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Einstein is credited with saying it but the fact is, Shakespeare got there first.
King Lear; after making a mistake in dividing his kingdom, is driven mad, wanders outside during a thunderstorm and says;
‘that way madness lies’…
… in the context of repeating the mistakes of the past.
Despite having been reproduced on a gazillion PowerPoint slides, apparently there’s no evidence that Einstein ever said anything like madness is repeating the same mistake twice.
None of which matters to HMG.
Not just this one, but successions of them. One of the greatest talents that governments have is to put a huge amount of energy into trying, again and again, to do things that don’t work.
There’s a sort of institutional arrogance that whispers in the ear of politicians… ‘this time it will be different’…
... when ‘this time’, the only discernible difference is the politician in whose name the repetition is being carried out.
Shifting the fulcrum point of care. Moving stuff out of hospital into a primary or community setting.
We’ve tried;
1. National Service Framework for Older People (2001)
2. Our Health, Our Care, Our Say (2006)
3. Next Stage Review: High Quality Care for All (2008)
4. Care Act (2014)
5. Five Year Forward View (2014)
6. NHS Long Term Plan (2019)
7. Adult Social Care Reform White Paper (2021)
8. Intermediate Care Framework (2022)
9. Urgent and Emergency Care Recovery Plan (2023)
Forgive me if I’ve left anything out.
Each of these worthy documents, distilled from the best thinking that was around at the time, in their own way tried to reduce avoidable admissions, advocate for better integration of health and social care and one even introduced a legal-duty to promote well-being and prevent needs from escalating.
The upshot; district nurses became an endangered species and care has stubbornly been focussed in hospital.
Why?
For the same reason Tesco puts all its good stuff in shopping cathedrals, with car-parks on the edge of town. Excellence attracts excellence and costs are easier to squeeze, if they are in one place.
Local is convenient and OK, if you don’t care about costs and quality.
The common law of business logic however inconvenient, applies to the NHS as it does with supermarkets.
We know shifting care is never going to work. However...
... redesigning care is a different proposition… and there is an urgent need to do it.
People aged 65+ account for over 40% of NHS spending and will continue to consume a large share of attention and resources for at least the next 20-30 years.
According to ONS modelling, after 2050 the growth rate of the older population begins to stabilise.
In the meantime, a nation with more older people than younger people is economic hara-kiri. That’s why immigration policy, allowing healthy young families to come here makes good economic sense… but that’s too difficult.
So, a shift in health service design is required.
Services shaped around the needs of older people, with the emphasis on keeping them fitter for longer is in everyone’s interest.
In Brazil they’ve cracked it with a community care model. Proactively calling on people to make sure they’re OK.
Newspaper reports (nothing more), tell us Our Great Leader has a cock-eyed community plan to;
‘increase the efficiency of the NHS’...
... with healthcare workers, sent;
‘door-to-door’...
...to address issues such as;
... ‘debt, unemployment and bereavement’.
A pilot scheme, based on what works in Brazil, with a clinical emphasis, started in 2021 in Pimlico, by a group of GPs, suggested that the measures could reduce hospital admissions by 10% and A&E visits by 7%.
Streeting ‘plans’ for an expansion into 25 areas across England, with the goal of;
'alleviating pressure on emergency services'
and… wait for it…
… reducing sick leave’.
History repeating itself…
… as part of the National Insurance Act of 1911 people who were off work due to illness were provided with sickness benefits… certified by a ‘panel of doctors’.
Sometimes ‘The Panel Man’, a humourless, clipboard-carrying bureaucrat, checking for signs of malingering, would house-call...
... a mix of welfare check and fraud prevention, dare it be said with shades of our Leader’s intent?
To make this work Streeting has to persuade a suspicious public instead of catching fraud, his goal is to catch health problems, early.
To once again borrow from Shakespeare; The Tempest, Act 2, Scene 1
‘What's past is prologue.’
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