In 1962, President John F. Kennedy arrived at NASA headquarters for a progress update on the planned trip to the moon. He was treated to a tour of the facilities. And, midway through the tour, he met a man carrying a broom.

Kennedy asked the man what he did at NASA. Rather than saying, “I'm the caretaker”, the man replied:

“I’m helping to put a man on the moon.”

This story* is usually told to illustrate the virtue of organisations being permeated with purpose: that ‘even the caretaker’ knew how they were contributing to the mission. 

Faced with the same story, the NHS would probably see an opportunity for enhanced accountability. Surely the caretaker’s contribution could be measured and managed?

Before he knew it, the poor guy would be asked for quarterly KPIs. His review meetings would zero in on his performance against measures such as: ‘Number of Rockets Launched’, ‘Number of Men on Moon’, ‘Small Steps / Giant Leaps Taken’. That kind of thing.

Minus the absurdity, neighbourhood health seems to be facing a similar move. To an apparently growing extent, it is being judged by its ability to achieve outcomes largely out of its control. Namely: hospital activity and cost.

Perhaps because of the political heat on hospitals? Perhaps because available NHS data is so hospital-centric? Perhaps because there is a well-worn path to using hospital-based measures to assess community-based services? 

Whatever the explanation, the attentional spotlight seems to be narrowing. Effective neighbourhood working is being conflated with reducing hospital activity. This seems especially true when it comes to questions of funding and potential neighbourhood contracts.

The logic goes:

If neighbourhood working can prevent hospital activity…

…then commissioners could pay hospitals less (sometimes this point comes with discussion of ‘ward closures’ and ‘cashable savings’)…

…which means they could – perhaps via a new contractual form – then channel this money into neighbourhood health (sometimes this point comes with talk of ‘double running’***).

This logic is not entirely misguided. There is truth in it. Neighbourhood-based services can indeed mitigate some of the demand that ends up as hospital activity.

We believe in, and are supporting, these efforts. The Strategy Unit has exerted significant effort to show which kinds of activity can be mitigated by community-based support. We are working to apply these insights in practice. And we are pointing out other safe bets along the way.

On some level at least, it is utterly reasonable to ask about the effect of neighbourhood working on hospital activity. 

And yet, the main determinant of hospital activity is…well…hospital activity.

For example:

• Our recent analysis for the New Hospitals Programme showed that the growth in hospital activity between 2011 and 2019 was explained more by medical innovation than population need.
• Our work for the Health Foundation’s REAL Centre showed that this dynamic drives hospital based activity in a way that is not true for primary and community services. Workforce trends also seem to follow this explanation.
• Our analysis for Integrated Care Boards in the Midlands showed how increased diagnostic activity led to overcrowding and longer waiting lists.
• And our forthcoming analysis on efforts to mitigate hospital activity in English hospitals (2011 to 2020) shows that de-adoption – hospitals ceasing activity themselves – was more a more effective mechanism than demand prevention.

These findings are supported by wider evidence from the Office for Budget Responsibility and OECD. There is subtlety, but the headline is stark: hospital activity (and cost) is primarily driven by innovation and changes in clinical practice in hospitals.

So why put neighbourhood health on the hook for something largely beyond its control? Why make its resources contingent upon this?

And what should those of us who believe in neighbourhood health do?

I say: resist and comply.

We should resist because the main means of reducing hospital activity rest with hospitals and the wider system of innovation and policy. And if the success of neighbourhood health is judged primarily by this narrow metric, then it will almost certainly be deemed a failure.

Neighbourhoods can, and should, primarily prove their value in other terms: improvements in health, reductions in suffering, gains in wellbeing, improvements in staff experience / retention, for example. Part of resisting is producing evidence on these – much more central and much more achievable – outcomes. 

And we should comply because there is a contribution to be made. (And, to be clear: it is a contribution far greater than the caretaker and the moon). So, with the help of tools that the Strategy Unit and others are creating, we should show how community-based care can make a difference to slowing, stemming, and – hopefully – reversing the flow of resources towards hospital-based care.

Neighbourhood health can contribute to creating a less hospital-centric NHS. But, fundamentally, the burden of effort and proof for reducing hospital activity should be with those most able to make this happen: not with neighbourhoods.

Caretakers should not be on the hook for a moonshot.

^{* Probably an apocryphal tale, but as Mark Twain said: ‘Never let the truth get in the way of a good story’**}

^{** Probably also apocryphal.}

^{*** A nightmare PE lesson}.