We are in the middle of a winter crisis (again). So why do I want to write about Prevention? Well, history repeats itself usually because nobody listens or learns the first several times around. And we still haven’t really learned as a system about doing prevention well. (Not for a minute am I criticizing some of the truly wonderful work going on.)
It does seem that in the last week, with the confirmation of ongoing cuts to the Public Health Budget in England and the lack of any really biting coherent prevention plans at national level for wherever the NHS is going now, that we are about to experience what a colleague, Ben Bray, wittily and succinctly referred to as “a radical downgrade in prevention.” I’d love to say this insightful colleague is wrong. But the indicators suggest to me that in this year’s NHS he may very well be proven right.
Prevention – rhetoric rather than reality?
“Prevention” as a concept has become current, some might say “flavour of the month” in the public sector.
I could take a jaundiced view that we seem to be sliding into a paradoxical rhetoric on prevention nationally which is quite dangerous – being hailed as one of the tactics to deliver financial sustainability in a public sector despite the fact the proportion of GPD and public sector budget spent on it is declining, and fast .
The really serious policy imperatives behind it are increasingly difficult to find, and the preventive power of really getting to grips with unwarranted variations in primary care remains – despite valiant work in many places – unrealized, with concomitant waste of money and avoidable morbidity.
One could also see there are more risks from policy assumptions being made around the current system change. We assume that preventing high cost patients costing so much will bring major savings for nascent Accountable Care Systems/Organizations. But a very recent analysis in Health Affairs suggests this is not the case, and a more thoroughgoing approach to need and morbidity is needed. We seem to be happy to take the rhetoric of Accountable Care Systems and Organisations without necessarily thinking through the reality. Part of me wants to start a programme called “Brilliant Basics” where we focus down on the things we know will work rather than embrace yet more system change because someone somewhere has decided the current arrangements aren’t delivering.
Despite all of that, I am committed to making Prevention happen wherever I can. Time will prove me right or wrong.
Building a shared narrative with paucity of science and policy
Prevention means different things to different agencies. I think we should actually welcome this rather than getting precious about the body of “science” around prevention. Because to be honest, in some places, the “science” is pretty poor. I think we need a paradigm shift in how we approach prevention scientifically – and the biomedical pyramid of evidence isn’t it. For another time there is a detailed discussion of the evidential paradigms for all this, but I don’t have space here, and this is likely to be contentious.
What I have learned in listening to people this last year is that for some prevention is about preventing avoidable morbidity with its concomitant costs to peoples’ quality of life. For others it’s about reducing and preventing waste from our increasingly throwaway society (the less sustainable we are as a society, the more it impacts the health of our biosphere and human health.) The point is we’re trying to build an ethos across services of prevention. Maybe we need a different word? And maybe we need to be more pluralist around prevention, as long as we can deliver a “good” to the public.
Some fundamental questions of evidence and efficacy
But there are some fundamental questions we still have to address:
- can we stop people needing services as much as possible in a way which gives value to citizens (not just financial value?)
- Can we ensure people remain healthy and independent as long as possible?
- Can we provide public services in a way which supports peoples’ independence as much as possible?
Prevention has been part of policy rhetoric since the Griffiths Review led to the 1990 NHS and Community Care Act (remember that, anyone?) It’s time to look at what we’ve achieved and where next. Public health people have a right to expect that government and other policy actors should take prevention seriously. And everyone else has a right to expect from us that we have some evidence, pathways and principles of how we set about doing it. For some things (eg hypertension, diabetes, HIV) we have the evidence and the pathways despite implementation being patchy. For others (reducing hospital admissions) we have a long way to go and for yet other issues (public mental health) we have a long way to go to achieve the aspiration of getting our population resilient and healthy.
Trying to make it work: our local experience
Prevention forms a core part of the narrative around our Sustainability and Transformation Plans and those of many others  and is now also a part of the shared Hertfordshire Public Sector action plan across 30 organisations. Great. Policy commitment. Now what? Now the hard work really starts.
Locally, we’re currently working out what each agency will do. We have some things working very well (I’m just going to pick out our Warmer Homes initiative and Social Prescribing, our Physical Activity work and embedding behaviour change into that, our bit of the National Diabetes Prevention Programme.)
We recognise we can’t cope with existing let alone projected demand. There is much more to be done through before we have a consistent view. A recent Prevention Summit got over 100 agencies together and identified some shared priorities. Stopping people from needing services, helping people stay as healthy and independent as possible, and helping people who need services recover as much function and independence as possible.
For the rest of the stuff I make no apologies that our run in to some of this will probably be eighteen months before we see tangible results, at least. This is work in progress. Some of this may work, some of it will fail. But we have to find a way to deliver some value.
This raises several important questions for us . First, nobody seems to share the same idea of what prevention actually means (is it avoiding or delaying a need for a health or social care intervention? Or is it something else? Does it matter as long as the logic is clear and the intended outcomes evaluatable?) Second, what does quality look like in prevention? Third, how do we embed a culture of good quality prevention if we can’t agree what those things mean?
We do need to get prevention right, but at the same time we are at real risk of doing with Prevention what we often do with health and care policy. we need to avoid making it the next panacea (remember Community Care? ) And what often happens is a new bright shiny thing emerges. It’s hailed to work. We find it doesn’t for the same reasons we always do, we decide it hasn’t worked and go down the road of structural change instead. I can’t be the only one who things the new ACO/ACS combo is the next prelude to structural change in the NHS. And if these new organisms are to be effective, I think they need to work in a different way. It will come as no surprise that I believe they really need to get to grips with systems and complexity approaches, but
Learning from Failure
We know enough from the literature and experience on health and care activities not working to know why things fail. Rarely is it down only to evidence of effectiveness…often it is down to the fact we don’t do it properly.
- We settle on a policy option without considering how it will work properly
- We decide on a national roll out or buzz word
- Guidance appears and is expected to be followed slavishly
- We don’t create the right plans or models for it to work
- We don’t put the right resourcing into it and we don’t implement systemically
- We still “do unto” patients rather than “work with” people
- We behave as if the system is a machine not something far more complex and so we take a linear “press a lever, it will happen” rather than a “this is complex change so let’s manage that well” approach to implementation
- We don’t give it long enough to embed
- We don’t consider the dependencies which will make it work better or worse (eg Adults with complex needs work won’t work without somehow addressing some of the huge constraints on housing supply. Very few of the existing models have really solved that problem.)
- We decide too early it hasn’t worked
- We quietly sideline it
It will be a great shame if we do this to prevention. And some of the signs are this is where we are going. I predict also, though, that in two years time we may well be saying ACOs haven’t delivered on reducing costs in complex high cost patients to the extent we wanted.
I believe if we don’t tackle this issue as a system problem starting with culture and language, and prioritising some areas for action, our recourse will be further rounds of restructuring and cuts as the only option for financial sustainability. Moreover, if we can’t agree what we want as a system, then implementation will not happen , and neither STPs nor healthcare will achieve their must dos, let alone the rest of the public sector.