Equality is both the NHS’s great achievement and its great remaining challenge. It was set up to end the inequality of the pre-war system, where some could afford to be ill and others could not. Today, healthcare professionals treat rich and poor alike, but poverty remains correlated to healthy life expectancy and BME groups and other minorities can experience multiple exclusions and even active discrimination. Even where there is equality of healthcare there is not equality of health.
Michael Marmot established the social determinants of health almost twenty years ago. Julian Hart’s inverse care law—that those groups most in need of health care are least likely to receive it—is fifty years old. Those maxims are accepted, yet numerous strategies and initiatives have not addressed the social determinants nor inverted the care pyramid. Inequalities are treated by national and local policy makers as an unfortunate but unavoidable fact of any ‘universal’ service. It is said that delivering healthcare to whole populations makes it hard in practice to reach smaller groups.
I don’t accept these arguments, or excuses. My book, A new health and care system: escaping the invisible asylum, argues that we have built the wrong relationships between services and people—individuals, families and communities— into the NHS and social care, and that we could choose to build our long term support system around more personal, longer-lasting and ultimately more effective support relationships.
Models which do this have existed for decades, but the technology-led explosion in our capacity for connectivity now means we can create frameworks within which huge numbers of people can shape and control their own relationships with services.
First, we must redefine the supportive relationship at the heart of our concept of long term support. This is where the greatest challenges lie, as the number of people living with one, or often several long term support needs, continually rises.
To do this, the NHS and councils must look to the best voluntary, community and social enterprise (VCSE) organisations. Those which invest time in engaging with people on their own terms, where they live thinking whole-person and whole-family, even in a crisis. We support people who are growing two such models, Shared Lives and Homeshare, which bring people together into supportive shared households with carefully selected housemates, chosen by the individuals not by an agency.
These are two of dozens of approaches taking an ‘asset-based’ approach: looking for what people can do, or could do with what Nesta calls ‘good help’, and which recognise that, for most of us, our close relationships are our most valuable assets and route to wellbeing.
With NHS England and seven Clinical Commissioning Groups (CCGs), we are scaling Shared Lives as a healthcare model. Shared Lives carers recruited and approved over several months are matched with an adult who has a learning disability, mental health problem, dementia or other health or care need. Once they find a good match, the individual moves in with their chosen Shared Lives carer and lives as part of a supportive household, or visits them regularly for short breaks or day support, instead of their family getting breaks via a care home stay or day centre.
14,000 people use Shared Lives as social care, but although the model has been used, for instance, to help people with stroke or brain injury recover in the community, it is not well known in healthcare. It provides a simple solution to people who have a range of ‘complex’ medical and non-medical needs.
We have found health leaders both keen to get involved, and in some areas, struggling to ensure their teams use the new provision they have invested in. Our project is relatively small, but has huge potential and requires local NHS leaders to rethink their definition of healthcare and how people who do not fit into neat boxes can move through their often rigid systems.
VCSE organisations bridge between large health systems and the very personal goals, preferences and needs we bring to the NHS when we need long term support. The NHS needs new voices in the room to redesign itself, including from communities which feel under-reached by big statutory bureaucracies. The Joint VCSE Review set out nine ways in which this could happen, with some VCSE organisations helping people to co-design the public services they use and others delivering more personalised, preventative and long-term care.
The NHS is drawing up its Ten Year Plan. It must be as much a Ten Year Plan for the VCSE sector’s role, as for the NHS’s, in delivering health and wellbeing.
This blog is part of a series, in the month of the 70th anniversary of the founding of the NHS, exploring the relationship between the health service and the voluntary sector. See the second part by Asthma UK Chief Executive Kay Boycott here.