The head of NHS England gets his blood pressure tested. Photo: Getty
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How people-powered personalisation could lead the NHS to recovery

The NHS needs a highly personalised and co-productive approach that calls on the creative collaboration of individuals, families and communities.

It’s been an important month for personalisation in the NHS. For the first time, around 60,000 adults eligible for Continuing Health Care now have the legal right to a personal health budget. Health and social care leaders have been finalising applications to participate in the potentially ground breaking Integrated Personal Commissioning Project seeking to blend social health and social care funding for individuals and allow them to direct how it is used. And publication of the NHS’s Five Year View set a course for the organisation that commits the organisation to enabling patients to have far more control over their care, including but not only through greater control over shared budgets.

Encouragingly, these moves towards personalisation appear to be based on a deep understanding of why producer-led forms of provision have had their day. The Five Year View makes a strong defence of the values and professionalism of today’s NHS, but makes no bones about where it has fallen short, operating as if health and wellbeing can be delivered to people, rather than achieved in partnership with them. 

It warns that the NHS has been prone to "operating" a "factory model of care and repair" instead of harnessing what it calls the "renewable energy represented by its patients and communities". At a point when 70 per cent of today’s health spend is on long term conditions, rather than isolated health problems that might respond to one-off "repair", agreeing forms of support that fit with people’s own lives and aspirations, and plug into their own resources, could hardly be more important. 

So, as health prepares to speed up its journey to personalisation, it makes sense to look at what can be learned from the experience of other sectors, particularly the sector in which personalisation was born – social care. Much of that learning is very encouraging. We now have detailed evidence of the impact of personal budgets, for example, on the lives of those who use them. 

This month saw the publication of the Third National Personal Care Survey. In line with previous research it shows that the overwhelming majority of budget users believe that their lives have improved in terms of independence, dignity and family and paid relationships. As Alex Fox has noted in a new report for the RSA, people who make long term use of social care have repeatedly demonstrated over the past two decades that they are often better than highly trained professionals at making effective use of public resources. 

Yet personalisation remains highly controversial as a philosophy and as a set of practices. Critics worry about colluding with neo-liberal models of individual choice and control, about the de-professionalisation and fragmentation of the workforce, about creeping inequities, and about abnegating proper risk management. Even some of those who are well-disposed towards its aims are concerned that personal budgets in particular have become expensive bureaucratic thicket in which rationing and provider-interest continue to thrive.

For Alex Fox, the way of resolving these problems is to go back to the roots of personalisation and recognise the true challenge it presents, which is not one of administrative adjustment but of profound culture change. Far from being founded on an individualised view of wellbeing, personalisation rests on a deep understanding and respect for how we thrive or falter as people who are embedded in families and communities. So personalisation must go wider than budgets and individual choices, as clearly recognised back in 2007 in the government’s Putting People First concordat. For personalisation to succeed it needs to be part of a shift towards prevention and the development of inclusive and supportive communities.

The RSA’s own research and practice supports this approach. Our work on social isolation and drug and alcohol recovery, for example, is based on building trust in the capability of individuals, families and communities to forge solutions that are right for them, with the support of services that are re-shaped to respect and support the support ecosystems – formal and informal – of the places they serve. 

For example, the RSA’s Whole Person Recovery Team in West Kent is testing, at scale, a service delivery model that fosters community networks in order to support sustainable, long-term recovery from drug and alcohol abuse. The service attempts to build people’s "recovery capital" by connecting them with the people, groups and places who can become their support ecosystem.  It is a highly personalised and co-productive approach that calls on the creative collaboration of individuals, families and communities. 

Ironically, given the aspirations of the NHS Four Year View, Whole Person Recovery explicitly rejects a medicalised model of addiction and recovery – a reminder, if one were needed, of the  and scale of the task ahead if the health service truly wants to embrace personalisation. For social care, the culture change challenge has been huge. For health, it is likely to be even greater.

Paul Buddery is director of RSA 2020 Public Services

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Is defeat in Stoke the beginning of the end for Paul Nuttall?

The Ukip leader was his party's unity candidate. But after his defeat in Stoke, the old divisions are beginning to show again

In a speech to Ukip’s spring conference in Bolton on February 17, the party’s once and probably future leader Nigel Farage laid down the gauntlet for his successor, Paul Nuttall. Stoke’s by-election was “fundamental” to the future of the party – and Nuttall had to win.
 
One week on, Nuttall has failed that test miserably and thrown the fundamental questions hanging over Ukip’s future into harsh relief. 

For all his bullish talk of supplanting Labour in its industrial heartlands, the Ukip leader only managed to increase the party’s vote share by 2.2 percentage points on 2015. This paltry increase came despite Stoke’s 70 per cent Brexit majority, and a media narrative that was, until the revelations around Nuttall and Hillsborough, talking the party’s chances up.
 
So what now for Nuttall? There is, for the time being, little chance of him resigning – and, in truth, few inside Ukip expected him to win. Nuttall was relying on two well-rehearsed lines as get-out-of-jail free cards very early on in the campaign. 

The first was that the seat was a lowly 72 on Ukip’s target list. The second was that he had been leader of party whose image had been tarnished by infighting both figurative and literal for all of 12 weeks – the real work of his project had yet to begin. 

The chances of that project ever succeeding were modest at the very best. After yesterday’s defeat, it looks even more unlikely. Nuttall had originally stated his intention to run in the likely by-election in Leigh, Greater Manchester, when Andy Burnham wins the Greater Manchester metro mayoralty as is expected in May (Wigan, the borough of which Leigh is part, voted 64 per cent for Brexit).

If he goes ahead and stands – which he may well do – he will have to overturn a Labour majority of over 14,000. That, even before the unedifying row over the veracity of his Hillsborough recollections, was always going to be a big challenge. If he goes for it and loses, his leadership – predicated as it is on his supposed ability to win votes in the north - will be dead in the water. 

Nuttall is not entirely to blame, but he is a big part of Ukip’s problem. I visited Stoke the day before The Guardian published its initial report on Nuttall’s Hillsborough claims, and even then Nuttall’s campaign manager admitted that he was unlikely to convince the “hard core” of Conservative voters to back him. 

There are manifold reasons for this, but chief among them is that Nuttall, despite his newfound love of tweed, is no Nigel Farage. Not only does he lack his name recognition and box office appeal, but the sad truth is that the Tory voters Ukip need to attract are much less likely to vote for a party led by a Scouser whose platform consists of reassuring working-class voters their NHS and benefits are safe.
 
It is Farage and his allies – most notably the party’s main donor Arron Banks – who hold the most power over Nuttall’s future. Banks, who Nuttall publicly disowned as a non-member after he said he was “sick to death” of people “milking” the Hillsborough disaster, said on the eve of the Stoke poll that Ukip had to “remain radical” if it wanted to keep receiving his money. Farage himself has said the party’s campaign ought to have been “clearer” on immigration. 

Senior party figures are already briefing against Nuttall and his team in the Telegraph, whose proprietors are chummy with the beer-swilling Farage-Banks axis. They deride him for his efforts to turn Ukip into “NiceKip” or “Nukip” in order to appeal to more women voters, and for the heavy-handedness of his pitch to Labour voters (“There were times when I wondered whether I’ve got a purple rosette or a red one on”, one told the paper). 

It is Nuttall’s policy advisers - the anti-Farage awkward squad of Suzanne Evans, MEP Patrick O’Flynn (who famously branded Farage "snarling, thin-skinned and aggressive") and former leadership candidate Lisa Duffy – come in for the harshest criticism. Herein lies the leader's almost impossible task. Despite having pitched to members as a unity candidate, the two sides’ visions for Ukip are irreconcilable – one urges him to emulate Trump (who Nuttall says he would not have voted for), and the other urges a more moderate tack. 

Endorsing his leader on Question Time last night, Ukip’s sole MP Douglas Carswell blamed the legacy of the party’s Tea Party-inspired 2015 general election campaign, which saw Farage complain about foreigners with HIV using the NHS in ITV’s leaders debate, for the party’s poor performance in Stoke. Others, such as MEP Bill Etheridge, say precisely the opposite – that Nuttall must be more like Farage. 

Neither side has yet called for Nuttall’s head. He insists he is “not going anywhere”. With his febrile party no stranger to abortive coup and counter-coup, he is unlikely to be the one who has the final say.