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?
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?
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 think 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?
The Department of Health Responsibility Deal has been in the news recently as it has claimed credit for reaching agreement with the food industry to remove one and a half olympic swimming pools worth of fat from our diet each year. Now I don’t know whether this is a big figure or not – because I don’t know how many olympic swimming pools of fat we eat each year. Nonetheless this coup allows the Department of Heath to say:
“The Responsibility Deal brings government and industry together to tackle public health issues and improve the health of the nation.”
Lets look at a less high profile area – but arguably one where the potential for impact on peoples lives is far greater – the Responsibility Deal “Mental Health and Wellbeing Pledge”
This pledge aims to “ensure that employers are committed to creating an organisational culture where staff felt valued, respected and able to flourish. The new pledge includes promoting wellbeing and resilience and challenging stigma and discrimination.”
This is a pledge that is not just about supporting people with mental health problems stay in work but is also about creating an organisational culture thats supports good mental health for all.
While the food industry example might appear to be ambitious with DH claiming that over half of the food manufacturing and retail industry have signed up, the mental health pledge actually needs to be even more ambitious this needs to affect all employers.
So it is slightly surprising that so far only 60 organisations have signed up! There is clearly a long way to go. The organisations who have signed up are a mixture of very big private sector companies (for example SERCO) and very small local businesses.
They are also a surprising mixture of statutory, private, and voluntary sectors. The 60 signatories break down as follows: We can see that the private sector makes up approximately one third of signatories, with Government Departments and NHS Trusts making up slightly more than this and the Voluntary and Community Sector comprising just under a third with the remainder being taken up by 1 local authority and 2 educational institutions.
I have created a full list of signatories by sector which is here - Mental Health Responsibility Deal Membership by Sector
This is not system change!
Unfortunately the situation is worse than this. Of the 60 who have signed up to the pledge more than 20 have not published their delivery plan on the website. That means that over one third have not actually committed publicly to any action at all!
So as the following web links show organisations who have not submitted delivery plans (if they had been submitted they would be highlighted in blue as a live link) include:
- Norfolk and Suffolk NHS Foundation Trust
- Guys and St Thomas NHS Foundation Trust
- The Big Life Group
- The Royal College of Opthalmologists
- Public Health England
- Department for Education
- and so on…..
Never mind the width feel the quality!
Things get worse – there is a real variation in the quality of the actions that the remainder have committed to. I am not an expert in this field but it seems to me that there is a clear distinction between standard good HR practice – having systems in place to support individuals with mental health problems and transformational organisational culture that takes employee wellbeing – in particular their mental health – seriously.
A quick scan through the delivery plans of the remaining two thirds who have shared them shows on my count that just over 30 have in place some sort of HR policy that supports people with Mental Health problems and just over 20 have a wider ambition for culture change within the organisation and plans to address this.
I have created a full list of delivery plans by organisation which is available here - Responsibility Deal – Mental Health Delivery Plans from this it seems that only one third of the organisations who have signed up to this pledge have any plans to try to meet it!
What does this mean?
Having read through all of this stuff the first thing to say is that there are some organisations who clearly take this issue really seriously. So, purely on the basis of what they have committed organisations that I take my hat off to include:
- Adnams the Brewers
- Rossendales Ltd
- Government departments including Communities and Local Government and Department for Work and Pensions.
I have no idea what if feels like to work in these organisations – but their plans and intent seem good. However, I have to say that I would be a bit disappointed if I was in the list above and found that that organisations where who appear to be doing little are able to appear as co-signatories. That does rather devalue the commitment given by responsible organisations.
It is important to note that aside from SERCO other big outsourcing companies such as ATOS and A4E have not signed up to this pledge at all. It might be reasonable to expect government contracts to be conditional on employers supporting a pledge such as this?
I touched on this issue in a blog a year ago. Presumably one of the main reasons for publishing this information on the website is to motivate and encourage organisations to join. I have tried to demonstrate in this post that the way information is presented on the website means that it is very hard to get a clear view about what the real picture is with regard to:
- Which sectors are engaged
- Whether organisations are large or small
- The quality of their pledge
- and so on
I suspect that if I were to look at other pledges I would find the same deficits I have identified here, which does make me rather sceptical of the government’s trans-fat claims that I mentioned at the start of the blog. The way in which the information is presented, the poverty of analysis, the lack of quality control speaks not of responsibility but of lack of support and disinterest….by the Department of Health.
What do you think?