‘Integration’, ‘value-based’, ‘local’, ‘patient-centric’, ‘accountability’– health and social care is rife with buzzwords that embrace normative ideas about how it should be delivered in the UK. Yet, the NHS is often criticised for nebulously defining these idealisations, rather than succinctly outlining policies for their realisationi.
However, recent NHS funding legislation and the ten-year scope of the NHS long-term plan, published in 2019, has provided a platform for successfully shifting healthcare policy. This coupled with the new majority within parliament should lend years of stability on which to realise ideas about how health and care should be delivered in the 21stcentury.
In this article I aim to outline how services can be redesigned in the future for one such buzzword – namely, the ‘local’. It uses the context of the rehabilitation of adults with complex psychosis to demonstrate the recent and successful shift in focus to the local by healthcare policymakers and commissioners. It also analyses the rationale for the localised healthcare agenda.
One of the key aspirations from the NHS long-term plan is to provide joined-up care in the optimal setting for patients. For instance, the NHS encourages patients with minor or moderate symptoms of many conditions to be treated in a local GP surgery or community pharmacy, rather than taking trips to hospital.
To accommodate this model, the government has guaranteed that over the next five years, investment in primary and community services will grow faster than the overall NHS budget, albeit from a comparatively low base. NHS England has also been pushing through the development of Integrated Care Systems (ICSs) that bring together local organisations to redesign health and care, as well as forming primary care networks of local GP practices and community teams.
Care for adults with complex psychosis
The recent NICE guideline on the rehabilitation of adults with complex psychosis and related mental health conditions adopts the localisation model.
The guideline proposes that mental health services for adults with complex psychosis should be designed locally and the use of out-of-area placements limited. Commissioners are expected to work alongside local authorities and the third sector when commissioning these services.
Evidence reviewed in NICE’s guideline shows that shifting the service delivery of mental health care from specialised regional centres to smaller, more local sites improves the quality of life for those treated. This is because patients are closer to support networks at home such as family, friends and peer support groups. This contact can help to improve a patient’s prognosis and expedite discharge from care.
Evidence also shows that local care reduces the average length of stay of these patient, which not only improves patient experience, but also saves money for the NHS. Given stretched NHS resources, including for the 220,000 people in England and Wales who live with schizophrenia, reducing the stay of patients and tackling bed shortages should be a priority.
Another positive aspect of local care, when it has the sufficient expertise to deliver psychiatric and psychological care, is it can enable the diagnosis of mental health conditions earlier. Early detection in primary care offers the potential to treat the illness during the critical early phases. This has been shown in studies to reduce exacerbation and prevent chronicity and episodes of relapse.
Problems with the local
Commitments made in the Five Year Forward View for Mental Health and the NHS Long Term Plan have ensured that investment in mental health care is higher than ever before. Yet, as the King’s Fund outlines, it is still under-resourced to meet demand and transform services.
Furthermore, mental health funding needs to be ring-fenced at a local level to ensure that commissioners invest fully in mental health rather than competing demands. Therefore, the move towards local governance – such as primary care networks – needs to be matched with sufficient, ring-fenced funding.
Last year, psychology was designated as a shortage occupation. There are simply not enough UK psychologists and other mental health professionals to administer treatments. This creates lengthy waiting times, for example, follow up appointments for the national IAPT programme (Improving Access to Psychological Therapies) is over four weeks for half of patientsii.
Local staff shortages limit the implementation of local service redesign. This can slowly be improved by Health Education England and NHS England’s interim NHS People Plan, to develop future multidisciplinary credentials for mental health, with a focus on multidisciplinary training in primary care.
Recent policy announcements signal a move away from delivering specialist and consultant-led secondary care towards multi-professional teams providing care in more localised settings. In the future, care will increasingly be delivered in the community.
Providing care closer to home has a number of benefits, when adequately planned, resourced and financed. The example of the rehabilitation of adults with complex psychosis and related mental health conditions demonstrates this.
Therefore, expect the local to move from being a term of NHS managerial jargon to an increasingly mainstream health policy that meaningful improves clinical practice and health outcomes.
By Sebastian Guterres
iCarr, S. (2018) Tackling NHS Jargon: Getting the Message Across. CRC Press.