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To tackle Health Equity we must get the Citizens Voice into Due North

January 19, 2015

citizens blog 1

In February there is a ‘one year on’ conference at the University of Chester to consider progress and next steps, since the launch of Due North the report that seeks to articulate a North of England analysis of how we tackle health inequalities.

One of the key points made by the original report is:

“The most disadvantaged members of society lack influence over how public resources are used”

Recommendation 3 of the report focusses on this area specifically:

“share power over resources and increase the influence the public has on how resources are used to improve the determinants of health”

Actions for bodies in the North of England include:

  • Regionalism and government structures – bringing policy making a bit closer than Westminster and developing a stronger collective local government voice across the North of England
  • Access to information – greater transparency of decision making at a local level
  • Participatory Budgeting – more involvement for citizens in financial decisions
  • Mutuals – create more collective forms of ownership
  • Building capacity in communities – to strengthen engagement

There are also a set of actions that government should consider which include:

  • Strengthening the role of local government – increase proportion of public expenditure spent locally, prioritising health equity spend, increase ability of local authority to raise funds
  • Expand role of local healthwatch to hold govt to account for action and progress on health inequalities
  • Co-produce national programmes with local government

There is nothing intrinsically wrong with these recommendations but I think they lack coherence and don’t sufficiently address the original challenge.

The actions feel as though their starting point is concerned with what local public sector bodies consider to be important, their role, their relationship with government; rather than challenging the way in which local public sector bodies relate to communities.

There is not enough about the lived experience of citizens and the relationship that the local state has with them. This means that this section (indeed the whole report) is weak on the role of the community and voluntary sector – especially grass roots community organisations.

So, while I support the calls for more regional government, greater access to information about need and services, and participatory budgeting I think the document over emphasises these at the expense of a weak section at the end (where else!) on community capability.

Regrettably this is reflected by the general lack of emphasis on the contribution of the voluntary and community sector as a whole.

We need more honest local debates about relationships with communities and citizens

If Due North is to achieve real change then I think it needs to revisit its approach to citizens and communities.

Lets face it the arguments articulated in Due North for localism are predicated on the belief that the strongest relationships with citizens happen best at a local level.

The credibility of any proposal to shift power from Westminster or to redress inequality rests on our ability to demonstrate that we can deliver these powerful relationships with citizens.

We have to recognise that we need to put our own house in order, a culture change is required at a local level too. The way Due North is written does not convince me that this is sufficiently recognised.

Of course it is possible to give lots of examples of action at a local level – from Doncaster through to Blackburn with Darwen – that is not sufficient!

We need to recognise that there needs to be ongoing debate with citizens and community organisations to develop a shared view about how to strengthen engagement, involvement and yes…..solidarity.

There is plenty of hopeful stuff going on. I am impressed by the work of the Co-operative Councils who have been leading some of the work here. Local Authorities such as Lambeth are doing really interesting stuff – including developing their Competency Model for Co-operative Councils looking at how to change their relationship with local citizens. I suspect that some of this work is informed by seminal reports like “The Relational State” whose strap line calls calls for “recognising the importance of human relationships could revolutionise the role of the state”

There is a great deal out there – the challenge is to locate this promising activity within a broader analysis of why this is important, where current deficits are and what we need to be doing differently.

We need to avoid leaping into our usual behaviour of renewing neighbourhood committees, laying on a bit of community capacity building and providing some better information and then saying job done”

What do you think?

Making health data more accessible – a good news story from NHS England!

January 5, 2015

data blog 1

What sort of information do we need to influence local health systems effectively? Recently, I came across a good piece of work from Ipsos MORI that raises the bar for good quality accessible information for local activists.

Managing data

We are awash with data, its possible to get hold of useful information if people know where to look. However, finding the data is just the beginning. Too often it is presented in a way that makes it hard to use and interpret unless you have access to analytical expertise which most members of the public and local voluntary organisations don’t.

Not surprisingly much of this data is gathered by Government and national agencies so when we are trying to understand what is happening locally we usually have to look at national data sets and hope that this provides us with local information.

Here is a typical example of a national data set. I wanted to answer the question:

“How many homeless 16 to 17 year olds did Wakefield Council place into Bed and Breakfast in a given year?”

The web search “CLG Homeless Statistics” brings up the page “Homelessness Statistics”. Its a bit unclear where to go from here but a click on the sub heading “live tables” brings me to a page with over 30 spreadsheets and another sub heading “Detailed local authority level responses” a click on this takes me to a collection of 10 spreadsheets showing data by quarter.

I have arrived!

I open the most recent one and find that I am in a large spreadsheet with 8 pages and 330 or so rows (one for each housing authority in England) and some 50 or so columns. If you don’t want to download the spreadsheet you can get a feeling for its size from the screenshot below.

Homelessness Spreadsheet

 

The data I want is in there – but I want a years worth of data – so will need to work my way through 4 of these spreadsheets.

I realise that digging out the Wakefield information is basic bread and butter work if you can use a spreadsheet.

My point is this is not easily accessible information.

Unfortunately providing information in the form of vast spreadsheets is the norm – have a look at the Health and Social Care Information Centre website it is littered with examples, here is one:

Provisional monthly HES for admitted patient care, outpatient and accident and emergency data April to September 2014

Screen Shot 2015-01-04 at 14.21.33

It need not be this way – there is something better.

For another piece of work I was doing I wanted to understand the following:

“How easy is it for people (by age) who work full time to get an appointment at their GP?”

I did a web search for the latest “GP patient survey” This took me straight to the delightfully simple GP Patient Survey Website which has been designed and maintained by Ipsos MORI on behalf of NHS England.

Clicking on “analyse the results” and then “Data Analysis” (this bit is not immediately obvious) takes me to a page where I can pick and choose what I want to look at – click a button and out pops a nice graph – answering my question!

Patient Survey 1

This is a completely different experience. Here there is a helpful interface that allows anyone to gather together data that reflects their area of interest – with the ability to choose a wide range of variables and compare and contrast areas.

It works quickly and apparently reliably. It is possible to produce easily understandable graphs that are clear and straightforward. Ok, I did have to produce 2 graphs to cover the entire age range – but my question is answered!

Credit and the Challenge

Credit to Ipsos MORI and to NHSE – I think I could even give Tim Kelsey a compliment here – first time in this blog!
The question for me is why is this approach not used more often – we should expect more government data to be available in this way. Of course this is also a local issue. If we are to make it easy for local citizens to engage with and influence local health and wellbeing systems then this sort of approach needs to be used more by CCGs, Local Authorities and those putting together Joint Strategic Needs Assessments.

I am sure that there are more good examples out there – if you know of any let me know!

What do you think?

Tackle Health Inequalities? “Due North” says invest in debt advice, cheap credit & welfare rights

November 30, 2014

Blog Due North C4L 2

I set out in an earlier blog how disappointing the Public Health England strategy is and drew attention to the more relevant analysis and strategic framework provided by Due North. This analysis – freed from the hand of government and away from the clinical eye of the CMO is much more focussed on the multi-sectoral, social determinants agenda that local authorities work within.

The analysis of Due North is essentially a socio-economic one which builds on this to also make the case that economic inequity leads to alienation – the ‘Antonovsky argument’.

The report identifies four areas to focus on these are:

  • Tackle poverty and economic inequality
  • Promote healthy development in childhood
  • Share power of resources and increase the influence of the public
  • Strengthen the role of the public sector

I support this framework it makes a refreshing change from the usual lazy public health analysis that invariably defaults to “smoking is the biggest cause of health inequalities”.

The challenge faced by this report is that many of the actions it calls for are long term in nature and are ‘wicked issues’ in other words they are not just complex but addressing them requires a change in the balance of power.

I think that Due North tries to address this complexity by talking to 4 different agendas:

  • National Government – in effect these are manifesto points
  • Aspirational Actions for Local Players – calling for actions which are ethically correct but unlikely to be achieved systematically – across whole populations in the short to medium term.
  • Practical Actions for local players – actions that local leaders can take that could in the short to medium term impact on whole populations.
  • Process Actions – Capturing evidence at a local and national level to challenge and improve policy

As an example I will focus only on the actions on tackling poverty and economic inequality.

There are 17 actions here – however I think that they are mainly in the National Government or Aspirational Actions category as the pie chart below shows. My working out is here

 

Due North Pie Chart II.001

I am not arguing against any of the recommendations but it is crucial that local authorities focus on what they can do to make a practical difference to people now.

Action 1 – Draw up health equity strategies that include measures to ameliorate and prevent poverty among residents in each agency’s patch

On the pie chart above this is the one action that I have put in the category of having the potential to have a population impact in the short/medium term, it is concerned with:

  • supporting networks of credit unions and other community finance initiatives
  • controlling pay day lenders
  • debt counselling
  • benefits advice

Although appearing first, this is only one action among many – but I think it is the most important, because local commissioners can make a real difference here through investing in the above provision systematically. It is therefore crucial that local health and wellbeing boards prioritise action to develop strategies that ensure that all of their most vulnerable populations have equitable access to these services. I find it surprising that most local authority areas still do not have clear, aspirational strategies on financial inclusion. Due North is a powerful powerful spur to resolving this.

There is a good body of evidence on population groups that must be targeted systematically for example:

People with Mental Health Problems – Royal College of Psychiatrists – Debt and Mental Health and Centre for Mental Health Welfare Advice for people who use mental health services

People with Disabilities – New Policy Institute (commissioned by JRF) Disability Long Term Conditions and Poverty

People with progressive long term conditions such as Cancer – Macmillan Local Benefits Advice Services an Evidence Review  and Cancers Hidden Price Tag

Local Authorities custodianship of public health is now at an important stage in its development. They can either look to Public Health England with its emphasis on clinical and behavioural change or they can consider rebalancing their public health budgets to ensure that they respond to the Due North challenge by investing in programmes that address financial inclusion for their most vulnerable populations.

What do you think?

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

 The Department of Health’s Health and Social Care Volunteering Fund have published 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?

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