helping to keep people out of acute hospitals and allowing them to return locally quickly. The quote you choose to use by Enoch Powell on dismantling hospitals is already being used negatively in relation to support plans to close small local community hospitals that actually have quite a different role and function. Some of the best ,models for community capacity have a blend of home care, care homes, community hospitals and community teams. We will need them all!

andrew field

Comment date
07 September 2012
Primary care physician numbers have been basically stable for decades while we have seen massive growth in all sectors of secondary care provision. The changes outlined in the report will never happen without a massive re-think around the primary - secondary care boundary and how inflexible we are with regards to our working patterns in relation to this boundary. The same is true for nursing and allied healthcare professions.
Part of the problem lies in medical and other training programs where undergraduates are still inculcated with inappropriately biased ideas about the distinctions between primary and secondary care, mainly by secondary care providers.

Ed Macalister-Smith

Wiltshire and Bath PCT Cluster
Comment date
06 September 2012
Thanks Chris, a good report and commentary.

The point about disinvestment being necessary in order to allow new forms of care to develop is vital, but is often resisted or not planned for in the NHS. The logic is that new forms of care need to be locally proven before change can be allowed to complete.

The lesson of history in many parts of the NHS is that such new initiatives become seen as mere pilot projects, they frequently fail to become the preferred way of doing things, and they end as adjuncts of alternative capacity which are unable to fully prove their way. But new service development without clear and driven disinvestment plans are unlikely to add value.

This approach without disinvestment plans is unaffordable. It also fails to recognise the realpolitik that new services need space in which to thrive. And if the research evidence base exists, why do we need more pilots rather than wide-scale implementation?

I think one of the difficulties for managers (clinical or otherwise) is to have confidence in the research evidence for alternative ways of managing care, so as to be able to make sufficiently bold changes of service direction. That is a challenge to the health research community, and one with which the Health Services & Delivery Research panels need to address.

It is also a challenge to NICE, to provide clear steers to the health community when the evidence warrants it, not just about the best ways but also about ineffective ways to provide care.

Nick Pahl

British Acupuncture Council
Comment date
06 September 2012
I would like to see a more inclusive attitude to who provides health care to the UK population e.g. the British Acupuncture Council's 3100 members sport the health and wellbeing of people across the UK, with over 2.3 million treatments a year. As you may be aware, there is a strong evidence base for acupuncture, which will be further demonstrated by significant new evidence published next week regarding acupuncture treatments for chronic pain. There is also evidence that acupuncture improves outcomes for long term conditions and assists with changes in attitudes to self care.

BAcC members share the Department of Health’s commitment to ensure that patients can exercise choice and receive world-class treatment. At this time of austerity and change, our members stand ready and willing to engage with the NHS through personal health budgets, the any qualified provider process, and directly with local hospitals and GPs. We firmly believe that acupuncture has the potential to offer cost-effective and personalised healthcare that demonstrably improves health and wellbeing outcomes for patients. Indeed there are many examples from around the country where our members have successfully worked both inside and alongside the NHS to meet patient needs.

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