Published: 27 August 2020

Authors: Donna Hall, Warren Heppolette

“Place” is Where The Heart is

We’ve been prompted to write this article together following a series of thoughtful responses to an exasperated post on twitter recently. One of us (Warren) posted about how integrated care systems need to fold themselves into people and place and not the other way around. An interesting social media debate followed!

The latest national health and care policy contained within the NHS Long Term Plan and other Government policy guidance, comprises a plethora of embryonic spatial footprint structures and concepts that rely on the key role of “place” in transforming health and care.

These include PCNs (Primary Care Networks), ICPs (Integrated Care Systems), STPs (Sustainability and Transformation Partnerships), BCF (Better Care Fund) and that’s just some of the health and care bit!. We could be in danger of drowning in a sea of confusing and disparate piecemeal “place” initiatives and missing the point of place and people (not just as patients) at the beating heart of our local neighbourhoods and our communities?

All of these well intentioned but centrally designed initiatives are created with the aim of encouraging primary care, housing, acute and community providers to work better with councils and other agencies in localities. However what we can actually end up on the ground with is a set of shiny new partnerships, sometimes with new money attached, overlaying the same old responsibilities and loyalties. The friction still exists and the big ticket changes we need to make to really radically shake up our fractured and confusing health and care offer to local people seem a long time coming.

Sometimes we need to simply make the time to take a giant step back and get back to basics; put our new governance structures, strategic commissioning and pooled budgets to one side and start to get back to communities and focus on the individuals and families who rely on our services. It’s the “so what?” question...so what actual difference will this reconfigured service make for our local communities in their day to day lives? Have we designed it with them? Does it address the issues that people and families face and the reality of how they live their lives?

There are so many fantastic case studies of how small grassroots neighbourhood community and voluntary groups, especially mutual aid groups during the Covid-19 pandemic, have worked day and night to improve the health and well being of people struggling hard with shielding, with mental health issues, social isolation and loneliness, bereavement, loss of employment and social status, domestic violence and family breakdown.

Sometimes when we develop “people focussed services” they are about hierarchies rather than networked solutions badges with a different title. So our “Ageing Well” initiatives become about reducing delayed discharge processes and improving care home quality rather than supporting people to live at home and link in with local neighbourhood networks.

Sometimes its not the medical prescription that makes the real difference its developing new friendships, sharing common interests and building social networks, gaining self confidence, losing weight, moving more and feeling like you have a stake in society. It’s not just social prescribing by GPs - its so much more than that.

Community organisations, most unfunded and informal neighbourhood networks, are working on the streets of our estates and in the most deprived areas to support people who are struggling to get jobs and training, to build confidence and sometimes just to listen really hard and build a trusted relationship.

And yet we tend to focus on reshaping and reorganising the deckchairs of our formal paid healthcare professionals and the legal structures and contractual arrangements of health and care whilst its the social fabric of communities that needs our investment and support.

We also know in our hearts that place will be pivotal in the implementation of the new NHS People Plan. Exactly how we remodel and make more flexible our health and care workforce will depend to what extent we work with local councils, the police, schools and other local public services to develop a place based workforce and system rather than organisational values based development plan. We’ve all experienced the layers of professionals from different organisations and disciplines descending often in an incoherent fashion on households who need our seamless support.

We know from all the international evidence and from Hilary Cottam’s “Radical Help” that this way of working is the only way we will transform public services and rebuild communities for the better. It’s critical that our housing partners; social landlords and private landlords embrace this as a win win for every agency and every tenant who is supported into good health and good employment. A place based approach to primary care networks, integrated care systems and strategic transformation partnerships need to be driven by much more than health and care professionals meeting once a month to agree stuff. They need to be rooted in the anthropology of place, listen to people’s stories and understand the reality of their lives.

There are also some truly fantastic and challenging best practice lived experience panels and citizens assemblies where people are courageously brutally honest with organisations about what doesn’t work across the system. It’s then how we systematically use this to extensively redesign all of our services around people and their families. They are fearless speakers of truth to power and yet we don’t consistently use this intelligence to overhaul our public service partnership with people in place; very often we just use the feedback to redesign the presenting issue or need and “fix” it.

We also now know the essential role of adopting a place focus to public health and epidemiology from all the evidence we’ve seen during the Covid-19 pandemic. The countries where a rapid, fine-grained, local intelligence led, devolved approach to testing, tracing and isolating were the ones who suffered lower infection and mortality rates. Those that centralised their responses suffered the greatest loss of life.

Social care could be moving into the NHS but we know that the best examples of high quality social care for older people and for adults of working age currently in local government are rooted in person-centred, place based partnerships with local third sector partners and charities. Do we need to nationalise social care or do we need to localise the NHS?

Economic recession has also meant that very often the only secure jobs in local areas are in the public sector in local government, housing and the NHS; very often we are the largest employers in the area. We are not hermetically sealed off shoots of a large national machine. We have a key role in place as anchor institutions supporting the population through our role as an employer and a purchaser to contribute towards the social value of our communities.

Until we stop obsessing about the process of place, organisational sovereignty, commissioners vs providers and the strange dance of the annual contracting cycle, partnership governance and genuinely and meaningfully begin to reconnect with the public and the places they live in on our public service reform journey we haven’t got a chance of reforming anything.