The future of the NHS looks increasingly bleak. Demographic pressures, along with the spread of chronic illnesses such as diabetes, are adding to huge pressures on a healthcare system that is consuming an ever-increasing portion of public spending. And yet health outcomes for many are getting worse.
In this climate, there is no infinite source of money. Nor will efficiency savings and improved tech be sufficient. We need to be smarter, and that means taking prevention seriously. Rather than simply responding to crises and demand as it presents in hospitals and GP surgeries, we need to target ill health at source. But people and communities must take the lead.
We need person-centred, strength-based services that put individuals at the heart of delivery. One highly effective mechanism to enable this is outcomes-based social prescribing. This involves using relational, non-medical support for those with chronic physical and mental health conditions to help them make meaningful, sustained changes in their own lives. Around the country, there have been some hugely promising projects. For example, Thrive, a community-led service, worked with over 1,600 people in north-east Lincolnshire, succeeded in reducing hospital attendance and costs by 35 per cent, while also reducing GP usage by 11 per cent. Similarly, in Newcastle, Ways to Wellness has worked with over 6,500 patients and seen a 14 per cent reduction in GP usage and 27 per cent lower hospital costs than a control group.
These partnerships are so successful because they have been designed differently. Instead of the standard model of paying for specific activities that may or may not be effective, commissioners such as local authorities and the NHS only pay when meaningful, long-term outcomes are achieved and evidenced. This change of focus enables collaboration, unlocks flexibility and innovation in delivery, improves data and accountability and gets more value from spending. Done at scale, this could radically improve health outcomes and bring down waiting lists.
How pivoting to outcomes liberates delivery teams
A traditional public sector service specification sets out precisely how the budget must be spent, and what activities must be performed by each delivery organisation. In some areas of healthcare – where there is a discrete, clearly diagnosable problem requiring a single, standardised solution – this approach works. But for the multifaceted problems facing the NHS today, it is not fit for purpose. Where people are experiencing multiple long-term health conditions, it is pointless to treat this just as a simple medical problem, or even as a set of unconnected lifestyle issues (poor diet, lack of exercise, loneliness etc), and attempt to fix these issues using standardised solutions; different people will need different types of support at different times.
Switching to outcomes-based approaches brings commissioners and delivery organisations together to achieve shared goals. Instead of a fixed specification, delivery organisations have the flexibility to tailor their services to the individual and the place. This approach removes the shackles from front-line experts, enabling them to innovate. Not only do we get better outcomes for participants, the jobs of front-line workers become more fulfilling as they are allowed to exercise their expertise and autonomy.
At the heart of these programmes is an idea that is both radical and common-sense: putting people and communities at the heart of services. It gives participants agency and choice. By empowering partnerships with local organisations, it enables communities to choose their own priorities, and it dramatically improves our understanding of what actually works. Switching the focus to outcomes makes all of this possible. As the assistant director of the Humber and North Yorkshire integrated care board Lisa Hilder says of Thrive, “participants report that the interaction with this social prescribing programme has been life-changing”.
Delivering services in this way dramatically improves health outcomes, reduces costs and supports increased economic activity. But for this kind of preventative model to realise its full potential, the way we fund and commission services must change.
NHS budgets are predominantly organised to respond to primary care demand. This means NHS budget holders have limited ability to redirect funding towards preventative interventions, even if they can prevent or slow the onset of long-term conditions that will ultimately cost the NHS more money to treat. The current NHS Social Prescribing Service, with its £120m budget and team of 3,500 social prescribing link workers, is a positive development. But it has not been set up to succeed. Caseloads for link workers are far too high, restricting their ability to provide meaningful support. There is no effective way to track and capture outcomes, hampering efforts to develop and share best practice. Placing the service in primary care, which is already overstretched, means the NHS is struggling to justify its funding. And the system has not been designed around the individual, bringing inherent inefficiencies.
The good news is that the next government has the opportunity to change this – by dramatically expanding the use of holistic, place-based, non-medical services. We need a whole-system approach that seeks to:
Pivot to outcomes partnerships: social prescribing programmes should be delivered through place-based outcomes contracts, enabling greater community engagement, personal tailoring and better data and accountability.
Organise the system around the individual: health, social care and public health services should be commissioned around shared goals with the individual at the centre.
Invest for the long term: NHS leaders must be empowered and incentivised to fund preventative interventions, with budgets allocated on a longer-term, more flexible basis. Budget holders should also be able to keep and redeploy savings from prevention and innovation, creating a virtuous circle of investment.
If we want the NHS to become a health service, rather than a sickness service, we need a different approach. The question should no longer be whether we can find the funding for community-based prevention. The data is clear: we can’t afford not to. Every year the costs of not investing in prevention rise. The question should now be about how we deploy preventative interventions at scale.
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