There’s a phrase… ‘putting your head above the parapet’…

… from the days when battles were fought from turrets. Looking out to see what the enemy was doing was a risky business… you might get an arrow in yer head.

Nowadays; 'to do or say something that could be unpopular but it’s worth the risk'.

Politicians used to do it. Float policy ideas. Some called it kite-flying... gauging reaction. Debating, discussing.

Now they avoid being challenged and hide behind a different kind of parapet... called paywalls.

Charmer did it, in the Times; talking about how the NHS must be ‘transformed’. Unchallenged, a fan-boy interview.

He said three things;

• a shift away from hospital towards community-care,
• more evening and weekend working and
• stopping people getting sick in the first place.

Overtime and extended working?

The NHS is already doing it, just like they did in 2000. Waiting list initiatives. It cost the absolute earth. Today, evening and weekend working has screwed NHSE’s budget and the DH+ want to rein back.

The growth in queue numbers indicates much wider capacity issues. They'll not be resolved without sustained investment and that will take time. Plus a resolution to the strikes.

It's not a quick fix. Demanding overtime working... not a sustainable HR policy... obliging people to do extra encourages bullying... institutionalising overtime is not value for money.

Stop people getting sick in the first place? Yup it’s a good idea but nothing to do with the NHS.  

The WHO tells us about 60% of people pitching up in healthcare systems have symptoms that are correlated to lifestyle.

Environment, jobs, education, income, sleep, sexual behaviour, exercise, housing, substance misuse, diet, social status all play a part but the NHS can’t fix any of that.  

Not that the NHS hasn’t tried. The ‘Making Every Contact Count’ (2016) initiative. 

Encouraging staff to have; ‘health messaging conversations with the patients they came into contact with’.

Nothing much happened.

In 2010 the Marmot Review suggested that prevention should be shared across the NHS, Local Authorities, communities and individuals.

I can’t point to much that came of it.

For a relatively small investment in staff training, embedding health messages into conversations seemed easy. 

NICE produced guidance. Health Education England came up with a toolkit. The NHS ran smoking cessation clinics.

The fire brigade did well, they gave away and fitted smoke alarms...

... but housing authorities still rented out substandard buildings, damp and mouldy and still do. Zero hours contracts, the Gig economy, the social determinants of health, all ignored by policy makers and...

... none of it could be changed by a conversation with a community nurse.

What happened? It fizzled out. Not enough training, not enough time, not enough headroom, not enough enthusiasm.

The NHS does not have the space to fix what politics can’t fix… poverty, education, opportunity and hope.

Moving care into the community is Charmer’s other big idea… actually he’s pinched it from the NHS 5 year forward view document (page 29 onwards) published ten years ago.

It would be wrong to say nothing happened but in the main there’s not much to show.

Why…

• Consultants can’t be in two places at once.
• Very few surgeries have the capacity and staff and no room for diagnostic kit.

… investing in digital first NHS would be so much better.

• Carving services and their revenues, out of Trust's top-line and giving the £ to primary care to run them, leaves Boards trying to run a piece of Swiss cheese.  
• Hospitals use cross-subsidy from services that are high volume and income generating, like hips and knees, to pay for rarer, low volume activity such as ophthalmic services for people with rare eye disease…
• Similarly, imaging and diagnostic services, must be in place for A&E but income generate through the day-to-day work on electives.

… and there's scant evidence shifting care saves money.

As far back as 2017 the Nuffs produced a paper. They said;

‘Schemes that deliver healthcare closer to home… largely fail to save the NHS money…’

They reviewed 44 local plans and deduced…

‘… [they]… will struggle to reduce overall numbers of patients requiring hospital treatment unless they are given additional money and staff to develop new services.’

And, there’s the fact that between September 2009 and December 2022, the number of community and district nurses has fallen by nearly 50%.

I have no idea who advises Charmer. Serving up a cold plate of leftover ideas doesn't do it for me.

Whoever it is, I can only assume they have no sense of history, can’t read and don't have enough brains to ask why… if all this is such a good idea… 

… aren’t we doing it already?