Against this background, current government policy seeks to make ‘three strategic shifts’ – one of which is around moving care from hospitals to communities. While shifting care has long been a policy aspiration, previous attempts are widely perceived to have been insufficient to rebalance the health care system. Some argue that the balance may even have shifted the other way, inadvertently serving to prioritise hospital-based care at the expense of primary care and community-based support.
However, this is not for the want of trying – for more than 20 years, different governments have been trying to achieve a similar aim, with lots of scope to learn from previous policy and experience.
In response, researchers at the University of Birmingham were asked by UK Research and Innovation to review previous attempts to shift care. This included a policy roundtable for former policy makers and senior leaders, as well as a review of key policy documents and the academic literature over the last two decades.
This identified ten lessons that need to be heeded if current attempts to shift care are to be more effective than in the past:
- It is important to be clear on outcomes (so everyone agrees what success would look like and is clear about why what is proposed is the best way to achieve these aims). At different stages, different people have sought to improve efficiency in acute care; improve patient experience; deliver care in more convenient, homely settings; tackle health inequalities; free up money to re-invest in other priorities; and/or actively save money. These are all laudable aims, but they are very different - it feels unlikely that one set of policies could ever really achieve all these different aims simultaneously.
- Most previous policies have been based on small-scale, time-limited pilots and have not been at a sufficient scale to more fundamentally change the overall system.
- Previous pledges have tended to lack a detailed and realistic plan for implementation – with predictable results.
- Shifting care is a major undertaking and will only be possible if everything is lined up in support of this aim. This might include things like payment mechanisms, performance measures and incentives, capital funding, IT, education and training, leadership development, communications, and so on. For example, if we say we want to shift care to the community, but introduce a capital funding scheme that only focuses on hospitals, we undermine our overall aim before we have even started.
- We need to make sure we have the right leadership skills – these are often taken for granted, and we don’t always ‘do change’ well.
- The right people need to be involved, including people and communities, the voluntary and community sector, general practice, social care, public health and local government. Where these wider partners have been considered in the past, they have tended to be seen as a way of supporting hospitals, rather than in their own right and on their own terms.
- Our health service needs to do more to intervene early and target those groups who need the most support and might benefit the most.
- Most policies tend to focus on people with physical health problems and potentially overlook the needs of people living with dementia. While some approaches focus on people’s clinical condition, we also need to make sure that people are supported to ‘live well’ with dementia.
- There is a lot of scope to learn from others – across the four nations of the UK, from other sectors and from other countries. The health service is so big and complex that it can sometimes become quite inward-looking and struggles to learn from others.
- There is plenty of opportunity to harness new technology, but we have to see this as a cultural challenge (thinking through issues of implementation, involvement and engagement, training and development, ethics, etc) rather than just a technical issue.
None of these lessons are easy to implement (hence not having really happened previously) – but being clear on them is hopefully part of a possible solution. As Maya Angelou once said: “history… cannot be unlived, but if faced with courage, need not be lived again.”
