Feature

Community, not consumerism

How can local communities change how services are provided? Community-oriented primary care is one way, explain Steve Iliffe, Kalpa Kharicha and Penny Lenihan

The NHS is struggling to change, with the emphasis on responding to consumer demand and using market resources and forces to bring about change in the ways services work.

Many NHS staff and patients are concerned at the shift towards market thinking in healthcare but do not know if there is an alternative way to promote change and make services responsive to individuals and communities.

An alternative requires ‘bottom-up’ approaches that allow practitioners and service users jointly to lead the process of service re-engineering, with guidance and support from outside sources of information and funding. Methods for doing this have been tested internationally over a 50-year period and are ripe for application in the UK. The key to change lies in the voluntary sector.

The population is ageing and many people, especially in disadvantaged groups, are experiencing an increase in illness and disability. Meeting their complex health and social care needs challenges services and professionals. The Department of Health is attempting to stimulate service development by introducing packages of care standards – the national service frameworks – that require health and social care professionals to meet defined standards of care and to change the ways in which they work.

Although costly and problematic services like care homes preoccupy many NHS and social care managers, the bulk of medical and social problems are dealt with in the community, by primary care services. Primary care trusts require GPs and primary care teams to improve the health of their communities by addressing the health needs of their population, promoting the health of that population and working with other organisations to deliver effective and appropriate care.

Primary care is well established but oriented towards acute illness, single conditions (for example, asthma and diabetes) and health promotion (screening and prevention of illness) in younger age groups.

The complex health problems of later life are insufficiently understood and poorly managed, while the divide between general practice and social care has proved difficult to bridge, causing confusion and allowing needs to go unmet.

Primary care services need to change if they are to meet the needs of an ageing population. But re-engineering primary care is a major challenge, particularly in the ‘top-down’ culture of the NHS where professionals with established roles are well positioned to resist change introduced from above.

Older people’s influence over their own health services is limited by a sense of powerlessness, the complexities of the ever-changing systems and feeling that they are a ‘problem’ or ‘burden’. The extent of participation and involvement of older people in developing health and social care frequently stops at consultation and assessment.

Both service users and professionals find it difficult to translate the outcomes of consultation into sustainable innovations which make a difference to health status and the quality of later life.

Voluntary sector groups face many requests to contribute to consultation or to work in partnership but real change appears elusive. It is time for them to move beyond consultation and closer to ‘ownership’ of services.

Involving patients is seen by the government as a way to make services more responsive and to produce better health outcomes.¹ Invitations to communities to participate in decision making about healthcare will be counterproductive, ‘unless they carry a commitment of time and effort to allow people to feel that they are active partners, and unless policies and plans are open to change as a result of their contribution’.²

However, involving citizens in planning and developing healthcare is in its infancy, with limited research to guide practitioners.³ The most evolved methodology for making public involvement central to service development appears to be Community Oriented Primary Care.

COPC, which has been used as a service development methodology in the US and to a lesser extent in Israel and South Africa, is a ‘bottom-up’ approach. US researchers and practitioners have experimented widely with the COPC approach, primarily in deprived areas. The American Medicine/Public Health initiative has six goals,⁴ recognisable to anyone on a PCT board. They are:

• working together to provide healthcare
• developing a shared view of illness between clinical and public health medicine
• engaging the community
• changing the education process
• creating joint research efforts by clinical and public health investigators
• working jointly to develop healthcare assessment measures.

COPC is ‘more than a philosophy and an orientation: for the COPC practitioner it is an investment in the community and in a practice that restores the social contract between medicine and society’.⁵

In the UK, general practice has likened the introduction of PCTS to COPC.⁶ Earlier exploration of COPC approaches in the UK suggested it creates an educational approach relevant to all the team members, helps practitioners identify patterns in disease, illness and health, supports and develops teamwork processes, and extends audit to explore the whole practice population.⁷

In short, COPC is an interdisciplinary model for planning, implementing and evaluating primary care, health promotion, and disease prevention in the community using a dynamic model (see diagram).The tasks specific to each stage of COPC development are as follows:

1 Define the community: identify the community to be targeted and collect relevant demographic, economical, historical, political and cultural data.

2 Identify the health problem: review existing information, obtain relevant demographic, social, economic, and health data, conduct interviews, focus groups and community surveys where appropriate. Identify unusual clusters of health problems, compared to the national picture. The consultation process should ensure that the community’s priorities are included in the community diagnosis and prioritising stages.

3 Implement an intervention: community members are involved, with existing community resources are used wherever possible. Training community members in skills specific to the COPC intervention may be important. The intervention should include short-term as well as long-term measurable goals and have a public health focus.

4 Evaluate the impact: monitoring, evaluating and reassessing the COPC programme are ongoing and will generally involve qualitative and quantitative methods.

A small research and development team in the department of primary care and population sciences at London’s Royal Free and University College Medical School has had some success in using COPC methods in urban general practice.^{8 9} It has extended from four to 48 practices in a three-phase programme of primary care for older people and is now in a fourth phase, designed to shift the focus from practice level activity towards changes at locality or whole PCT level. Among the lessons learnt is that GPs can be creative in designing and implementing new services for older people, but they have little experience in applying public health perspectives to service re-engineering and so fail to learn from past experience (for example, about the minimal impact of whole population screening).

They also find involving citizens in service development extremely difficult, even though they can understand the advantages in a theoretical way. And multidisciplinary working is understood in narrow terms, with professional roles being retained and work re-design being avoided.

For PCTs, COPC approaches have the potential to make coherent sense of a fragmented set of managerial actions, and to fit with current policy directions, particularly with public involvement in decision-making and management.

PCT managers are aware of the weaknesses of the COPC approach and know that individual professional groups may resist changes in their traditional working styles, but they are seeking ways to integrate multiple policy demands. Will they be able to overcome their own professional narrowness and incorporate the demands of the target culture into a community-centred approach? If they can, is this the alternative to consumerism and the market?