The Lowdown has heard that some health workers are being warned to brace themselves for “radical” proposals in the government’s 10-year plan, scheduled for June publication, and that it will centre on “neighbourhood health.”
This helps explain a recent extraordinary 3,000-word feature by Health editor Laura Donnelly in the Telegraph, the chosen platform for so many policy announcements by Wes Streeting and Keir Starmer.
The article (copied more briefly the next day by the Daily Mail) is headlined ‘NHS sent door-to-door to tackle sickness crisis.’ It announced that “an army of health workers” is to be deployed to the most deprived areas of England, with every specially recruited (but not necessarily professionally qualified) “community health and wellbeing worker” calling monthly on 120 homes:
“Their brief is to knock on doors, and to build relationships with residents, in order to tackle the health problems and social ills limiting, and in some cases destroying lives.
“Almost no subject is off limits. Many of the obstacles to good health – damp, poverty, worklessness and debt – are not those of the health service to mend. But left untended, they cause ever more pressure on a health service which increasingly seems to teeter on the verge of collapse.”
How will it work?
Exactly what a community health and wellbeing worker (CHWW), who are apparently recruited “based on character, not qualifications” can do about these non-health problems is not explained.
It’s likely a fair number of the people they want to help will be even further disadvantaged as a result of the government’s plans to axe disability benefits, which is likely to pile additional annual costs of £1.2 billion on the NHS and social care. And the CHWWs themselves would be recruited at a time every other NHS organisation is seeking to shed jobs and cut spending.
The scheme at the centre of the Telegraph story, covering the Pimlico estate in the London borough of Westminster, is backed by the local council, health bodies and the voluntary and community sector. But none of these are flush with funds to tackle deep-seated social issues like poor housing, unemployment and debt, and not all local authorities are willing to fund such work.
The theory, apparently based on the system in parts of Brazil 25 years ago, could be of genuine help, but are the plans realistic?
Key elements of what’s needed to make it work seem to be missing: the workforce to carry it out, the funding to pay them, and the funding to enable the other necessary partners to play a role. Indeed without appropriate and timely follow up action from suitably qualified and resourced staff there is little point in identifying health needs.
Sadly, when it comes to tackling the health and other problems of the most deprived areas, these elements have not just gone missing in the last 15 years of austerity – they represent long-standing inequalities and neglect.
Within the NHS, too, at least since Virginia Bottomley in the early 1990s called for a primary care-led NHS, there has been over 30 years of failure to match bold promises of increasing resources for, “community,” “local” or “neighbourhood” services to address such issues with the wherewithal to carry them out.
In many areas, building PFI hospitals drained all of the resources from other health services, and these contracts are still being paid off.
The costs of simply knocking on all the doors are high enough. The Telegraph reports that CHWWs are paid £29,000 in Pimlico, and the aim is to have 100 staff. But there is also a need for local management, offices, and admin to ensure the staff work efficiently and that their work links properly to other health and care professionals and the voluntary sector. The costs of each project are considerable.
To carve out a large enough slice of the current NHS budget – which is already tightly stretched – and redirect significant resources to such neighbourhood schemes could halt the limited improvements that have been made in the 7.4 million waiting list, lead to a further continuation of the pressures and missed performance targets in A&E services, and make it even less likely that the drop in mental health services’ share of NHS budgets could be reversed.
The Telegraph tells us advocates of the neighbourhood health approach recognise that rolling it out for the whole of England (which has around 25 million households) would cost £2.2 billion. To minimise the cost, they are proposing only to set up such initiatives in the most deprived areas and estimate this cost at £300m.
This seems very optimistic: the Telegraph article notes that among the successes of the Pimlico project has been an 82 per cent increase in uptake of cancer screening and increased NHS health checks. This should obviously be welcomed, but it does mean there are additional costs, and of course, a percentage of those screened and checked will need further treatment, which will be an additional cost for the NHS.
However, the Telegraph article’s discussion of finance and staffing is far more concrete than the 20-page NHS England ‘Neighbourhood health guidelines 2025-26,’ which was published with little fanfare at the end of January and updated in March.
It reads like a fantasy. The entire paper does not mention funding or costs, although it does admit that “2025/26 will be a challenging financial year for the NHS, local government and social care.”
The Guidelines do make it quite clear that more work – and more liaison work – will flow from the shift of focus.
“All parts of the health and care system – primary care, social care, community health, mental health, acute, and wider system partners – will need to work closely together to support people’s needs more systematically, building on existing cross-team working ….”
Indeed, the Guidelines argue that the neighbourhood health approach also requires:
“multidisciplinary coordination of care for population cohorts with complex health and care or social needs who require support from multiple services and organisations. They are expected to deliver proactive, planned and responsive care, and prioritise care based on individual people’s needs and the opportunity for greatest impact.
“Functions include overseeing or delivering holistic joint assessments, case reviews and deployment of coordinated provision, medication reviews, care planning for long-term conditions and personalised care and support planning, including social prescribing, comprehensive geriatric assessments and advanced care plans.”
Complexity
It won’t be easy to get all of these sectors, involving staff employed by various different bodies, on different contracts, and with different management structures, to work together after years of jogging along separately, let alone to get them to take proactive action.
It will require a great deal of effort and fresh management resources at a time when NHS England is rapidly winding down towards abolition and demanding that Integrated Care Boards and trusts also slash their spending on management and administration.
Primary care needs to be a key player in any expansion of community-based services, but General Practice is currently suffering from a shortage of GPs (even after the recruitment of an extra 1500 newly qualified GPs, equivalent to 851 whole-time staff in the last six months). Thousands of GPs seeking locum employment remain unemployed because practices cannot afford to fill vacancies.
The successful roll out of the scheme would also need more staff in community and mental health services: but the latest NHS vacancy statistics show vacancy rates for community nurses as high as 10.6% in London and 11.3% in the South West, and only two of the seven English regions have mental health nursing vacancies below 10%, and East of England close to 15% of posts vacant.
The Guidelines assert, perhaps reasonably, that if properly resourced to respond to the needs they identify:
“By delivering proactive, planned, responsive and urgent care close to or in people’s own homes, effective local neighbourhood services will relieve pressure on acute services.”
Case studies accompanying the Guidelines include a mental health project in Cambridgeshire and Peterborough, where the existing Primary Care Mental Health team was strengthened by including “mental health community connectors,” funded as mental health practitioners through the Additional Roles Reimbursement Scheme.
Many will be concerned at the possibility that the switch to neighbourhood-based health care leads to a further growth in the use of less qualified staff, while the numbers of health professionals remains insufficient to deliver the full range of services to the patients who need it.
The bottom line
At the end of the day, if Labour switches resources out of already struggling hospital trusts and emergency departments just as they have begun to show improved performance, it will further demoralise staff and leave millions of people dissatisfied.
To secure support from staff, patients and the wider public, investment in improved community services and proactive measures needs to come on top of, and not instead of secondary care until the longer-term benefits start to show.
There must also be concern that the focus on “strategic commissioning” in recent documents from NHS England CEO Jim Mackey and (much more so) in the recent NHS Confederation document Pioneers of Reform will result in yet another resurgence of plans based not on integration, but on the separation of the NHS between “commissioners” and “providers” – and a renewed appetite for drawing private sector providers into the “market” for health care.
And in a week when Health and Social care Secretary Wes Streeting has just rubber-stamped a series of closures of smaller and local units and given the green light to others to follow suit to cut spending, there must be questions of whether an NHS squeezed on both revenue and capital will be able to develop and sustain sufficient hospital and community infrastructure and services to safely meet demand.
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