An Open Letter to the Secretary of State for Health

Abstract

Dear Secretary of State for Health and Social Care

Congratulations on The Labour Party's victory at the last election and your appointment as Secretary of State for Health.

In your speech to the Labour Party Conference on 25 September 2024, you reiterated your manifesto pledge to shift hospital care into the community. Moving care from the most expensive part of the NHS to primary care, and supporting the development of general practice, is a laudable aim. However, the history of successfully achieving this across the United Kingdom is very poor. For instance, despite the NHS Improvement Plan of 2004 aiming to reducing hospital, emergency admissions to hospitals increased by 42% between 2006 and 2018.

The principal aim to reduce hospital care by increasing primary care capacity is unrealistic without promoting the health of the nation. This aim can only be achieved if we move away from an illness service, that is, reactive to people when they become unwell, to one that is more focused on improving health and well-being as a ‘health’ service.

It is globally recognised that the single biggest driver of health, as opposed to disease management, is good social relationships [1]. Evidence shows that good social relationships are four times more effective at reducing all-cause mortality over a 7.5-year period than treating hypertension and more effective than giving up smoking, abstinence from alcohol, losing weight or taking healthy exercise [1]. The reason for this is that humans evolved to be kind. We survived in small groups of 25–100 people over a 2-million-year period through cooperation and care. In this regard, survival of the kindest is a much better phrase than ‘survival of the fittest’ at describing how evolutionary processes work. It is no surprise that the impact of good social relationships is so large when this is used in a therapeutic manner, given that it is mediated through biological pathways, from morphology to the level of gene expression [2].

Good social relationships and belonging have a positive impact on health and well-being [3], with communities based on belonging and connection being a major key to health. Therefore, if the health of the nation is to improve, the emphasis must be on developing strong and supportive communities. The approaches of Compassionate Communities and community development create environments that encourage health promotion [4]. Reorientation of healthcare services in the context of supporting strong communities is in keeping with the five action points of the Ottawa Charter of Health Promotion [4]. Without developing communities and linking this to healthcare, a goal of significantly reducing hospital care is no more than a pipe dream. Simply increasing the workload and workforce in primary care will not resolve the problem of unnecessary health service usage. Rather, health promotion, prevention of ill health, harm reduction and early intervention are the public health principles that can lead to a reduction in health service demand. Whilst the recent Darzi Report on the NHS has strong recommendations of reinvestment in healthcare, there is scant mention of the fundamental role of communities [5].

There are only two published examples of effective interventions that successfully reduced whole population emergency admissions to hospitals. The first is the Nuka System of Care in Native American communities in Alaska [6]. The second is the Compassionate Communities intervention in the market town of Frome–a town of 28,000 people in the county of Somerset, which has a 500,000 population. Whole population emergency admissions in Frome fell by 14% in a 4-year period, whilst in Somerset they went up by 29% [7]. This was achieved by combining building a compassionate community in the town of Frome and reorientating healthcare in the large primary care practice to make the most of community resources.

The Campaign to End Loneliness report in 2023 highlighted that 49.6% of adults (equating to 26 million people in the United Kingdom) feel lonely occasionally, sometimes, often or always when responding to the ONS Direct Measure of Loneliness. Alarmingly, 7.1% of people in Great Britain (3.83 million) experience chronic loneliness, meaning they feel lonely ‘often or always’ [8].

A well-funded, highly functioning social prescribing team may only see 1% of the population, so the vast majority of people who experience loneliness or isolation are untouched by social prescribing. Thus, whilst social prescribing is helpful, in reality, it can only offer support to a small fraction of the people living with loneliness who continue to suffer in silence.

If the government is going to successfully shift healthcare usage out of hospitals, we strongly urge that community development and reorientation of healthcare be embedded at the heart of this effort. The low cost of investment in community development makes this a realistic possibility, where changing the partnerships between primary care practices and communities is critical to the success of improving population health [9]. The importance of this approach has been increasingly recognised over the last 20 years. For example, the 19th and 21st US Surgeon General, Dr Vivek Murthy, published an Advisory on Social Connection [3]. The World Health Organisation also now has a Commission on Social Connection. Furthermore, as Birrell and colleagues point out, a variety of models of care, making the best use of social relationships in groups are preferable to one-to-one management of chronic diseases [10]. The basis for the management of chronic diseases is through group consultations and this should be embedded across the NHS. The reason for doing so is threefold–making use of social connection, codesigning healthy lifestyles at a local level and reducing the cost of provision of a one-to-one chronic disease management service [11].

The Labour Party Manifesto discusses the role of a neighbourhood NHS workforce and this pledge has been repeated a number of times in public by senior politicians, including yourself. Whilst this will help the management of disease, health and well-being come from community connectedness. At the same time as bolstering professional health care support in primary care and community, investment is needed to build strong communities through the practices of compassionate communities and community development. The implementation of the Frome model, which involved the reorientation of health care to align with building connected communities, reduced total health care costs locally by 5% through whole population emergency admission reduction alone. The cost savings released a sixfold return on every pound spent. Some of the infrastructure for this shift is already in place through the development of primary care networks. Moving the emphasis on a protocol-driven service to one of local community development and health service reorientation will be a low-cost alternative to the expensive deployment of large numbers of new staff.

With your support it would be possible to integrate these principles into future healthcare reforms, ensuring that community health becomes central to public health strategy, ultimately improving the health of the nation.

Yours sincerely,

Signatories

Julian Abel

Director, Compassionate Communities UK; retired consultant in palliative care; Visting Professor, Health and Life Sciences, Northumbria University Newcastle, author of The Compassion Project–The Town That Cured Loneliness

Fraser Birrell

Editor-in-Chief, Lifestyle Medicine; Principal Fellow, Higher Education Academy; Engagement Lead, MRC-Versus Arthritis Centre for Integrated Research into Musculoskeletal Ageing (CIMA)

Director of Science & Research, British Society of Lifestyle Medicine; Academic Lead, Shared Medical Appointments UK; Visiting Professor, Northumbria University

Adjunct (Honorary) Professor, Southern Cross University; Honorary Professor of Lifestyle Medicine & Innovation, Population & Health Sciences Institute, Newcastle University; Consultant Rheumatologist, Northumbria Healthcare NHS Foundation Trust

Frances da Cunha

Retired GP and lead for implementation of the Frome Model in the West Mendip area of Somerset

Austen El-Osta

Director, Self-Care Academic Research Unit (SCARU); Department of Primary Care & Public Health, Imperial College London 

Primary Care Research Manager, School of Public Health, Imperial College London 

General Manager, Directorate of Public Health & Primary Care, Imperial College Healthcare NHS Trust

Nina Goldman

Honorary Research Fellow, Manchester Institute for Education, School of Environment, Education and Development, University of Manchester

Honorary Lecturer, School of Public Health, Faculty of Medicine, Imperial College London. Early Career Editorial Board of the journal Health & Place

Chris Ham

Co-Chair of the NHS Assembly; Emeritus Professor of Health Policy and Management, University of Birmingham; and Senior Visiting Fellow at The King's Fund. CEO of the King's Fund 2010–2018

Allan Kellehear

Professor, Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle; Founder of public health palliative care, compassionate cities and compassionate communities

Helen Kingston

Lead GP Frome Medical Practice and founder of the Frome Model

Ed Straw

Visiting Research Fellow at the Open University's Applied Systems Thinking in Practice unit, previous partner and management consultant with PriceWaterhouse, Coopers

Thomas Wood

Associate Professor of Paediatrics and Neuroscience, University of Washington

Trustee and Treasurer, British Society of Lifestyle Medicine

Deputy Editor, Lifestyle Medicine