Paul Gray’s blog presents some critical challenges to us as we move forward, making an NHS that is fit for purpose for today and not relying on a 1948 or 2019 context. However, perhaps we need to pull back to a broader lens. A reason that the NHS is not where it needs to be is design, structure and function. But if we look with a wider horizon, we come back to the key determinant of ill health. We know realistically that the majority of the NHS is designed to treat illness, not to deliver ‘health’ to a population. Paul touches on prevention, but far too often we redesign the machine we have, rather than put the time and intensity needed into remodelling a broader system.
A decade ago Campbell Christie and his Commission, with sharp clarity, specified the challenges we needed to face to really move on with a prevention agenda. There have been very positive moves in the time since then but not at the radical level required to stop the endless and growing inflow to the NHS. Until we truly tackle this, we are charging the NHS with an impossible task.
It is very easy to agree with a rhetorical position on prevention, but historically we have failed to make the large system changes – which in truth boil down to where money is spent – and have not bitten the bullet to move significant spending out of acute services and into communities.
Through the work of many in the last decade with deep, long-lasting, community-based interventions, we do actually know what works to improve individual and community wellbeing. We can help individuals and communities take the actions that reduce illness and improve broader wellbeing, including the ‘wicked issues’ Scotland has faced with alcohol and wider substance misuse. We have endless reports and studies that confirm and evidence successful impact. We are not struggling with knowing what to do, but with actually implementing it.
Nearly a decade ago Inspiring Scotland started Link Up, with the belief that the ingredients for lasting change lie in our communities, in the passions, strengths, skills, knowledge and interests of local people. When people are inspired, connected and energised, real and radical change can and does happen.
Since 2012, Link Up has worked with over 27,000 people facing the harshest realities of poverty and disadvantage across Scotland. We have a strong understanding of how to really drive community-led, positive change, once the foundations for human development – self-esteem, confidence and positive relationships – are in place.
It may seem that focusing on self-esteem, confidence, and relationships is too simple an approach. However, if these foundations are well built, with a deliberate focus, and with skilled workers who are well supported and empowered, they have a profound impact helping people turn their lives around. People no longer feel like the passive recipients of external help; instead, they become active agents in their own lives and changemakers within their communities. As that happens, wellbeing improves, and ill health is reduced.
If we continue to view people purely as service users or problems to be solved, where external parties decide on the solutions, then we risk the continued cycles of poverty we have seen over decades. If instead we shift our perspective and allow people to be seen, heard and valued for their whole selves, and support them to take positive steps forward, we will shift the dial significantly in terms of health in our most challenged communities.
Paul mentions the Buurtzog model. Utilising this disaggregated approach and community empowerment, it is possible to see how an intense community-based response would work hand in hand with NHS reforms at a relatively modest cost, certainly compared with the billions we commit to the NHS.
We do need to pick up Paul’s challenges, but this must include the wider prevention agenda and actually work with what we know proves effective in our most challenged communities.
Helen Chambers is the Deputy Chief Executive Inspiring Scotland
Transforming relationships: This places the work of Link Up, and the special contributions it makes to communities across Scotland, front and centre of a narrative whose time has come. People, relationships, and kindness are where the changes are being made – and with people and in communities where the need is greatest
https://www.inspiringscotland.org.uk/wp-content/uploads/2020/11/Link-Up-2020-report.pdf
The Place-based Programme Learning Exchange, a collaboration of national organisations that champion ‘place’ in their practices, has released a report highlighting what works and what doesn’t in place-based approaches.
https://www.inspiringscotland.org.uk/publication/link-up-working-better-together-in-place/