Policy, preventative healthcare

Opinion

Towards a ‘national wellness service’

How can we tell if the NHS is succeeding or not? It sounds like an obvious question with a set of obvious answers but, actually, it isn’t — at least it isn’t if you are charged with running it. As recently as 2001, the health secretary (then Alan Milburn) was boasting that he knew that the NHS was becoming more effective because the number of prescriptions administered was going up.

What this actually meant was that there was more activity and that it was getting more expensive. Milburn was neither the first nor the last senior manager to mistake more spending for more success — but it is an error that the NHS is particularly prone to.

In any case, the answer to the question depends upon what the NHS is for. Is it about the successful management and resolution of people’s ill health, in which case, greater throughput might mean success? Or is it about increasing the health of the nation — in which case, a few empty PFI hospitals might mean the service was going in the right direction?

Questions such as these underlie an NHS dilemma which began as a question of almost theological obscurity, but is fast becoming urgent: how on earth can NHS managers control the rate of demand?

Traditionally, of course, it isn’t their business. They are supposed to stick to what they know best. But of course their ability to control demand does affect the bottom line of foundation trusts, clinics and GP surgeries — and as they are given more independence, so they find themselves thinking about demand and the sheer cost of ill health.

How does King’s College Hospital, for example, reach out into the surrounding community and tackle the underlying causes of diabetes or depression (which are both increasing in prevalence each year)? They and others are beginning to wonder — now that their funding regimes increasingly encourage them to reduce costs per patient. They are also increasingly aware of how few levers they have, and how few techniques of proven success there are.

Of course, the Department of Health has gone through the motions of exploring the issue of preventative health in recent years. But so far it has been little more than that, because most of their levers — apart from those which actually concern early diagnosis — are in the remits of other government departments.

We are therefore heading towards a period when the key health issue — not immediately but in a decade’s time — is how to turn the National Sickness Service into a National Wellness Service. What kind of accounting tools are needed? What kind of technology? What kinds of co-ordinated resources and what kind of new professionals will be required? What new kinds of budgeting?

Technology is going to be important for navigating people through the multiplicity of different options and interventions — social, technological and medical — that will be available. It is going to be vital as well for helping people take more responsibility for their own conditions. But it isn’t the only question.

New project

These and other issues are at the heart of a new long-term project, Towards a National Wellness Service, which is being developed by two think tanks with unrivalled experience of community organisation, innovation and well-being: the new economics foundation (nef) and the Young Foundation.

The objective of the project is partly to hold the reins in a new national debate which is already taking place both inside and outside the NHS. And it is partly a matter of inquiring into the success of current systems for the challenges ahead — and partly about actually putting the new NHS into practice. That means being clear about what is possible and how.

Without this clarity, the NHS will remain at the mercy of factors like pollution, stress, diet and patient isolation. Its delivery systems are not well-designed to tackle the growing problem of chronic disease (80% of GP consultations and 80% of the NHS budget now go on this), for which mutual support, social networks, IT solutions and complementary therapies are frequently more critical.

Many of the elements of the Wellness Service are already in place, inside and outside the NHS and voluntary sector. There are health organisations that are already providing signposts, volunteers, mutual support networks and software that supports self-organisation. Many individuals inside and outside the NHS are already aware of the questions and are working, usually unaware of each other, towards solutions. 

A huge number contacted us after the publication of last year’s draft report Life Begins at Sixty: the NHS after 2008 and asked if they could get involved. The success or failure of the project is going to depend largely upon our ability to build networks of people in and around the NHS to hammer out solutions to the most intractable problems including:

• are there better healthcare delivery structures that can help patients get to grips with chronic health problems?
• how can commissioning systems incorporate the broader social objectives that underpin a Wellness Service?
• is it possible to develop a system of accountability that provides equal, sustainable and effective relationships between healthcare systems, patients and the voluntary sector?
• how can we maintain the old system while the new one emerges, without causing a financial or administrative crisis in the former?
• how can people build relationships with professionals in the face of the cultural shift towards specialisation?

In the end, the bottom line is that the purpose of health is wellness, and health services are means towards that, and not ends in themselves.

The priority for healthcare in the 19th century was public health. The priority in the twentieth century was universal access to medical care for infectious and acute diseases. The priority in the 21st century is increasingly the management of chronic diseases, in an emerging partnership between individuals, social networks and medical services. This implies some radical changes to how health is organised.

It seems likely that there will be less of a role for big hospitals, and that the emerging National Wellness Service will involve more power for users, not just as individual consumers, but in groups — and more emphasis on providing information and advice to enable self-management.

The key drivers for this include public expectations and values, but also new knowledge about the social determinants of health and very powerful evidence on life expectancy and link to status, stress and social support.

This government has emphasised moving towards a consumerist model of health. But it is increasingly clear that this will not be the final destination, and that a new kind of NHS — in the tradition of public service and putting the assets of staff and patients alike to use — will emerge. This service will not only focus on wellbeing, but it will employ a partnership model of health rather than a production/consumption one and will seek out new assets and resources that can pay for wellness.

Many of the elements of the project are now in place and we are now looking for long term partners in the corporate, public and voluntary sectors, to help us take the project forward. If you are interested in helping fund an aspect of this work, please get in touch.

For more information on nef see: www.neweconomics.org