Neighbourhoods: are they really the future of the National Health Service?

“Labour’s reform agenda will turn the NHS on its head.

– From hospital to community.

– Analogue to digital.

– Sickness to prevention.

A neighbourhood health service as much as a National Health Service, pioneering cutting edge treatment and technology, preventing ill-health, not just treating it.

And what gives me hope are the people working with and for the NHS today, who are leading the way to that better future.

There is nothing wrong with the NHS that can’t be cured by what’s right with the NHS.”

Wes Streeting’s speech at the Labour Conference, 11^th October 2023

Following the departure of one government after fourteen years, and a landslide majority for a new one, many commentators have taken the opportunity to share what they think should happen next.

The future of health and care, critical alike to communities and to any new government’s success, is a good example; in a world where trust and confidence in politics and politicians is at rock-bottom, it is perhaps also not surprising that what recently empowered politicians said they are going to do, particularly in opposition, is taken with a pinch of salt.

Nonetheless, when someone who was Shadow Secretary of State for Health & Social Care, and is now the Secretary of State for Health & Social Care, says publicly before, during, and after an election that they are “determined to make the NHS more of a neighbourhood health service” – and that commitment is written into their party’s winning manifesto – this feels like something we need to take seriously.

In recent weeks we have heard quiet but real challenges to the idea of the NHS becoming a neighbourhood health service.

These are expressed not as opposition to the principle, but as concern:  that so much which relates to population health and wellbeing at a neighbourhood level sits outside the NHS’ direct control and that, as such, the ambitions may not be realistic; the focus misplaced; the money and resources simply not there; or the concept vulnerable to being reframed, rephased, reprioritised, and left in the “too hard” box.

Given that it is less than two months since the election, this is an interesting place to be.

There is recent precedent for a Secretary of State who shadowed the role doing what they said they were going to do in office.   Within two years, between 2010 and 2012, Andrew Lansley introduced a series of reforms based around a central idea that “commissioning should be led by clinicians and should be the central focus of NHS activity in delivering better outcomes within budget” which reshaped the NHS in ways which are still being felt today.

Wes Streeting has been clear that his focus in on improving collaboration over introducing further structural change in the NHS in the NHS [HSJ, paywalled].

However, fear of change, and particularly fear of the unintended consequences of change, feels very present.  For all those in the service who long been habituated to constant restructures, the idea this change might involve not structures but the very character of the institution is even more concerning.

Alongside this, there is another fear – that of nothing changing.  What if, in a period of growing pressures on individuals and services, we invest time and energy, leadership capital, even enthusiasm, in an idea – and it simply doesn’t happen?

And even whilst these debates play out nationally and locally, as patients we may not appreciate the hoops we jump through to access care and support; the long waits when we do finally get on a list; repeated, unnecessary journeys to hospital; the routine failures to co-ordinate around, or even recognise, our individual needs – but it’s only human for us to think “what if what comes next is even worse?’”.

At the time the NHS was created, the population was smaller, needs were seemingly less complex, ambitions were huge but arguably smaller than our ambitions today.

We may not like the language of the NHS being “broken”, but there are few people working within the health service or its partners who think we can carry as we are; or that we can fix this simply at a national level.  Patients and carers do not have the luxury of thinking about national structures and targets.  We may appreciate the ideas of fairness and equity implicit in the concept of a national service, but we live in communities and neighbourhoods, and our experience of health and care is largely shaped by our local GP practices, our local pharmacies, our community-based physical and mental health services, local authority-run social care, and our local hospitals, amongst a range of other diverse local institutions and local assets.

In this context, neighbourhood and national are more than just words, and the reason the Secretary of State is talking about a transformation is not incidental.

One of the big challenges we have is that we persist in thinking of this in terms of the national, the institutional, the ‘big’ – even whilst it is the local, the relationships, the ‘small’ that determine our individual and collective successes and failures.  We are at the beginning of a five year government term, and the clock is already ticking.  There will be a new plan for the NHS, but services are under pressure, and the next winter is coming.  Even more significantly, within our Integrated Care Systems, Place Based Partnerships, and partners in Local Government and the Voluntary & Community Sector, there is already a huge amount upon which to build, if leaders are ready to empower people to change, and if we believe that change is possible.

Few people would disagree with the idea that hospital is not the best place to be, if better care can be delivered closer to or in our own homes; or, even more fundamentally, that prevention is better than cure.  The period we are in cannot simply be about second-guessing political direction, any more than it can be about waiting to be told next steps.  If we cannot use existing shared knowledge, experience, partnerships and resources to tailor provision, based on the identified needs and assets of local communities (and, crucially, a more connected relationship with individuals, carers and families who live within them) then no amount of investment in larger institutions will ever address growing inequalities and unmet demand.

The drivers, centrally and locally, of this change are not going away.  For those working within the health service and its partners, now is the opportunity to engage with this change and to help shape, in delivery, the concept into a success.  It will not be the answer to everything – but the process of transformation into a neighbourhood health service needs now to be moved forward, together and at pace.