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Public rate NHS England higher than GPs and Hospitals!

April 7, 2014

BLOG Insight dashboard NHSE

The latest data from the NHS England Insights dashboard shows that the public are making more positive comments about NHS England on social media than negative ones this compares far more favourably than comments the public are making about General Practice and Hospital Services.

 

Data for March 2014

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What is the NHS England Insights Dashboard?

The NHSE Insights Dashboard is meant to be a triangulated insight tool that provides a set of measures reflecting feedback to the NHS from patients using services and conversations being had about the NHS. It was due to be launched in April 2013 as an iPAd application – I don’t think this has happened yet. I have no idea how much it costs. However it is part of an ambition that NHS England has to:

“Use online social listening tools to monitor conversations (online comments about the NHS) in detail”

The intention was that from April 2013 NHS England would be able to:

“monitor real time and historically…. a wide range of metrics including volume: force (aggregate influence of conversations); sentiment (whether conversations are positive or negative); demographics (who is having the conversations); and trends (identify trending topics and themes)”

Both of the above quotes come from a paper by Tim Kelsey for the NHS Commissioning Board (now NHSE England Board) produced in February 2013

What does the March Insights Dashboard tell us?

There are a number of possible conclusions here.

  • The first is that NHS England is simply so good that the public holds it in very high regard and this is reflected fairly in the scoring.
  • Second, it could be that as a national agency it may be that NHS England staff and their associates use social media more in the course of their work and are more likely to say positive things about NHS England. Furthermore most members of the public have no idea about NHS England at all so are unlikely to comment or complain about it. The March dashboard includes the period of the NHS Expo.
  • Third, it might be that most of the negative comments about hospitals and GPs could be about the cuts.

Other Insights

If we compare this “insight” data to others we get a different picture. IPSOS MORI in their latest report for the Department of Health note that when people were asked to rate how satisfied they were the last time they visited an NHS hospital or GP their satisfaction ratings were as follows:

  • Inpatient – 85%
  • Outpatient – 84%
  • GP – 83%
  • A&E 80%
  • NHS overall – 66%

Since publishing this blog Steven McDermott at the University of Leeds has sent me a link to a social network analysis he has done of tweets about the NHS – 400,000 tweets by 21,000 over a month. You can see it here.

Comment

Tim Kelsey is clearly keen to drive innovative approaches to insight and voice in NHSE. As he notes in the February report I mention above:

“each month there are approximately 500,000 unique online comments made about the NHS” 

So on the surface it might appear to be a real opportunity to attempt to analyse these. However, so far the insight tool reach seems very limited for example for GPs (using the data above) it only captured comments that equate to about 16 comments per CCG (N = 211).

Tim Kelsey’s Black Box

In addition to the points above the biggest problem is that we cannot see the “workings out” for example:

  • What is the demographic profile of the social media comments being captured – employed/unemployed, old/young, ethnicy, employed/unemployed, professional/non professional
  • What is meant by hospitals – Acute, Community etc?

Of course it could just be that the Insights Dashboard is just not very good… and that this is an example of an ambition to innovate distracting us from focussing on current priorities.

What do you think?

BMA survey of public health workforce – transition and division?

March 31, 2014

BLOG BMA PUBLIC HEALTH

The recent BMA survey of the public health profession provides a useful insight into the current concerns of public health professionals and into the general condition of public health as a profession.

The survey is worth reading. However, I think its message is quite different to the headline statements from the Faculty of Public Health and the BMA. They have chosen to focus on two areas of loss.

Loss of Independence and Loss of Medical Professionals.

“We are particularly concerned that over half of the people surveyed say they don’t have the freedom to speak out. That freedom has saved countless lives in the past when public heath leaders have spoken out, often going against the grain of popular opinion to do so.”

“This survey confirms what our members have been telling us for several years: public health specialists are very concerned that the new public health structures in England are a risk to people’s health. We know the system is working well in some places, but the number of professionals who are considering leaving the public health profession is one of many reasons for concern.”

John Ashton President of the Faculty of Public Health

John is supported here by Penelope Toff the BMA Public Health Committee Co-Chair

“Two thirds of doctors who responded are considering leaving the specialty and more than half of medical trainees are planning to move on.”

Lets have a look at these two questions in turn.

Q – “I have the professional independence I need to speak out on public health issues”

  • Agree – 49.90%
  • Neutral – 23.7%
  • Disagree – 26.4%

Ok, it is possible from the above data to truthfully claim that less than 50% of public health professionals believe they have the professional independence to speak out, after all the figure is .1% below 50%.

But it is equally possible to say:

“Hooray! Twice as many public health professionals feel that they have the professional independence to speak out, compared to those who do not feel they can speak out”

Indeed if we were to put aside those who were neutral we could even claim  that almost 2/3 of public health professionals who have an opinion about this feel that they do have the independence to speak out.

Q – Medics – have you considered leaving the profession in the past two years?

  • Yes – frequently and or seriously – 25.7%
  • Yes – it has crossed my mind – 34.7%
  • No – 36.3%

So from these figures Melanie says 2/3 of medics have considered leaving the profession – presumably she has added together “frequently/seriously” and “its crossed my mind”.

Of course we don’t know how many people who said ‘yes’ have actually left the service and the single largest group are those who have never thought about leaving the service.

In the last 3 years it has ‘crossed my mind’ on a number of occasions that I might go and live on a canal boat, in a remote cottage, travel round the UK in a trawler etc – I have no intention of doing any of these things. (Yes, I know that some people reading this wish very sincerely that I had taken up one of these options.)

I think it is perfectly reasonable for people to indicate that leaving the profession has ‘crossed their mind’ and for them still to be generally happy and committed to their job.

More Survey Problems

Of course the survey has no base line either – so it is hard to know what public health professionals might have said when they were based in the NHS. I can still just about remember those happy days and there were plenty of public health professionals then who felt constrained by the bureaucratic and apolitical straightjacket of the NHS.

So we do not know what the variation is between present perceptions of independence and past perceptions when public health was in the NHS. That is of course what matters.

My favourite question has to be:

Q “In my local authority, the public health grant is not seen as a resource to be raided”

This is beauty! What a loaded question! This implies that some local authorities are being run by Highwaymen or Vikings – excellent! For those of us long in tooth I remember a constant complaint in the NHS was that there was no specific public health budget allocation at all – with any funds having to be fought for and protected every year.

For a good objective account of the current state of play in public health funding read the article by Gareth Iacobucci in the BMJ.  In this there is a thoughtful response by John Middleton (Vice President of the Faculty of Public Health) who notes that:

“My (council) is no different (transferring money from the public health budget), although we are taking the opportunity to remould services in a more evidence based and public health focused approach … Its not wrong to apply public health funding to other areas, but some councils have just done it very crudely”

In the same article Duncan Selbie Chief Executive of Public Health England notes that:

“I welcome local government reviewing where the money has been spent. Local government is pretty advanced in looking at outcome based commissioning and of course they will be looking for more value….. the duty is to improve the public’s health, not to provide a public health service”

 What is the real issue?

I think focusing on loss of independence and funding distracts from addressing a much more important and serious issue which I would suggest is something like this:

“How to develop a strong fit for purpose public health profession that is seen as relevant and useful to local government.” Importantly it also distracts from building on some of the strengths and positives that also come through this survey.

What the survey tells us

This is a profession in transition and as the introduction to the report on the survey notes – a divided one. It seems to me that non medical public health professionals and trainees in particular are generally more positive about how they view the future.

It also seem to me that there are quite large numbers often around 30% who are undecided about the present and future prospects for public health. In some ways this is fair enough – we are only one year into this transition.

There do seem to be as many concerns about Public Health England as there are about working with Local Government.

Some thoughts

  • This is a profession in transition, the Faculty in particular has to come to terms with a changing membership that is increasingly non-medical and recognise and represent their interests more.
  • Public Health is still bedding into the new structures.
  • Its not just about local government – if anything there are more fundamental concerns about Public Health England
  • Trainees are generally positive about their future.
  • Non Medics are positive about the future
  • The independence of Directors of Public Health (whatever that means) is not under threat
  • It is tough in public health – but that is no different to the experience of the rest of local government and the voluntary sector – there are common causes to be made.

Conclusion

It is really important to be working closely with local authorities to design a profession that works for them and not to try to impose the existing model onto them. It is particularly important build on and support those in the profession who are successfully establishing credible relationship within local authorities.

What do you think?

I am really tired of ‘conversations’ about health

March 4, 2014

Conversation Blog

I was pleased to see the recent blog by David Buck at the Kings Fund “Health Inequalities we need a national conversation” calling for more collaboration and clarity between Public Health England, NHS England and the Department of Health. I share his frustration at the continued lack of co-ordination and leadership shown by these big (and comparatively well funded – compared to local authorities) national institutions.

I do however, take a different line. 

First, I am really tired of the way national agencies and government launch into these  national ‘conversations’. So was concerned to see (thanks to David drawing attention to it) that Public Health England have started one of these.

Remember the “NHS Listening Exercise”? What about Tony Blair’s “Big Conversation”? Or David Nicholson’s Call to Action? None grabbed me, maybe some of you reading this thought they were tremendous and made a real difference – if so please leave a comment!

Thus far I have been unimpressed by these attempts to establish a national dialogue with  citizens and local players. They too often feel like a half hearted attempt to engage with the public and front line who already have quite enough to do with getting on with local challenges.

Having said that Public Health England do seem to have a  more considered process which involves focussed interviews with Directors of Public Health, Councillors and local voluntary organisations.

Of course it is important to bring local voice and experience powerfully to national agencies. I just think that dialogue should be built around substantial long term relationships which recognise independence of view rather than fixed term conversations.

As a trustee of Citizens Advice I am impressed by the model that this organisation uses – but they are not unique – There is a long list of NGOs who provide evidence based challenge to policy – they include MIND, CPAG, Barnado’s, Disability Rights UK etc. Some of those get funding from government and its agencies to the irritation of right wing think tanks like the Institute of Economic Affairs who pejoratively  brand these organisations “Sock Puppets” in their recent publication “The Sock Doctrine”.

One of the important services provided by Citizens Advice is to capture the evidence of need that emerges through front line delivery by its 350 or so member Citizens Advice Bureau across the country and interpret this, using it to bring suggestions for policy improvement and sometimes direct policy challenge. Through doing this they directly contribute to making policy better, society fairer and democracy stronger.

I think DH, PHE and NHSE in particular should look across the communities and people they serve and check that they are providing sufficient resource to advocacy organisations ranging from local government to the voluntary sector to ensure that they are exposed to continuous evidence based policy challenge. If they were to do this consistently and in a co-ordinated way they would not need one off ‘Big Conversations” instead they would be continuously exposed to powerful debate and dialogue from organisations who are directly connected to citizens and front line services.

Second, a little comment on David Bucks three national agencies and his suggested actions.

  • NHSE – fully support his call for a greater focus on what primary care can do to tackle health inequalities – as I pointed out in an earlier blog the NHSE inequalities strategy is to put it politely – weak. I do think it is unfortunate though that the two areas that David focusses on are both to do with physical health – the role of  of primary care in addressing poor mental health is crucial here.
  • Public Health England – I am not convinced that David is right in calling for PHE to do more on health impact assessments of other government departments – for the reasons I outline above I think it would be better that PHE funds local government and NGOs to do this work – this will give much more independence and transparency to the challenge.
  • Department of Health – I struggle to have expectations of the Department of Health. While I take David’s point on the Social Value Act I think that local commissioners just need to get on with it and guidance would probably better come from the sectors concerned.

We need to push government not rely on government departments giving us permission.

What do you think?

What on earth are voluntary sector trustees for?

February 19, 2014

trustee blog 2

I have been involved as a trustee or committee member of various voluntary organisations for a long time. Well actually – for a very time.

I have become increasingly concerned that it is us in the voluntary sector who are too often unclear about the role and contribution of trustees. This is ironic because the voluntary contributions of trustees is one key element that makes the voluntary sector different and brings so much added value.

The dead hand of governance

I know that as the conversation turns to governance its time to switch off…. don’t stop reading just yet! I am going to try to avoid getting sucked into a piece on the bone dry world of corporate governance here.

I know they are not elected but being a trustee of a voluntary organisation – local or national – is just as political (with a small ‘p’) as being a councillor, MP or non exec on an NHS trust board but I don’t think this similarity is sufficiently understood or utilised within the sector.

It is too often the case that executive teams see trustees on voluntary bodies as a necessary evil – who will go through and check their work at board meetings – provide some useful support to key internal processes such as HR and Finance and sometimes bring a bit of internal testing on user experience and that – more or less – is it.

This is frankly not good enough. If we are to play to the strengths of the voluntary sector we need to expect that trustees will bring with them much more than this -  here are three examples:

Specialist Technical Knowledge – When I was a trustee of a specialist CAB working in the mental health sector we always had at least one specialist NHS mental health worker on the board and often a current or ex service user of mental health services.

Environmental Analysis – another voluntary organisation that I am currently a trustee of has clearly worked hard to ensure that they have a wide range of trustees who have powerful connections and current experience of the wider social policy environment in which the organisation operates. The board spends little time on long discussions on finance, HR and programme implementation – the CE clearly understands that they have to do the bulk of this work and report on it to the board. Instead the CE uses the board to understand the environment, test ideas and develop strategies for action.

External Relationships – Trustees can bring real added value to developing relationships at the top of organisations. In many cases voluntary sector managers – even at Chief Executive level are compromised. I think that some of the challenges they face can include:

  • Status – executives in a voluntary organisation may be at the top of their organisation but large funders – for example a local authority funding a local voluntary organisation – will see them as effectively a middle manager at best. They will often allocate a fairly junior manager – usually responsible for contracts to manage the relationship. This immediately reduces what should be a strategic relationship to a contractual service provider one.
  • Conflict of interest – discussions about funding – particularly at a time of cuts – can be particularly difficult when these are led by managers whose staff (and indeed the manager) may be materially affected by the outcome of negotiations. This is particularly true when local funders will know that the final decision about financial viability and strategies to address deficits rests legally with the trustees not the manager.

Trustees are actually the custodians of an organisations values and vision – they should be in the best position to articulate these to leaders of other organisations – elected members, MPs, trust governors. They bring with them an experiential authority that comes from their willingness to take on unpaid positions of leadership on voluntary organisations boards. In my experience politicians and non executives understand, respect and value this role and welcome the opportunity to have this sort of dialogue and relationship.

It is through building these strategic relationships that foundations are laid for long term practical joint action and sometimes even funding!
What do you think?

Primary Care, Neighbourhoods and Health Inequalities

February 3, 2014

NHSE in their recent report “Promoting Equality and Tackling Health Inequalities” note that “inequalities in both health outcome and service experience have endured over time despite substantial investment in healthcare” I Neighboorhood blogthink that the reasons are fairly well established – the root causes of health inequalities are fundamentally to do with the social determinants of health – and as the NHSE report says only…

“15 to 20% of the life expectancy gap can be directly influenced by healthcare interventions”

As a CCG non exec I know that there are front line GPs who have a long history of working hard to improve the health and wellbeing of the communities they serve. They are frustrated by the limited range of interventions they can offer – many of which assume that people are in good housing, have stable incomes and have had access to a good education.

We know that there is no magic wand here, many of the people experiencing the greatest health inequalities are under the cosh, even more so at the moment as they are hit from all sides by government policies.

Yet there is more that we can do. There are tremendous long standing examples of good practice which are built around peoples own relationships and communities, they build on their strengths as well as addressing their needs.

One of the best examples in my view are neighbourhood organisations (sometimes referred to as community anchors) that:

  • Provide a range of services and therefore respond holistically to peoples needs
  • Have a history and experience of working with people as assets – as volunteers, employees, trustees
  • Are independent and accountable to local communities

The relationship that these organisations have with some of the most excluded communities is so much more coherent than the transactional one that health service providers find themselves forced to adopt.

The example that is often cited is Bromley by Bow Healthy Living Centre, but there are plenty of other longstanding neighbourhood based community organisations. Many of these are members of Locality – which is the umbrella body for these. Locality was formed through a merger of the British Association of Settlements and Local Action Centres (BASSAC) and the Development Trust Assocation.

…and yet these organisations rarely appear on the radar of health and wellbeing boards and Clinical Commissioning Groups as agencies that are a key part of the solution to addressing health inequalities.

At Leeds Metropolitan University Health Together we did a piece of work with a small number of Locality Members. working with them to capture their views about how local commissioning can better support them in their work. The full report “Strengthening the Voice of neighbourhoods” is available here – its not very long!

Some of the issues that emerged from this work and subsequent discussions at the 2013 Locality Convention included:

The tyranny of public health evidence – There is very narrow view of the evidence which ignores peoples experience as a whole and focusses too much on measurement of clinical conditions and the evidence for clinical solutions. We at Leeds Metropolitan University recently organised a national conference on this topic – and there is more information including speakers videos here.

The commissioning delusion – there is an assumption that most health services need to be commissioned at ‘place level’ (local authority or CCG) rather than at neighbourhood level. I know that many Local Authorities have ambitions to push budgets out to neighbourhoods through Area Committees, Area Panels etc but in my experience they have struggled to gain interest and the amount of funding they have available is usually trivial.

There are a number of options here, some of these are spelled out in ideas from the project we did with Locality members which include:

  • A greater focus on the contribution of neighbourhood structures – not just area committees and panels – but the role of Parish and Town Councils
  • A need for more work at a national level to support good practice guidance on neighbourhood led commissioning
  • A great emphasis on joint/integrated commissioning across CCGs and Local Government
  • More visits to and presentations from grass roots community organisations by health and wellbeing boards and other governance structures.

There are real possibilities to be generated through formal alliances between General Practitioners and their local community neighbourhood organisation – usually a Locality Member or a neighbourhood based health living centre. As well as providing the opportunity to tailor services directly to particular communities it also starts to develop a service model which may help the sustainability of not just small community based organisations but also of independent primary care.

All of these ideas have a fit with continued government interest in Whole Place and Community Budgets. The always excellent House of Commons Library has a useful summary report on these here.

 What do you think?

At last! NHS England Report on health inequalities – but is it any good?

January 6, 2014

NHSE Inequalities

The NHSE board paper “Promoting Equality and Tackling Health Inequalities” is an important paper – it outlines NHS England’s obligations and strategic approach to promoting health and tackling health inequalities and it sets out the priority deliverables for advancing equality and tackling health inequalities.

I am only going to look at the outward facing elements of the paper – not those to do with NHS staffing Equality and Diversity issues.

Role of NHS England

The paper describes the NHSE role as threefold:

  • a system leader
  • a commissioner
  • an employer

This is helpful – particularly the first point – I think that Clinical Commissioning Groups need to think of themselves in this way too – as local system leaders – not just as commissioners. This is expanded on later when it sets out the system leader role:

  • collaborating with other parts of the health and care system
  • convening debate
  • brokering agreement
  • holding up a mirror on performance to the whole of the NHS

Again, I find this confident description of system leadership really helpful – it is precisely the way in which Clinical Commissioning Groups will need to work at a local level if they are to make an impact – and if NHSE will let them! Old fashioned notions of achieving success purely through commissioning, tendering, contracting and performance management have utility but are not sufficient of themselves.

Inequalities

The paper recognises the persistence of inequalities in both health outcomes and service experience in two small sections (7 and 9) and gives some examples – in relation to geographical inequality, poor mental health, rough sleepers and lesbian, gay and bisexual people. It also makes reference to the variation in satisfaction by ethnic group. However, the paper does not place these examples into any wider framework to give a view about why such inequalities and injustice persist.

The paper makes no reference to the wider policy context for example:

  • The impact of cuts to local government and social welfare
  • Government intention to charge migrants for NHS services
  • The impact of government re-calculation of the funding formula to give greater favour to areas with larger elderly populations at the expense of those with greater inequalities
  • the impact of re-assessment of people with a disability to determine eligibility for Employment Support Allowance

Frankly its not acceptable for the key NHSE paper on health inequalities to ignore the impact of the current policy agenda on the most disadvantaged. As I have noted NHSE says that it is ‘the system leader’ here. Well, it needs to work out a way of honestly describing the policy context and its implications for addressing local need. If it cannot present a picture of the world that has some connection with the reality experienced at a local level then its plans will lack credibility.

NHSE needs to raise these issues in a way that recognises the challenge and helps the system navigate solutions and maintains its relationship with Government. I know this is hard – but pretending that this wider policy context does not exist is not the solution.

The report sets out a range of actions.

  • Systematic adoption of the most cost-effective high impact interventions as recommended by NICE
  • Diagnosing killer diseases earlier
  • Improve access to health care for vulnerable populations
  • Involve communities in design of services
  • Integration of care and services
  • Making every contact count – is this really still around? This seems to be one of those phrases that senior NHS and Public Health officials come out with when they are scraping around for a credible sounding action in a meeting.

What is the problem?

Where the paper is particularly poor is in setting out the reasons why the NHS continues to perform poorly in this area. After all this has been a concern for a number of decades – Julian Tudor-Hart – was talking about the inverse care law some 40 odd years ago and a range of agencies and institutions have already identified the challenges a number of which are mentioned in the National Audit Office Report that is mentioned in the paper.

I think some of the key ones are:

  • Fewer GPs weighted for age and need in deprived areas – I would imagine this can be extended to other primary care services.
  • Inconsistent quality primary care practice in deprived areas – including continued use of ineffective interventions.
  • Poor relationships with patients from disadvantaged communities
  • Poor integration of community based NHS services with other neighbourhood services be they VCS or Local Government

Actions

Here are the NHSE Actions with my comments:

  • Robust and visible leadership…….. fairly obvious one this.
  • Robust data – this will be made available for JSNA – nothing wrong with this, although we have much of this already – the Public Health Observatories have been doing this for many years. What would help though would be clear information on the quality of primary care services, range of services and level of investment per head at ward level.
  • Resource allocation supports NHSE duties around inequalities – I have no idea whether the funding allocation agreed by NHSE England on the 18th of December 2013 is a clear indication  of commitment to this objective – can anyone enlighten me?
  • Incentivise and prioritise improvements in primary care – these mainly seem to be financial mechanisms.
  • Embed equality and tackle health inequalities in the CCG assurance regime – the main mechanism here is to develop a mortality indicator – I would have thought that a morbidity indicator is at least as important.
  • Remove derogations that permit geographic variations in care standards – I have no idea how important this is – it does not feel that significant.
  • Support the reduction of mental illness inequalities – I hope this does not get reduced down to trying to persuade people with a mental illness to stop smoking.

Comments

These actions  feel rather narrow, transactional and traditional – basically lets drive change through gathering information, tweaking funding allocations and performance management.

They ignore the need for energy, the need to share promising practice quickly, existing innovation and local diversity. I think we need actions that:

  • support local leaders to drive and participate in powerful active programmes that share learning and experience with local government and the voluntary and community sector.
  • help to develop coherent models of good practice at a neighbourhood level in disadvantaged communities and I think that the expertise for this is just as likely to rest in health and social care trusts, local neighbourhood organisations and local government as it is with CCGs.
  • encourage dialogue and debate about what good might look like locally

What next

I think Clinical Commissioning Groups and Health and Wellbeing Boards need to take up NHSE on its commitment to debate and invite its officer to their meetings to consider the question “are the actions that NHSE have outlined here really the ones that are going to help take this agenda forward?”

What do you think?

Why your NHS Mental Health Trust should provide an independent in house Welfare Rights Service.

December 9, 2013

Blog Welfare Rights and MHEvery year approximately 70,000 people with a Psychosis are supported by the NHS. In most cases while they receive good consistent support from health and social care services the same cannot be said about access to support to address their socio-economic circumstances. Yet these can have a huge impact on their wellbeing and the likelihood of their being admitted to costly NHS services.

Last week Norman Lamb the Minister of State for Care and Support hosted a meeting in the House of Commons launching a report by the Centre for Mental Health on the importance of welfare rights provision for people with a psychosis. As well as many guests from the NHS and voluntary sector James Morris MP who is the Chair of the All Party Parliamentary Group on Mental Health was also there.

The report “Welfare advice for people who use mental health services – developing the business case” is by the Centre’s Chief Economist Michael Parsonage, it looked at the service provided by Sheffield Mental Health CAB (Now part of Sheffield Citizens Advice and Law Centre). SMHCAB provide a service in the Sheffield Health and Social Care NHS Foundation Trust. Here are some facts from the report:

Need

  • Someone with a psychosis is 4 times more likely to be in problematic debt than some one without a psychosis.
  • Of the 622 people seen by Sheffield Mental Health CAB in the period of the study 45% have an income of less than £4,800 a year

The Intervention

  • 20% of the clients seen by the CAB had their income increased by an average of over £4,000
  • On  average there were 8 contacts per client with a further 5 contacts per client with third parties such as benefits offices, housing etc.

The cost

  • It costs the NHS £330 a day for every inpatient stay.
  • The average cost of funding the Sheffield Mental Health CAB Service was £230 per client

The Issue

Sheffield Mental Health CAB have been campaigning on this issue because this sort of specialist independent, but in house service should be available across the country – not just in Sheffield. This is important is because:

  • Welfare rights and advocacy is a specialist area – welfare systems change quickly and as we know are subject to policy changes and poor implementation that can easily disenfranchise those least able to stand up for themselves.
  • In order to support people with a psychosis welfare rights advisors need to be skilled at working within the mental health system and have a good grasp of the specialist clinical and legal practices and constraints in this field.
  • People with a psychosis even if they are not constrained from doing so are very unlikely to want or be able to access community provision. If the service is not brought to them when they are in greatest need the issues (indebtedness, low income, housing insecurity) that will have helped exacerbate their poor health will still be there to create anxiety and despair once they return to the community.

In 2010 SMHCAB began this campaign with a national survey conducted in partnership with the Sheffield Health and Social Care Foundation Trust and with support from Citizens Advice. This survey –  Specialist Advice Services in Mental Health Trusts was launched at a symposium in 2011 (summary of symposium proceedings). It showed that there is unacceptable variation across the country with regard to welfare rights provision for people with a psychosis:

  • Welfare Advice was more likely to be given to community patients rather than inpatients
  • A lot of trusts relied on highlighting services by posters and word of mouth rather than through building welfare rights access into assessments and care pathways.
  • While a lot of trusts indicated they provided services they were not able to say how these services are funded or how they were embedded into mainstream services.

The NHS prides itself on its ability to ensure consistent provision across the country,  this sort of variation is unacceptable. Where examples exist they are usually provided by the voluntary sector who have the expertise and independence but there are other service models – for example Dr Jed Boardman who is Consultant at the South London and Maudsley NHS Trust came to the launch and told me that his trust have their own welfare rights staff working alongside their clinical teams – excellent! But we should not have to rely on chance meetings in committee rooms in the House of Parliament to find out about good practice. At the launch we also heard from another Trust Chief Executive who felt that it was quite possible to develop these services with comparatively little extra resource.

What actions are required next?

The Centre for Mental Health makes the following recommendations in its report:

  • All Mental Health Trusts building access to welfare rights provision into the care pathway – including a recognition of the importance of welfare advice to recovery.
  • Early Intervention – including a greater focus on improved access for young people
  • Local Commissioners should ensure that the need for specialist welfare advice is included in planning and funding of mental health services
  • JSNAs should capture information about welfare rights need and provision with regard to this client group.
  • Key national agencies (Department of Health, NHS England, Public Health England, ADASS should promote awareness of this issue and promote good practice
  • The Department of Health should incorporate relevant indicators on this issue in all outcome frameworks
  • The Care Quality Commission should incorporate assessments on the availability and quality of welfare rights advice in its inspections of mental health services and in its annual surveys
  • There should be more research on this issue by the NIHR

Also lets just note – If Michael Parsonage’s figures are correct and there are 70,000 people with a psychosis seen by NHS Mental Health Trusts every year that means that providing a targeted service to them would cost approximately £16 million to provide this service to all. There are about 50 Community Mental Health Trusts – so thats about £320,000 per trust. In the scheme of things thats peanuts.

What do you think?

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