The idea of referring people to non-medical interventions is still unknown to many professionals and commissioners, writes Don Redding, director of policy at National Voices. But in the face of current challenges, such life-changing approaches must move further into the mainstream.
At the NHS Expo event last September, a career doctor described her journey after being diagnosed with a form of rheumatoid arthritis, and concluded: “The three things that helped me most were a listening GP, education in self-management and peer support.”
For most people with long-term conditions, only one of these things is currently available via the NHS.
That must change. At a recent meeting with National Voices members, NHS England chief executive Simon Stevens spoke of the burning need to “industrialise” these approaches wherever they might “swing the needle” towards greater sustainability for healthcare.
The idea of referring people to non-medical interventions is still unknown to many professionals and commissioners, but in the face of current challenges, it may have started the long journey towards mainstream acceptability.
By definition, long-term conditions do not go away. That middle-aged doctor will have a 30-40 year ‘career’ with the condition.
The need for a different model for such patients has been known for nearly two decades (see the Wagner chronic care model and the subsequent 2003[!] NHS version).
It is only now that it has become obvious that leaving people without proactive support, waiting for them to present with exacerbated symptoms or crises, brings them crashing into the urgent and emergency apertures in the health system, for episodes of care which neither they nor the system would have wanted.
The NHS Five Year Forward View signalled the need for “a new relationship with people and communities”. In the NHS planning guidance, there is a clear expectation that area plans must seek to achieve the ‘six principles’ that include coproduction with communities.
So why and how should local areas institute person-centred and community-focused approaches to health and wellbeing?
For the ‘why’, the NHS England-funded Realising the Value programme has now published evidence with regard to five types of intervention that look promising for mainstream development.
Our doctor would be pleased to see that this includes strong evidence for self-management education, which can improve:
- clinical outcomes, such as cholesterol and blood pressure across a range of conditions
- health outcomes, such as knowledge of the condition, self-efficacy and active self-management
- social outcomes, through better communication and relationships.
She would be encouraged to know that peer support is shown to improve people’s health management (knowledge, skills and confidence), their physical and social functioning, and their quality of life.
This evidence base grows rapidly over time. It is sometimes patchy, but lack of evidence can no longer be an excuse for not commissioning or providing.
But we also need to know ‘how’: what are the ‘active ingredients’ most likely to make a success of these approaches? For that, Realising the Value is working with local partners with demonstrable success in implementing the approaches.
Finally, we need to know more about the cost-benefits of mainstreaming. This is difficult when the approaches have never been mainstreamed, but again we are learning more from studying the local site data.
As knowledge grows, it needs to be set in a new context – one that does not judge only by instrumental accounting, but is capable of valuing the contributions of, and wider outcomes for, the people and communities who take part in supporting health and wellbeing, as discussed in a previous Realising the Value paper.
How, for instance, can our healthcare system recognise the kinds of quality of life and wellbeing outcomes described by this participant in community-based arts sessions run by one of our local partners, Creative Minds:
“I was a quivering, shivering wreck on 21 tablets a day… and 20 months later, I’ve been off medication for nine months and my children are amazed that one person can change so much in a short space of time.”
Or this young person who was diagnosed with HIV, and later joined peer support facilitated by another partner, Positively UK:
“Through the support groups I was able to make friends, and I now have a social life. Through the motivation I received I went back to school, have gained a BA and look forward to getting back to work.”
At National Voices, we are encouraged to see growing support for a different framework of value and practice, whether from the National Association for Primary Care with its Primary Care Home model; CCGs and frontline GPs who are developing social prescribing; integration pioneers who are coproducing new services with their communities; or the NHS Confederation and other allies who have called, via the 2015 Challenge, for scaling up self-management support and other approaches.
If we want to develop and understand these approaches and add to the cost-benefit data, we now need to change the research frameworks in the NHS to ensure more research, with consistently high standards of study. But that’s a blog for another day.
Don Redding is director of policy for National Voices, the coalition of national health and care charities; and a member of the Realising the Value consortium. Follow him and National Voices on Twitter @MightyDredd @NVTweeting
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