Place-based health: why local accountability would lead to better quality and outcomes.

AuthorStuddert, Jessica

The NHS is one of our most treasured national institutions. But it is nearly broken. Only localism and the integration of clinical medicine, public health and social care can update Bevan's settlement for the twenty-first century.

Designed in the middle of the twentieth century, the National Health Service is struggling to cope with the demands of the twenty-first. Reform of an institution held dear by the British public is inevitably subject to constrained political parameters. Yet the NHS is creaking under the weight of pressures building up due to demographic changes. Sooner or later it will need a fundamental repurposing. If it is to survive and meet our nation's health needs in the future, the NHS will need to move away from a centrally managed hospital-based model and towards a locally accountable community-centred system of support. (1)

The symptoms of systemic failure are presenting with increasing frequency. The NHS recorded its worst ever performance figures in the first month of 2016. (2) Hospitals are experiencing unprecedented demand and missing waiting time targets for time-critical care. The pressure on hospitals is reflected in their deteriorating finances, which the Public Accounts Committee concluded is occurring 'at a severe and rapid pace.' (3)

This pressure in the acute end of the health service is creating more public political pressure to respond to these symptoms, at the expense of addressing the root causes. The government has committed an extra 8 billion [pounds sterling] a year by 2020 to the NHS, which came at the expense of spending on social care and public health budgets that have been cut and whose reduction will create further burdens on health services. New funding for the NHS has been tied to 22 billion [pounds sterling] of efficiency savings to make up the remainder of the 30 billion [pounds sterling] funding gap the NHS Chief Simon Stevens identified by 2020. (4)

More money and more efficiency may well paper over the cracks. But short term fixes designed to ensure the system limps on until the next election will not address longer term structural pressures which need to be recognised, understood and addressed. Deeper reform should be informed not by the immediate requirements of existing institutions, but rather by the reality of the health needs of the population at large. To do this effectively, we need to take a step back.

When the NHS was established in 1948, life expectancy was sixty-eight years. Today we live an average of thirteen years longer--eighty-one years. As our population ages, more of us are living longer with one or more long-term...

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