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What no waiting times! NHSE 5 Year Plan – Localism, Challenge and Culture Change?

November 18, 2014

NHSE BLOG

I am surprised to be writing this – but the NHS England 5 Year Forward View  is rather hopeful – there is no reference to waiting times in the whole report!

Analysis

It affirms the resilience of the NHS despite the government’s austerity programmes.

“No health system anywhere in the world in recent times has managed five years of little or no growth without either increasing charges, cutting services or cutting staff. The NHS has been a remarkable exception.”

Its honest about where the NHS needs to improve, in particular the:

  • failure to implement the Wanless ‘fully engaged scenario’ by respective governments and the impact this has had on prevention
  • impact of barriers created by ‘artificial boundaries between hospitals/primary care, health/social care and generalists/ specialists
  • impact of austerity on funding
  • failure to shift funding from hospital to community

“hospital consultants have increased around 3 times faster than GPs and there has only been .6% increase in the number of nurses working in the community over the past 10 years”

It identifies three key gaps:

  • Health and Wellbeing – and the risk that ‘deep’ health inequalities will widen
  • Care and Quality – highlighting some of the particular challenges for a number of groups in particular vulnerable people over the age of 85
  • Funding and Efficiency – the need for ‘reasonable’ funding

Actions

It sets out a range of actions – some of them are helpful while others recycle existing NHS cultural approaches.

So we see the usual focus on behaviour change (hard hitting campaigns, labelling, targeted personal support….yawn) but not enough on advocacy, welfare rights and debt advice – even though there are many NHS services that do provide these. For these we need to turn to the recent Kings Fund/Joseph Rowntree report Tackling poverty: Making more of the NHS in England

“England is too diverse for a ‘one size fits all model’

There is a welcome emphasis on localism with a call for more power for local leaders and commitment to support whole system wrap around service models that bring together health care and community. Two models are proposed – one feels more General Practice led (Multi-Speciality Community Providers) and the other more Hospital led (Primary and Acute Care Systems).

What feels particularly hopeful is an assertive shift to break the purchaser provider split:

“It may make sense for local communities to discuss convergence of care models for the future. This will require a new perspective where leaders look beyond their individual organisations interests and towards the future development of whole health care economies and are rewarded for doing so”

Finally, there are some sections on the importance of the voluntary and community sector and communities. There appears to be a growing understanding of the important role that the VCS can play in building relationships with citizens and helping to bring a whole person approach to support through initiatives like social prescribing and volunteering.

This includes recognising that funding regimes must be more accessible to the VCS.

“we will seek to reduce the time and complexity associated with securing local NHS funding by developing a short national alternative to the standard NHS contract where grant funding may be more appropriate than burdensome contracts and by encouraging funders to commit to multiyear funding wherever possible”

Where next?

NHSE

Lets face it NHSE has inherited a cultural legacy that is too often hierarchical, target led, out of touch with place and used to pleasing government first and communities and citizens second. Thus far its approach to commissioning primary care has felt removed and not sensitive to local need – particularly with regard to disadvantaged communities.

If this documents ambition is to be realised NHSE needs to review its existing structures and the skill sets of its staff. There is talk of an ‘organisational fitness review’ the outcome of this will be crucial to the success of this forward look.

Inequalities

While the front end of the report has solid reference to the impact of inequalities and its causes the actions towards the end of the document are not so crisp. The clearest call seems to be the expectation that hospitals will step in to create community services in disadvantaged areas using the suggested Primary and Acute Care Systems model. If I was in General Practice I would feel uncomfortable about this.

There needs to be an explicit programme of work that focusses on the most disadvantaged communities with a commitment to ensure that additional resources for primary care are fast tracked to these communities.

The voluntary sector

While it is refreshing to see a stronger recognition of the contribution of the VCS and of volunteering there needs to be a major shift in investment and capability. The commitment to simpler procurement, grant aid and longer term funding is welcome. However, there needs to be more substantial and long term investment in:

  • Capturing good practice and improving VCS capability
  • Using portfolio approaches – as pioneered by the BIG lottery and the Health and Social Care Volunteering Fund to drive innovation and capture learning
  • Infrastructure Organisations – both local and regional
  • small grants – targeted at “below the radar” community groups – The Community Development Foundation have produced a good briefing on this recently.

What do you think?

Public Health England – Evidence into Action – I am not convinced

November 4, 2014

PHE Blog Illus

Reading the Public Heath England report ‘Evidence into Action” I sometimes get the feeling that Duncan Selbie is being held  in a room by the Governments Public Health Minister and a bunch of doctors from the Health Protection Agency.

Every so often he manages to get out a passing reference to inequality or the social determinants of health – but for most of the time all that escapes the room is talk of diseases, clinical interventions and changing the behaviour of the irresponsible public.

The values are right.

“Evidence into Action” starts by recognising the importance of a new approach:

  • that encourages everyone to gain more control of their health
  • where prevention and early intervention are the norm
  • where action on health inequalities is across all the wider determinants of health
  • where assets of individuals families and communities are built on to support improved health

Unfortunately aside from a passing reference to “Due North” which is in effect the unofficial Public Health England Strategy (it has a very strong focus on the social determinants of health) the report rapidly defaults to a clinical view of priorities with the majority of the document focussing on 7 very traditional public health areas with predominantly technocratic solutions that fail to recognise the socio-economic circumstances that people live in.

These traditional areas are:

  • Obesity
  • Smoking
  • Drinking
  • Best Start in Life
  • Dementia
  • Anti-Microbial Resistance
  • Tuberculosis

The rot sets in on page 6 with a graph which; while making the case that health care makes only a small contribution to preventing premature death also implies that the biggest contribution to premature death is behaviour. This contrasts with information that PHE was sharing in 2012 (Spotlight on wellness) when Duncan Selbie was clear that the biggest factors that affects the health  outcomes were socio-economic.

PHE Chart II.001

This is important because while the rhetoric is about tackling inequality and partnership with citizens the priorities and actions are predominantly all about medical conditions and interventions that fall into one of three categories – treatment, legislation and behaviour change. This approach ignores peoples socio-economic circumstances and reduces citizens to consumers of services or even worse those whose behaviour needs to be changed.

This very traditional approach to breaking people into chunks of conditions or behaviours and then trying to treat these has two effects. It takes away the focus on the whole person and it does not see the socioeconomic context within which people live their lives.

Mental Health

Failing to take a holistic approach allows the focus on mental health to slip through the net (again). Mental Health is mentioned 7 times but always within the context of something else – obesity, smoking, work etc. This lack of attention means that the impact that chronic mental health problems have on people’s ability to take control of their own lives is not acknowledged and as importantly the effect of socio-economic conditions on mental health – debt, impact of welfare reforms, stress of exploitative employment (zero hours etc) is not heard.

Tuberculosis is a disease of poverty

A further example of the effect of failing to recognise the impact of socio-economic context comes in the section on tuberculosis. In fairness the report notes that TB disproportionately affects the most deprived communities. However it then sets out a set of actions that focus on structural change and clinical interventions. Nothing about poverty, decline in access to and quantity of housing, the growth of low wages and impermanent employment economies!

What is to be done?

I have now seen two public health ministers in their addresses at conferences say directly to Duncan Selbie – ‘we want Public Health England to challenge government policy – be a thorn in our side’. I think it is clear from this document that this is the last thing the government wants. The Department of Health clearly treats Public Health England as one of its dominions and has no intention of granting it even the limited freedom that NHS England ‘enjoys’.

Luckily there are those in Public Health England who are willing to support arms length initiatives – such as Due North which better reflect local priorities and reality on the ground.

What do you think?

I am not going to play by your rules! The ‘value’ of Volunteering

October 20, 2014

Volunteering Blog 2

There are many organisations mainly in the voluntary sector that have a tremendous story to tell about what volunteers can achieve – and many need funding in order to sustain and develop this further.

In my previous blog I described the excellent work of 6 organisations and outlined some of the strategies that they have used to make the case for funding.

I think that the challenge we face is that in England we live in a state that is increasingly marketised and centralised.

Marketised

In the marketing paradigm the route to securing funding from the state is an apparently rational one – its something like this:

  • Demonstrate that there is an unmet need that has a cost on society
  • Show how you can meet it – and quantify how much this will cost
  • Evidence that savings can be generated
  • Prove that your option is cheaper than any alternative

Centralised

The UK is one of the most centralised western states. In order to be able to function government and its proxies (Public Health England, NHS England etc) need information that can assure them that public money is being well spent and issues of concern are being resolved.

Here is part of an infographic produced by the Centre for Cities based on information from the OECD contained in their report Cities Outlook 2014

Cities have little control over their own money

Because government and its agencies are so centralised they require a range of metrics that bring local experience closer to them – so we have developed a complex series of standard indicators (Outcome Frameworks, QALYs, QIPP etc) that all serve to provide information to these centralised agencies.

These measures – that we sometimes think demonstrate our technical sophistication at keeping track of population wellbeing can also be seen as showing just how centralised we have become!

What about volunteering?

I think that these two systems (the market and the centralised state) and their need for metrics are antithetical to the premise on which volunteering is based.

Volunteering often arises to meet need where there are no services or where there is a gap in services. Indeed, volunteering often develops in places that officials thought did not exist – and therefore did not fund. This is because these spaces had not been measured before or could not be satisfactorily measured because of their complexity and multi-causality.

For example, a lot of volunteering is concerned with the the relationship between the individual and society or between the individual and other services. Of course just because these areas cannot be easily measured does not mean that they are unimportant – far from it – our connection with the state and other people is crucial to our wellbeing – as some of the excellent national work on loneliness demonstrates.

An example of this multi-dimension benefit of volunteering to volunteers and wider society is set out here in this useful report from Citizens advice that came out last year.

Can we have some funding please?

The problem arises when organisations who provide volunteers are asked to justify their case for public funding. They find that they have to do so using a set of arguments that are designed to determine value in a market place or provide reassurance of impact to a centrally led government agency.

My point is that we – citizens who volunteer – do not go into this gift relationship (for that is what volunteering is) because we want to secure market position, generate savings or meet government targets – we do it because we wish to give our time and skill to help people and generally the only evidence of success we require is what the people who receive support from this volunteering feel and say.

So, while there is policy ambition and rhetoric for increasing volunteering – as long as we continue to try to measure and justify it using models that are about just about market value or government ‘outcomes’ volunteering will struggle to get funded – or risk becoming a commodity.

There is a real risk that this will actually lead to a less innovative, more ossified and less diverse system of delivery and  the contribution that volunteering makes to civic engagement and cohesion will be weakened.

Of course some of the work that is going on at present with regard to implementation of the Social Value Act may offer part of the solution – as part of this I think that there is an urgent need to look again at the respective roles of grants and co-produced service design to ensure that local commissioners are enabled to take a balanced approach when determining which model works best for them.

What do you think?

We need to be much better at understanding the contribution that volunteers make to health and wellbeing.

October 1, 2014

HSCVF Blog

This week the Department of Health’s Health and Social Care Volunteering Fund publish a piece of work that I completed with two colleagues (Sue Cook and Jennie Chapman). We have produced a guide on sustainability for projects that support health and wellbeing through services using volunteers.

The 6 voluntary organisations we spoke to worked with a wide range of people.

Care Network in Blackburn with Darwen – support isolated elderly people through providing an escorted shopping service and through that social contact.

Hull and East Yorkshire MIND – volunteers supporting mainstream mental health services provided by MIND

Opening Doors in Norwich – a self advocacy organisation for people with a learning disability supporting people access health and care services

Unite Carers in Mid-Devon – volunteers supporting carers of people with Alzheimers

Stroke Action – volunteers working as stroke ambassadors

Fast 4WD in Blackburn with Darwen – Recovery support volunteers support current service users

If you would like to get a feeling for what these organisations and their volunteers do – listen to them directly – there are good short videos all about 7 or 8 minutes long, here are links to each video  Stroke Action in Enfield Unite Carers in TivertonFast 4WD, Opening Doors, Care Network and Hull and East Riding MIND – watch them all!

Although at different stages of development these organisations had all been successful in providing services of consistently good quality and in some cases one that is a key part of a health and social care pathway (for example Fast 4WD and Stroke Action).

One of the issues that emerged from this work was that despite the fact that these projects had been funded by the Department of Health – the area where they really struggled to get funding was from the NHS. Often, the closest they seemed to come to getting ‘health’ funding was through the Public Health budgets – that are of course now part of local government.

There are of course a number of reasons for this – some of which are explained in the videos themselves. I want to touch on two.

Clinical Medicine is not the whole cure

The NHS still defaults too readily to thinking that heath interventions end when someone leaves the clinic – be that a hospital or a GP. In the past this was excused by the distinction being made between health and social care provision (some will remember the debate about when was a bath a social care one and when was it a health one!). I think increasingly it is understood that the dividing line is not sharp – particularly when we take into account mental health and wellbeing – as some of the stories on the videos eloquently describe.

I would like to think that the repeated statements of the need for greater parity for mental health and proposals for greater integration of health and social care might help resolve this artificial divide..

Local Commissioning

The other thing that was striking about the work was the lack of coherent commissioning strategies that set out the ambition an area has for what sort of voluntary sector provision and what level of volunteering it might like to see there.

Imagine having a commissioning strategy that described the local priorities and then ignored the local hospital or GPs? Well this is what it often feels like for the voluntary and community sector.

It is still the case that too many commissioning strategies fail to recognise the importance of the voluntary sector and volunteering and don’t consider what needs to be done to enable this sector to flourish and grow.

So, all credit to the 6 fantastic organisations (there are of course many more out there) who contributed their experience and wisdom to the videos and the briefing we have produced.

Sue, Jennie and I were inspired by the organisations and volunteers we met – the struggle continues!

What do you think?

Too weak on inequality – Chief Medical Officer Report on Public Mental Health

September 15, 2014

CMO IV

There are important messages in the Chief Medical Officers Report on Public Mental Health that will be welcomed by many – in particular her championing of the need for further investment in mental health services, reduction of waiting times and her call for greater support for people with mental health problems to maintain their jobs. There is a good section on the work of Time to Change a BIG lottery portfolio addressing stigma delivered by MIND and Rethink with strong support for its continuation.

Inequality is in there…just.

However, this is primarily a clinical report (not surprising with approximately 90% of the authors being medics) the wider social conditions that people live in receive insufficient attention. Frankly, given the evidence that the bottom quintile are more than twice as likely to be at risk of mental illness than the top quintile this is more than a small omission – this is very poor – not good use of the evidence.

Risk of Mental Illness Quintile

This failure to give due weight to inequality and in particular the impact of poverty, financial insecurity and indebtedness (for more on indebtedness and mental health see my earlier blog here) on mental health reinforces the focus on clinical solutions to social causes. To the credit of the authors of Chapter 7 (Stansfield, McManus, Bhui and Jones) indebtedness is mentioned in Chapter 7 where they recommend:

“evaluation of the impact of debt reduction intervention programmes is needed. The fact that, before the recession, a quarter of people with mental disorder were in debt has direct implications for effective clinical assessments and care planning as well as for awareness in debt counselling agencies, utility companies and financial organisations”

Shamefully even this recommendation does not float through to the key recommendations made by the CMO.

This is further compounded by the absence of any critique of the impact of Department of Work and Pension policies on the wellbeing of people with mental health problems.

There is one mention of Work Capability Assessments in the whole document with no comment at all on the effectiveness of this service. The current IPPR North briefing “In Safe Hands? Rethinking Employment pathways for ESA claimants with mental health problems” notes that:

“People with mental health problems, who make up 40% of those going through the WCA are being let down by a system that appears to be neither effective nor accurate in determining the appropriate level of financial or employment support for claimant with mental health problems. Equally, the system fails to provide the kind of support for claimants that is adequate or appropriate for people with mental health problems”

This briefing goes on to say that “of the 137,130 participants in the Work Programme with mental and behavioural disorders only 7,060 (5.1%) were successful in sustaining jobs.”

This is not just about stigma – this is a system that is systematically failing people with mental health problems.

Lets take it out on wellbeing

Consistent with the narrow clinical view of much of the document is an attack on the concept of wellbeing. By the way, the CMO clearly thinks that it is more important to spend pages putting the boot into wellbeing than give adequate space to inequality and mental health. The report attacks the concept of wellbeing using a report by CLES consulting and the New Economics Foundation (Big Lottery Fund National Wellbeing Evaluation: Final Report 2013) as a straw man. Frankly, I think it is unacceptable that a senior civil servant uses an official government publication to attack the authors of a report who are given no right of reply in that document.

“One of the most problematic implications of the use of grey literature is the widespread adoption of scientific-sounding statements from well funded but poor-quality studies which are based on flawed methodology. To explain our standpoint more comprehensively, we turn to a case study of a widely cited report covering aspects of well-being and mental health: (prepared by CLES Consulting and New Economics Foundation, 2013). This report offers ‘lessons for service providers, commissioners, the Big Lottery Fund and Government”

This attack is part of a broader critique of the current state of play with regard to what we mean by the term ‘wellbeing’ this leads her to conclude that:

“Well-being interventions should not be commissioned in mental health as there is insufficient evidence to support this.”

Now precisely what does the CMO mean by the above sentence?

What do you think?

Long Term Conditions, Poverty, Welfare Rights and Health

September 1, 2014

welfare rights and health

Just before the summer I participated in a round table discussion on the relationship between health, wellbeing and welfare rights services. This discussion was supported by the excellent Baring Foundation and involved a range of welfare rights organisations including the Advice Services Alliance, Youth Access, the Low Commission and others.

There is a growing body of experience and evidence across a wide range of advice services of the relationship between access to advice and health and wellbeing.

I have written before about the experience of Sheffield Mental Health CAB (now part of Sheffield Citizens Advice and Law Centre) in this regard. What is clearer to me is that there is a strong relationship between increased vulnerability due to poor health and need for advice – I think the relationship is a bit like this:

image

 

The experience of MacMillan Cancer Care confirms this, in their report “Cancers Hidden Price Tag” they tell us that following a cancer diagnosis four in five people (83%) are affected and, on average are £570 a month worse off because of a cancer diagnosis with one in three people experiencing a loss in income averaging £860 a month.

Unfortunately it is still the case that many NHS commissioners are still unconvinced – they usually ask this question:

“Can you demonstrate that there is a causal link between receiving welfare rights advice and being well?”

They should actually be asking another question of course:

“What can we do to stop people with a progressive long term condition falling into poverty?”

For an eloquent and clear statement about the urgent need for reform of social welfare support see this 5 minute interview with Simon Duffy from the Centre for Welfare Reform.

What is to be done?

Despite these challenges and the continued attacks from central government on local authority funding there are some some opportunities that we need to respond to.

The Department of Health draft Care Act guidance recognises the importance of access to welfare rights and advice.

“Information and advice is fundamental to enabling people, carers and families to take control of, and make well informed choices about, their care and support and how they fund it”

The guidance notes that local authorities must ensure that information and advice services established cover more than just basic information about care and support.

The service should also address:

  • prevention of care and support needs
  • finances
  • health
  • housing
  • employment
  • what to do in the event of abuse and neglect

This draft guidance combined with the focus on integration through the Better Care Fund has the potential to transform the position of welfare rights and advocacy provision in the health and social care sector.

It could help ensure that welfare rights services in particular are targetted on the most vulnerable, that their contribution to wellbeing is recognised and that the NHS understands the importance of jointly commissioning services with local government.

What do you think?

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