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How local leaders have a role in moving care closer to home

By Deborah Fenney, Fellow, The King’s Fund 
19 February 2024

A major new report calling for a radical refocusing of the health and care system to put primary and community services at its core was published by The King’s Fund last week. But what role can local leaders play in making this happen?

At The King’s Fund, we wanted to understand why the long-held vision of moving care ‘closer to home’ has not been achieved, despite successive governments of the past 30 years stating a commitment to this ambition. This significant policy failure to grow and invest in primary and community care and the lack of support for people accessing primary and community services, such as reliable access to GP appointments – means increased pressures on already overstretched acute hospitals. Our report sets out the underlying factors that have prevented the vision being achieved, and highlights the role of national policymakers and local system leaders in starting a shift towards a refocusing of the health and care system towards primary and community services. 

A key factor was the lack of agreement about why it’s important to move care closer to people’s homes, along with misplaced beliefs about the potential for these initiatives to produce quick financial savings. We found many such initiatives have been abandoned before they had a chance to demonstrate their impact. The relative lack of data has created a cycle of invisibility for primary and community services, leading to a lack of evidence to support investment and lack of focus on those services by senior leaders who often have little or no direct experience of those sectors. Because urgent problems take priority over longer term issues, primary and community services again lose out. At a national level, neither financial architecture, nor policies and strategies, are aligned to the vision enough to facilitate a shift of focus.

Where provided with an enabling environment, several aspects of this work are in the gift of local leaders, and so I want to focus on what’s perhaps most important for you to hear from our findings.

First, for local leaders to be able to make progress with this refocusing of the system, we highlight the need to change how they are held to account – less of a singular focus on activity in acute settings, and more accountability for health outcomes, patient experience and the joining up of services. This also means ensuring these leaders have the conditions in which they have headspace to think about longer-term goals as well as immediate concerns, to make the right decision in a local context.

Second, too often senior NHS leadership teams lack experience in sectors outside of hospitals. While there is more to do to build a future pipeline of leadership talent with experience of multiple sectors, local leaders can start now by ensuring the senior local leadership has a wide base of experience for example in community services, primary care, and the voluntary sector. Where that’s not possible, leaders should proactively and meaningfully engage across these sectors to ensure decisions taken benefit from that experience and insight. Often this means engaging across organisations, as well as with local authority and voluntary sector counterparts. This is as much about NHS asking what it can do to help its partners, not just expecting those sectors to support the NHS. The value the voluntary sector can bring to supporting people’s health locally has long been recognised, and it’s also important for voluntary sector leaders to ensure their offer is clear to statutory organisations. Much of this comes back to developing strong relationships and partnerships across statutory and voluntary sectors, as we’ve found in previous work.

And finally, engagement doesn’t just stop with professionals. Leaders can make assumptions about the views of the public and patients when it comes to service design – and those assumptions can be wrong. Enabling local communities to engage with and understand system change means involving people meaningfully from the start. Leaders should set this expectation across their local systems – and provide their staff with the time and resources to do it properly. Deliberative work has shown that enabling people to understand and discuss a topic before being asked their views on it means that they can better understand what is happening and why it’s important. This kind of work has been used in health and social care to help people learn about funding and models of delivery. 

Of course, none of this is new, but in our current context it bears repeating. In the face of such complex barriers, there is clearly no one solution, or one single actor who can facilitate change. There’s a need for a wholesale refocusing of the system. Our research makes clear that shifting the focus to primary and community health and care services requires changes that are multiple, interconnected, layered and difficult; they will take time and require a willingness to implement. If we’re serious about making care closer to home a reality, everyone in the system – national leaders, system leaders, staff at all levels of health and care – has a part to play.

By Deborah Fenney, Fellow, The King’s Fund 

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