Covid-19 has reminded us that preventing illness is everyone’s responsibility. Staff working in the health and care system have made a vital contribution, but so too have the people and communities who have been affected. Measures like hand washing, social distancing, and wearing face masks have slowed the spread of the virus and have been underpinned by the willingness of people to come forward to be vaccinated.
This lesson must not be lost as the NHS moves into the next stage of the pandemic response and beyond. The focus should not be about placing responsibility solely on people and communities, but rather recognising the contribution we all make alongside health professionals and the government. The language of shared responsibility captures this idea and is not confined to public health threats such as covid-19.
The rationale for shared responsibility can be found in the changing burden of disease. Medical advances have resulted in reductions in premature deaths from major killers such as heart disease, stroke, and cancer. At the same time, increasing numbers of people are living with at least one long-term condition such as diabetes, arthritis, and asthma. Caring for these people makes up the bulk of need and demand in our societies and requires a different response from care providers.
If the primary purpose of the healthcare system was once to provide episodic treatment for people with acute illnesses, it now needs to deliver joined up support for older people and others living with long-term conditions. It must also provide ongoing care for the growing numbers of people who have survived cancers and other major causes of premature death thanks to medical advances. Effective prevention self-evidently depends on people playing their part in making healthy choices.
In his landmark report on NHS funding in 2002, Derek Wanless argued that unless people were “fully engaged” in preventing illness, the costs of the NHS would become unsustainable. Despite progress in reducing cigarette smoking, the fully engaged scenario has not been realised and long-term improvements in life expectancy have stalled. Risk factors such as overweight and obesity have become more significant and inequalities in health have persisted as a result of austerity and other factors.
A few areas have bucked these trends by working differently with people and communities. A well known example is Wigan in the north west of England where during the last decade the council increased spending on voluntary and community sector organisations even as it made deep public spending cuts because of austerity. The support provided by these organisations was more effective than the services that were replaced, and health and social care outcomes for the population improved through the work of the Healthier Wigan Partnership.
Wigan’s experience was shaped by a belief in asset-based community development focusing on people’s strengths rather than their weaknesses. Council staff were trained to speak to the people they served with an open mind, and in so doing to understand the issues that mattered to them. By working to build independence and self-reliance, and giving priority to early intervention, Wigan gave practical expression to the ideas of Hilary Cottam and her arguments for doing things with people and not to them.
Shared responsibility in Wigan is expressed in the Deal with local people. The Deal sets out what the council will do, for example build services around people and families, and what people can contribute, for example get involved in their community. As an example of partnership working, the Deal challenges both paternalistic approaches to public service delivery and overdependence on the part of the public. It is also a pragmatic response to managing demand for and use of services in straitened times.
Examples of shared responsibility in action can be found in many other areas of health and care. They include the expert patients programme, shared decision making, and health coaching to support self-management and behaviour change. Approaches such as peer support and personalised care planning have also demonstrated benefits. The growing interest in co-production with patients, carers, and families shows how partnership working is entering the mainstream of healthcare delivery.
For too long politicians and healthcare leaders have focused on improving healthcare delivery and neglected how people access care and support. Now is the time to recognise that we need a new relationship between health professionals and the public based, as the Wanless report argued, “on the twin planks of public and patient rights and responsibilities.” The experience of Wigan shows that local authorities have a major part to play in forging partnerships with the NHS and the voluntary and community sector in making a reality of Wanless’s aspiration.
It’s important to emphasise that shared responsibility is not the same as personal responsibility which has rightly been criticised for seeking to shift blame to the public. Shared responsibility must recognise the role of government—alongside the NHS and its partners—in creating the conditions in which people can be supported to live healthy lives. The sense that “we are all in this together” may have become a cliché, but the essential truth behind this statement cannot be ignored in the continuing response to covid-19 and other health challenges.
Chris Ham is chair of the Coventry and Warwickshire Integrated Care System, non-executive director of the Royal Free London Hospitals NHS Foundation Trust, and co-chair of the NHS Assembly. He writes here in a personal capacity.
Competing interests: none declared.