Author: John Craig, Chief Exec, Care City

The Long-Term Plan’s message is that we have all the money, strategic direction and instances of practice we need to sustain our health and care system and improve the nation’s health, and it sets out all three in admirable detail. Thank goodness for this document. However, it has a familiar shadow.

Austerity – whatever you think of it – has closed the budget deficit. The shadow behind it is family debts of money, time and energy – shifted onto them from the public finances – which contribute to misery today and the risks of a crash tomorrow.

Similarly, the LTP risks displacing burdens into places where they are less visible. The plan acknowledges that it needs far more than just more and smarter doctors and nurses, but its proposals for people beyond this constituency are less clear and significant.

That is a validation of everything Care City is doing – the Plan says that self-care, informal care and social care and wider patient care are all vital, and doesn't pretend to have all the answers. That is exciting for Care City, and it means we need to both understand these gaps and work to fill them.

There are two key facts about the current health system:

• Since 2010, public expenditure on health has risen from 25% of the total to 38% of the total (IFS)
• Health services account for just 10-15% of the determinants of health (Mcginnis et al)

Too often, this tension simply creates a row about the distribution of resources, as between health and other services. We should talk about how health is created, and how this needs to change. The contribution of health services to the nation’s overall health is not immutable, and more money means it needs to contribute more by working radically differently. One simple way into these issues is to tell the truth about the workforce. Who needs to work to implement this plan, beyond doctors, nurses and midwives? At a minimum, we need support from:

• Other NHS staff
• Patients
• Informal carers
• Social care staff
• Community and voluntary organisations

But, one would object, you can’t treat all these groups as a ‘workforce’ in some undifferentiated way! The lives of other public institutions, families and neighbourhoods don’t just revolve around the NHS! Precisely. The Long-Term Plan is most confident about the roles of people they pay sufficiently well and relate to sufficiently closely that they can simply be deployed to the problem. The issue is that – more than ever – these people are in the minority. There are:

• 760,000 staff in the NHS who are not doctors, nurses or midwives
• 8 million informal carers in the UK
• 1.6 million people working in social care
• 600,000 people work in the voluntary and community sector

Compared to the 440,000 doctors, nurses, and midwives, that’s 11 million people – or a sixth of the nation. We might wish we could solve the health system’s problems by levying taxes, paying them well and bossing them about, but that alone won’t work. We need to work with these groups, supporting them to learn, earn, connect and build relationships as they wish to, drawing in resources from elsewhere to enable health. If that is a pretty abstract thing to try to do, Care City is awash with practical examples of this kind of work:

• Carers’ curriculum– we are developing tools and training materials, built especially for informal carers. When we talk about informal care, we talk about respite and resilience – but where informal carers are supporting loved ones, they want to do the best job they can.
• AF screening and counter assistants– we developed a new pathway for finding and treating atrial fibrillation that begins with a counter assistant in a pharmacy. Often, they take this role as simply a ‘job in a shop’, but being part of a life-changing service can transform their sense of their career and their potential.
• Social prescribing at scale- Social prescribing is much-discussed, but most examples are small-scale and temporary – we worked with HealthUnlocked to create a digital tool for social prescribing, enabling GPs to connect people to the community support around them quickly, cheaply and in large numbers.

• Homecare as healthcare– Digital revolutions in monitoring and diagnostics transform what a home carer can do, once they are in the home. We are testing an enhanced role for home carers, working in partnership with primary care to support complex patients to leave hospital and stay well.

• Escape Pain and leisure staff– we prototyped Escape Pain here in Barking & Dagenham, and are delighted to see it in the Long-Term Plan. Escape Pain now enables rehabilitation for chronic knee and hip pain to be provided by leisure staff, in leisure centres.

Work like this also tells us something about the future direction of health and care policy. It is said that ‘people are just going to have to live healthier lives, otherwise we cannot afford to give them the health services they want’. In fact, it works the other way. We need to re-orient our health and care system around the needs and aspirations of all of its constituents – not just for better health but for better work, learning and family and community life – otherwise, it will not retain their loyalty, on which it depends more than ever.

In each of these cases, Care City is seeking to unlock new opportunities for local people and new resources for the health system. However, it is also something more – it is about how innovation can enable both healthy ageing and economic and social regeneration for East London. That is Care City’s mission, and we believe it has a very significant contribution to make to the long-term plans.

To achieve this across the system, we will need new forms of business and public institution, and new forms of leadership and collaboration. It is scarcely realistic to expect any of these to be written into a national planning document for the next ten years – but its success depends on us building them.