In 1995, Francis Fukuyama wrote an influential book called Trust: the social virtues and the creation of prosperity. His central argument was that a nation’s wellbeing was predominantly driven by one thing – the level of trust within it. In particular, he said trust ‘is the expectation that arises within a community of regular, honest and cooperative behaviour, based on commonly shared norms’ (1995: 26).
This concept came to the fore of my mind last week when we jointly hosted a roundtable with ADASS and representatives from Royal Colleges, including the Royal College of Physicians. The question we were debating was whether the barrier to effective discharges from hospital were structural or behavioural. Specifically, why is there a bias towards focusing on different structures, rather than different behaviours or norms? A focus on new policies and systems, rather than new behaviours of cooperation and shared norms. Or as Fukuyama would argue, on building a high trust environment.
We have seen numerous examples of this working across health and care systems. For example, in one system we saw that while all leaders decided to invest in the intermediate care system and increase discharge to assess capacity, this did not automatically result in an increase in uptake. In November 2020, there was a large discrepancy between the number of available slots (14 per day) and those that were used (7 per day). Given the unprecedented capacity requirements during that time, why wasn’t this taken up? The feedback from frontline teams was clear – it was because behavioural barriers and new norms had not been set. This was a theme touched on a number of times during our roundtable discussion.
The roundtable discussion provided invaluable insight, which will feed into our forthcoming joint report with ADASS. What came through was that strategic sector leads believe that now is the ‘Age of Intermediate Care’ and that a focus on culture and behaviours will be absolutely critical to helping people remain at home or get back home following a hospital visit.
Building resilient capacity in hospital – and critically outside, across communities and places – will need to be a focus for central government, the NHS, local government and the VCS for this decade. We clearly need to take learnings into new structures and policies, but focus should equally be, if not more, on building ‘regular, honest and cooperative behaviour, based on commonly shared norms for all involved.
We look forward to sharing more insights with you through our forthcoming report and workshop at ADASS Spring Seminar and other events. If you would like a conversation before then, we would love to hear from you.
James Swaffield, Director and Head of Health, IMPOWER
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