Houses of care need solid foundations

There is a new rallying cry in health: let’s build the houses of care. A holistic approach to supporting people with long term conditions and disabilities, the “house” is both metaphor and methodology. 

It draws on both the Ed Wagner chronic care model and learning from the diabetes year of care programme. Its twin “pillars” are informed, engaged patients and health professionals, both of which work collaboratively. 

‘We have many plans and have had the mini-industry of reviews and regulatory changes sparked by Mid Staffordshire. Shouldn’t these all be aligned?’

Personalised care planning and support for self management lie at its heart, and it is shored up by commissioning and processes that are designed to promote the productive engagement of people with the health and care systems.    

This is what many patients, progressive clinicians and health charities have urged for years. Policy makers have willed the ends, if not the means. NHS England’s long term conditions lead Martin McShane is keen and publications such as a recent King’s Fund report add credibility. An alliance of organisations, including National Voices, is actively pushing for it. 

Are we approaching a tipping point? Perhaps. But three things will take us closer. 

First, it is time for consistency of purpose. A recent BMJ piece observed that: “consistent achievement of high quality care was challenged by unclear goals, overlapping priorities that distracted attention, and compliance-oriented bureaucratised management. The institutional and regulatory environment was populated by multiple external bodies serving different but overlapping functions.” 

Where’s the big plan?

That seems a perfect description of the post-Lansley NHS in England. We now have two departments of health (one called NHS England) pouring out plans, initiatives and challenges. 

We have the vulnerable older people plan, the national collaboration on integrated care, the various NHS England “calls to action”; the refresh of the mandate to NHS England and so forth. We have had the mini-industry of reviews and regulatory changes sparked by Mid Staffordshire. Shouldn’t these all be aligned? Call me old-fashioned, but where’s the big plan? Vision and leadership are required.

‘The house of care is a prefab home: the parts have been manufactured but skilled craftspeople need to assemble them’

Indeed, this is just another way of seeing the house of care. It means commissioners working in concert with their local communities. It means pooling the resources in general practice, community services, pharmacy, social care, public health, voluntary organisations and local communities themselves. 

It means seeing the value of social interventions like peer support, befriending, walking groups and so on, and marshalling their potential alongside doctors, nurses and medicines. Most of the ingredients of this mix exist in most places. It is as if the house of care is a prefab home: the parts have been manufactured but skilled craftspeople need to assemble them.

Where is the sense of urgency to make this happen? Many promising local initiatives are underpowered and need support and leadership to get real traction. Meanwhile, resources are flowing out of primary, community and social care services and into the acute sector – just the opposite of what is required.

Third – and fundamentally – patients demand to be seen differently. Despite all the pious words about “putting patients first” the health establishment lacks a coherent view of how to make this real and is ambivalent about the people it serves. Policy makers are in thrall to the notion of patients as consumers, mandating the offer of choices that matter more to health economists than patients themselves. 

More recently, in the wake of events in Stafford and at Winterbourne View, the patient as victim or potential victim has loomed large, prompting a huge “protect and inspect” response. Meanwhile, patients are also blamed, explicitly or implicitly – for exerting an ever-increasing “burden” of demand on the NHS, for bringing sickness on themselves, for using services inappropriately and so on. 

And whereas the unit of analysis is always the “patient”, we patients are also people with lives, relatives, carers, friends and neighbours, living in vastly differing communities. These are less seen. 

A sustainable future for health and social care demands embracing people as citizens with rights and responsibilities, as partners in decisions, as managers of their own care and as leaders. It demands working with communities in a spirit of coproduction. 

There is no shortage of help to draw on – for example, National Voices’ work on defining integrated care from the patient perspective, on care and support planning, and NHS England’s new guidance on participation. What is now required is the will – then we can really build the houses of care.

Jeremy Taylor is chief executive of National Voices.