The intense and snake oil oozing slogan of the year has of course been “take back control”. It was wot won it for the EU referendum and won the vote for the Brexiteers. Donald Trump noted the power of this verbal drug, and made it a central theme of his winning campaign. Choice and control, like the slogan, have been central planks of English dementia policy, but actually can pass under similar levels of lack of scrutiny. For example, anyone with dementia who has full legal capacity but is known to make dodgy risky decisions on account of the function of his or her brain one should have ready adequate safeguarding processes in the use of a personal budget, but unfortunately where ideology trumps good clinical practice, problems lie ahead.
In a rather quick answer in the evidence gathering session of the NHS Sustainability Committee, Dame Sally Davies, the current Chief Medical Officer, gave the briefest of description of the impact of austerity in strategy analysis and future implementation. And yet the implementation of this political policy, which has seen national debt explode and immeasurable cuts, has had an impact on an ability of provision of dementia care.
If you take as a basic definition that innovation is the successful implementation of new ideas, I feel that it makes intuitive sense to think of ‘frugal innovation’ as a valid solution for residential care in dementia, as it “responds to limitations in resources, whether financial, material or institutional, and using a range of methods, turns these constraints into an advantage” according to a Nesta definition.
It is anticipated that successful frugal innovations are not only low cost, but outperform the alternative, and can be made available at large scale, and, often, but not always, frugal innovations have an explicitly social mission. I came across this ‘social mission’ in a drive for innovation when reviewing the impact of the work of Buurtzorg Nederland earlier this year for my book on enhancing health and wellbeing in dementia to be published early next year.
Even the briefest scan of recent frugal innovations in India will convince you of the rather unusual skillset and mindset required for frugal innovation, along with a huge price-sensitive market and a willingness to experiment. There is no doubting the scale of the financial distress of the NHS and social care, and yet extreme conditions and major gaps in service provision are exactly what provide the perfect storm for the provision of frugal innovations.
Strengths in service and business model innovation create an advantage in creative remodelling of product-service ecosystems. In terms of thinking about the future ‘sustainability’ of the NHS, some further factors loom on the horizon, such as the sheer numbers of people in the ‘aged bracket’ (even though the prevalence of dementia is falling).
People I know are generally sick of ‘change’, ‘leadership’, ‘innovation’ and ‘social movements’ in the social media especially Twitter, and yet continuing with the status quo for residential care of people with dementia, with highly complex needs in health and social care, and profound co-morbidities, is barely an option. Prof Sube Banerjee kindly grew attention to the prominence of both factors in his plenary at UK Dementia Congress this year in Brighton, and I could not agree more with his appraisal. Sube kindly did the main foreword for my new book.
Caring for rapidly ageing societies will require completely new approaches to health and social care, including the radical rethinking of the generation of value that is apparent in some examples of successful frugal innovation. But also on the event horizon is that we do not know yet whether technology will provide a massive financial dead weight or will end up being the saviour. I suspect in fact it will be the latter, because new technology platforms are drastically reducing the cost of some forms of innovation, which is creating huge new opportunities for frugal innovators, particularly in services. When Tony Benn became Minister for Technology in 1968, the question was not whether to use technology, but how technology could be most intelligently used. This will continue to be a major theme in enhancing health in care homes (“EHCH”).
Formulating strategy for dementia is by and large difficult, for other uncertainties and risks on the event horizon (some of which extend far beyond the time scale of most electoral cycles). The compression of morbidity depends on the scale and pace determined by the success of neuropharmacological development, and, like the workforce in the care industry, Brexit might have a rôle to play there. At the moment, the Government has no idea how much money could be saved by adequately addressing the social determinants of health, although one could possibly hazard a guess at the financial costings of discrete areas of harm such as obesity in Glasgow or alcoholism in Liverpool, stereotypes aside. We don’t know how much there will be in the way of ‘proceeds of growth’ as the UK economy seems to become one giant ‘gig economy’, and essential drivers of policy seem to be undergoing volte face reform at the drop of a hat, such as the pension ‘triple lock’.
I myself am quite a way on the left of centre of politics, but I do worry about the extent of shroud waving concerning the future. The system as a whole needs confidence to listen to all views (“nothing about us without all of us”), and needs to fund innovations properly or else they will essentially will be set up to fail. There is no doubt in mind that two message that ‘sustainability and transformation plans’ concerning frugal innovation, namely ‘it entails making better things, not just cheaper things’ and ‘frugal innovation is about remodelling, not just de–featuring’, have become somewhat lost in translation in some areas. Given the sudden launch of the re-disorganisation of the Lansley reforms in 2012, there is a profound mistrust of Government introducing any change. Big Charity also loom large on the profound mistrust agenda, as nobody in public really knows where Dementia Friends from the Alzheimer’s Society came from at the drop of a hat in 2012.
The problem with the sustainability and transformation plans is that they can too easily be interpreted as a cover for cuts, downgrading drastically the offering from the NHS and social care, so that politicians can conveniently avoid funding care adequately. With a public sector on its knees, services then become ripe for privatisation. There’s no doubt in my mind that the ideological drive to introduce private markets in the NHS and social care has done much to add additional costs and waste, at the expense of quality (for example safe staffing), but likewise it would be unreasonable, to take the Aunt Sally argument, for every computer in the NHS to be built by the State.
I feel that there has now to be some degree of trust in ‘taking back control’, otherwise policy in dementia is run by mutual collusion behind close doors by Big Charity and the Cabinet Office. There is much better news from @NHSEngland’s EHCH programme. Currently, within six vanguard areas, care homes are working closely with the NHS, local authorities, the voluntary sector, carers and families to optimise the health of their residents. The enhanced health in care homes care model is an adjunct to the other new care models that are delivering whole population healthcare. It will become a core element of the multispecialty community provider and primary and acute care system models.
And for me there are essential shifts in gear which are going to take place in EHCH (full details of the new framework as published in September 2016 are here.) It’s essential to get rid of a narrow focus on medical rather than holistic needs; a financially distressed care provider market which will inevitably impact on quality in some care homes; and there are unnecessary barriers between organisations in different parts of the health service and between the NHS and other sectors, in particular social care getting in the way rather than facilitating the implementation of health and care planning.
The EHCH vanguards have identifed the following conditions which are critical for success, and I agree with all of them. [Figure reproduced under open government license.]
And we cannot get away from funding – if it is a choice between general taxation and insurance, general taxation wins hands down for me. Firstly, if NHS England wants to usher in a new age of personal genomics where risk of dementia can be predicted quite accurately to some extent, this can impose an information asymmetry unless there is full non genetic discrimination which would make the operation of private insurance markets unworkable. Also, if you wish to send out public health messages about prevention and risk reduction of dementia (and we know they’re unreliable – for example low education is a risk factor for dementia allegedly, and yet Ronald Reagan, Harold Wilson and Margaret Thatcher are all described as developing dementia in their latter years), then it falls within the scope of private insurance providers to invalidate your insurance if you do not disclose or misrepresent your lifestyle having taken out a policy (i.e. you claim to eat and smoke within safe limits, but you don’t, and actually are putting yourself at higher risk of dementia.)
Taking back control over dementia policy is going to be tricky, but in the same way immigrants are not to blame for the quality of your public services, the number of older people or people with dementia should not be blamed either. The future is a different place – they do things differently there.