It’s coming up to three years that I have been working with a broad range of teams in the NHS, mostly via NHS North West London and Healthcare Central London, and their overlaps with Westminster City Council, Kensington and Chelsea Council and the vital ecosystem of charities and other organisations that seek to understand and improve the lives, health and wellbeing of residents.
In that time I’ve helped GP practices balance digitisation with humanising technology, and seen the rise of AI as a Swiss army knife for organising conversations, analysing data and summarising direction. I’ve helped to co-design and deliver new operating models for organisational change, visualise and articulate offers such as SEND provision and Vibrant Healthy Communities. I’ve researched the 8am GP rush with patients and staff involving 33 practices, and supported newer initiatives such as Neighbourhood Teams and Community Health and Wellbeing Workers.
This series of three short articles highlight projects I’ve worked on that help describe the future direction of the NHS, supporting the government’s 10-year plan, and the ambitions of our wider health and social service systems in response.
NHS Futures 2 of 3: Better Technology, More Humanity
NHS Futures 3 of 3: Health Ecosystems & Open Cultures
Context and Why This Matters
Our NHS rightly has the cultural status of a national treasure. When the NHS is mentioned, it usually conjures images of hospitals, GPs, nurses, surgeons and clinical equipment, but this is not where most health ‘happens’.
Our homes, neighbourhoods, schools, parks and workplaces are where we spend our time. Our networks of family, friends, colleagues and community are what support our day-to-day health, from nudging us to see a GP to sharing advice on eating well, learning good (and bad) habits from one another and motivating one another to get out and exercise and socialise. All of this largely goes on under the radar, but we know that without these people and places to help our health, we may find ourselves needing clinical help sooner rather than later.
Successive governments can see the if-this-then-that logic case of acting early to improve health and save money, but often stumble at the business case. Most recently, the Government’s 10-year plan using the American vernacular of shifting from a ‘sickness service to a wellbeing service’ highlights a need to focus on preventative and proactive health. It also echoes the systemic challenges and shortcomings of different parts of the US health and social system that I have experienced first-hand as a professional working in that space, and as an occasional patient back when I lived there.
No challenge is more significant than the perennial need to find better ways to support preventative (daily health and wellbeing) and proactive health (early detection and managing conditions) to take pressure off the fire-fighting and reactive part of the system (treating more advanced conditions and freeing up capacity for urgent care).
The Project
The ask was broad and evolving: Convene health, social care and community leaders around a single model that shows the needs and provision amongst 300,000 residents, and can be adopted to show live data, bottlenecks of need and provision, and help to define and commission research and develop high-level business cases for new, renewed and evolving services while retaining and improving the quality of experience, efficiency of delivery and effectiveness of outcomes.
Over the course of a year I switched between an analytical mode; sifting through reports, data, models, strategies and initiatives, and a collaborative mode; gathering consensus and momentum, summarising learnings and running online and in-person workshops, meetings and research initiatives to bring the data and thinking to life and clarify routes forward.
Three definitions and how to respond
Aligning thinking with different stakeholders within the NHS and amongst the ecosystem of social care and community partners helped to drive challenge identification, ideation and problem solving. We also developed a universal business case process for renewing existing services or developing new ones. Although there is a year’s worth of detail behind these, here is a useful summary of the three main areas that were key to outlining the system holistically, and inform the three sections of the ‘tube map’ model further below:
Preventative Health:
Most of our lives and what influences our health happens in our communities, homes and workplaces. Through education and behaviour change, self-management, friends and family support, community assets and activities we can live healthier for longer. This requires listening to residents and understanding our communities, and designing and supporting services that leverage existing community assets, detect and anticipate future need, and inform, educate and enable healthier lifestyles. This understanding should be ongoing and evolving, which is essential to ensuring that all services are accessible, appealing, relevant and effective for all.
Proactive Care:
When managing new or ongoing conditions, we will need professional and formal services to support us. Through diagnosis, population health monitoring, health visits, social care, voluntary and community sector enterprises (VCSE) and social prescribing to name a few, we can also focus upstream, getting people on the radar early and support residents to manage their conditions and recovery. This requires sophisticated data to focus the right resources and support in the right places in our system, and forging strong relationships with system and community partners and staff to continuously improve services.
Reactive Care:
Emergencies, hospital stays, advanced conditions and crisis support require the most intensive services, and is ideally where we would have people spend as little of their lives as possible. We should aim to treat and rehabilitate efficiently and effectively, and plan peoples’ ongoing care and their return home if possible. This requires collaboration between community health partners as well as the formal healthcare system to personalise and improve recovery and reduce future need by harnessing data to act upstream.
The ‘Tube Map’
A useful maxim I had in mind as I tried to represent different strategies and fulfil different purposes and uses was ‘if you can’t draw it, you haven’t figured it all out’.
Sometimes, a single idea and a compelling way to visualise it can help everyone come together.
Known internally and informally as the ‘tube map’, this visualisation of the health system helped to provide a high-level view of where preventative, proactive and reactive services existed on the map, but crucially showed residents as flowing through it, rather than static.
From Static to Flow
The tube map and the activity around it helped shift mindsets from coding conditions and seeing things from a static, system-first perspective, to seeing people flowing through a system at different times in their lives and through different states of health and service use. Rather than just looking at what numbers of residents had which conditions right now, we can see what interventions might impact where they might go next (downstream), what factors upstream have brought them to their current point, and how we can act earlier to keep them circulating in ‘eddies’ of relative good health.
By overlaying population needs with what services and resources are at each step or junction, managers and providers had a visual shorthand of what was going on now, why people were there and what might improve to alleviate pressure on the system by keeping people, wherever possible, in better health upstream. Once the thinking had a foothold amongst colleagues, we had requests for sessions zooming into specific junctions. Needs and provision stock takes were overlaid, bringing in more data, commissioning qualitative and quant research, new service design ideation and validation, and informing the business cases for continuations and changes to services.
This visualisation and the work behind it has taken on a life of its own: It brings data analysts, practitioners and community representatives together to see where resources could be shared and focused to alleviate bottlenecks of need, and what the on-the-ground and underlying causes are of hotspots across the map – from accessibility of services, language, suitability, efficiency, duplication and effectiveness.
The map helps to show where there are opportunities for new and improved formal services, as well as informal interventions such as health campaigns, behaviour change and using social services and community assets to help ensure every resident lives as much of their lives as possible towards the left-hand side of the map and away from the right hand side. Put simply; more healthy years lived relative to each individual.
The tube map helps to justify the logic of preventative and proactive wherever possible, encourages everyone to look upstream to alleviate future pressures and improve the long term health of residents, and aligns with the desire of our health system to be one of health, not just health care.