What is to be done?

In his latest article for Healthcare Management magazine, principal consultant Aidan Rave argues that integration should remain central to NHS long-term plans

“What is to be done?” The seemingly straightforward but frustratingly difficult polemical question immortalised by Lenin’s musings on the most effective means of provoking a socialist revolution. Then, as now, the question is easily misconstrued, with a presumption that it is focused on ends rather than means. As any strategist will tell you, defining ends is the easy bit; it’s achieving them that always proves more challenging.

So it is with the challenges facing the drafters of the latest NHS ten-year plan. The current consultation, due to conclude by the spring of this year, will surely set out a series of hugely important but all too familiar priorities. Prevention will certainly figure strongly; getting upstream of health challenges rather than waiting to treat the consequences later in life. This in turn will inevitably—and rightly—bring health inequality into sharp focus. As the pandemic demonstrated in the most brutal and stark manner, poor health and premature mortality are emphatically not born of indiscriminate causes; they are subject to laser focus through specific characteristics such as wealth, education, ethnicity, and the like. Like a playground bully, health inequality picks on those with the weakest means of defence; what’s more, it’s a fixable problem; we should absolutely plan to fix it. We can also be sure there will be mention of the shift to digital services, placing more agency in the hands of patients and service users, as there will be of shifting services away from acute to community-based healthcare.

All of this is predictable—absolutely right—but utterly predictable.

But what is to be done about turning these worthy aims into reality? After all—and without sounding too cynical—the next ten-year plan is highly likely to contain many themes contained in the last one, the one before that and so on.

In framing a response to his own question, Lenin recognised that the change he sought would not simply happen because working people were fed up with being exploited, nor because the bourgeoise class would suddenly decide to share their accumulated wealth more equitably. He argued that in order to create change, an organised vanguard would have to be created and mobilised and that this would ultimately catalyse the changes he considered necessary. That vanguard eventually became the Communist Party of the Soviet Union.

While resisting the temptation to suggest a revolution is the answer to the current challenges faced by the NHS (though many might well argue this is necessary), there are lessons to be learnt from the thinking of the Soviet revolutionary. Principal among these is the need to recognise that in order to prosecute strategic aims, effective organisation is critical and in keeping with the credo that form should follow function, the aims set out in the NHS ten-year plan should precipitate at least a review of the means of achieving them.

No, that needn’t mean yet another top-down restructure of the NHS. The aims of the new plan, especially the critical ones relating to prevention, tackling health inequality, and shifting to more community-focused healthcare, actually require the optimalisation what we already have: a structure that brings together key partners focused on the needs of their local communities and training their resources on the shared goal of enabling people to live healthier and more fulfilled lives. Sound familiar?

Integration contained the blueprint for success before the current planning cycle and it should remain central to the means of realising the new plan when it emerges.

There is, however, a need for a meaningful and sustainable shift in the leadership, culture and governance of local systems, building on some of the progress made over the last few years but honestly confronting some of the challenges that continue to inhibit further progress. There has to be a candid recognition that the potential of integration has thus far barely been scratched, mired as ICBs have been in tackling backlogs, confronting financial crises, and generally trying to establish themselves during a prolonged period of political instability.

So, what is to be done? Put integrated care at the centre of achieving the new ten-year plan, give ICBs the resources to succeed and hold them closely to account in enabling the leadership necessary to lead the cultural transformation—indeed, revolution—that is so desperately required.

Remember, “without revolutionary theory, there can be no revolution”.

This article first appeared in Healthcare Management magazine.