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.