Why we struggle to cash the prevention cheque

Image: Carmen Zuniga on Flickr CC

By Phil Swann, Exec Chair

When I first heard about Betty she was in her mid-80s and lived in rural Dorset. Her husband had died a few years ago. She often got nervous at night, sometimes because of a urinary infection. She got in the habit of dialling 999 and an ambulance was sent. She was often admitted to hospital for a night although clinically this was not really necessary.

Betty’s GP spotted what was happening to Betty and to several other people her age. She encouraged of group of ‘younger’ older people to set up of befriending service who were happy to be called by Betty when she got nervous.

She never dialled 999 again.

In theory this should have saved the health service in Dorset tens of thousands of pounds. In reality it didn’t because the capacity freed up was quickly used up; the prevention cheque was not cashed.

I was reminded about Betty when I realised this is the tenth anniversary of Total Place, Gordon Brown’s initiative launched in summer 2009. I worked on the Bournemouth, Dorset and Poole Total Place Pilot which had at its core the following question:

How can we secure improved outcomes for older people at less cost through improved collaboration between agencies, deeper engagement with citizens and communities, and a genuine focus on place?

I’m biased, but I still think that’s a really useful question.

We answered the question. Our report (you can read it here) set out a costed programme to meet the needs of 15 per cent of the older people then in hospital, at home or closer to home. We also developed proposals to enable us to go further, reflecting the data which showed that at least a third of local older people then in hospital did not need to be there and did not want to be there.

In many ways the most significant aspect of our report were the barriers we said had to be overcome in order to deliver our programme:

  •  Leadership and political challenges, particularly around closing cherished local institutions.
  • Organisational and cultural change, including building the trust of patients’ relatives.
  • Governance, particularly winning the confidence of directors of finance.
  • Not being distracted by changes in government initiatives.
  • Building staff capacity to support this level of collaboration.

After Total Place I often shared four reflections on the process. They all still resonate today, ten years later, because the same issues still hold us back from cashing the prevention cheque.

First, the importance of getting buy in at all levels. In the work in Bournemouth, Dorset and Poole I think we neglected middle managers, heads of service and team leaders.

Second, the need to maintain momentum particularly when things get tough. In this respect the very tight timetable for the pilots helped rather than hindered.

Third, the challenge of unleashing people’s ambition and creativity. Three ways of doing this we pursued in the Bournemouth, Dorset and Poole pilot were:

  • Keeping the user and citizen perspective centre-stage and asking the question “how far will what we are proposing go towards delivering what users and citizens tell us they want?”
  • Remembering the money and asking the question “how will what we are proposing help us cope with less resources?”
  • Getting out more and inviting new voices and perspectives in.

Fourth, the need for creative spaces. Those of us who are parents know that children learn as much from playing as they do from school. Organisations need opportunities to learn from playing too, and at its best Total Place provided an opportunity for them to do so.

For some it may seem depressing that the Total Place question – about improved outcomes for less cost through collaboration – and the lessons I identified resonate so strongly ten years later. I remain hopeful, however. Today’s financial imperatives are more powerful than in 2009 and continue to grow daily. If Brexit has taught us anything it is the importance of listening to citizens and communities and acting on what we hear. So as we adjust to another ‘new normal’ I sense renewed appetite to get out more and learn from others and as we do so. But we must do so optimistically, and most of all, be sure not to neglect the need to carve out time for organisational play.

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