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NHS England Inequalities Resource on Access to Primary Care

September 6, 2017

NHS Inequality Blog 1.jpg

Here’s the problem. Health Inequalities continue to grow (Kings Fund 2017) and many people who under the Equalities Act are described as having “protected characteristics” such as people with disabilities and mental health problems have seen little improvement in their circumstances (Being Disabled in Britain April 2017).

So, I was pleased to see the launch of the NHS England Inequalities Resource for reducing inequalities in access to general practice.

I have spent the last 4 years or so working with GP, Public Health and Voluntary sector colleagues trying to develop a stronger focus on health inequalities in primary care, problems include:

  • The challenges faced by GPs working in very disadvantaged communities are insufficiently understood and more importantly insufficiently owned at a local health system level.

  • Much guidance fails to sufficiently recognise the social and economic circumstances that affect people’s health and their ability to take control.

  • Many GPs who don’t serve communities who experience multiple disadvantage struggle to understand the complexity of the challenge and why their peers need additional resources.

In many places there are GPs who have dedicated their working career to responding to the needs of disadvantaged groups – such as the homeless, substance misusers and people with a learning disability. Many of them work in economically deprived neighbourhoods – these often have higher numbers of people with protected characteristics too.

Does this resource help?

Well, it is good that it has been produced – better something than nothing in my view – it gives us something to build on.

It is clear that a small team of people have worked hard to pull together existing knowledge on into one place. Regrettably the layout is not up to the task of making this information accessible – its largely a gateway to further large and complex documents  rather than an expert analysis of this complex issue.

This document says it is for CCGs and GPs. I don’t think it is. It offers little challenge to CCGs and no coherent view about what actions CCGs should take to tackle inequalities. I think the main audience are trainee GPs and other relatively new staff working in primary care settings – there is nothing wrong with this but it does not do what it says on the tin.

Its not the fault of the authors of the document but its existence highlights where the deficits are:

  • Tackling inequality is NOT an issue that is experienced in the same way across local health systems. For GPs serving very deprived communities this is the day job – for others inequality is not a systemic issue. This disparity creates an unbalanced discourse at a local level.
  • in my view experienced GPs and their collaborators need help developing strategies to change the hearts and minds of their peers and CCG officers who are not working in disadvantaged communities and that will help challenge CCGs  and Accountable Care Systems to raise their game and their priorities.

We need to recognise that this issue exists primarily because of an imbalance in power – not because of a lack of skills and knowledge. It is a truism that services that seek to respond to the needs of people who lack power are themselves disempowered.

What we need next

We need to establish a systematic and ongoing programme of knowledge exchange – we can learn from the models of the last Labour Government – see David Bucks Kings Fund blog here  and most importantly check out Reducing Health Inequalities – System, Scale and Sustainability from Public Health England who have asked the Chris Bentley to share the learning from the Labour Government’s  National Support Team for Health Inequality.

NHS England and Public Health England needs to commission a long term  system change programme here. Its not just for General Practice to do the changing – that will be easier if we get the right leadership at a local level.

It would help to have:

  • Strategic Analysis of the local equality/health inequality challenge its scale and why it exists – at a place level.
  • Advocacy at a national level for explicit local strategies to tackle inequality
  • Clear examples of systemic models that can be used to create change

What do you think?

 

Access to communities: tailoring services to meet different health needs

August 27, 2017

vcs blog #2

Following my last blog on the growing interest that local health and care systems have in services that connect people with the voluntary and community sector in order to improve their health and wellbeing, I have tried to order some of my ideas into the following tables.

Please bear in mind that these are just some of my thoughts on this – I am not claiming that it is a complete picture or a completely correct one!

One of the problems with putting tables like this together is that I can justifiably be accused of having oversimplified matters – please see the tables as providing a frame for discussion not an exact representation of “what is”.

Please respond with comments suggesting how I could improve the information below and I will try to amend.

Definitions

  • Social prescribing enables GPs, nurses and other primary care professionals to refer people to a range of local, non-clinical services.
  • Local Area Coordination is a long term, integrated evidence based approach to supporting people with disabilities, mental health needs, older people and their families/carers
  • Health Trainers support people to adopt healthier lifestyles through empowering them and helping them to set a personal health plan (PHP). This outlines the individual’s goals for a healthier lifestyle and a plan to achieve these goals.
  • Community health champions are people who, with training and support, voluntarily bring their ability to relate to people and their own life experience to transform health and wellbeing in their communities.
  • Advocacy means getting support from another person to help you express your views and wishes, and to help make sure your voice is heard. Someone who helps you in this way is called your advocate.
  • Welfare rights means the rights of people to be aware of and receive their maximum entitlement to state welfare benefits, and to be treated reasonably well by the welfare system
  • Community anchors are independent community-led organisations.

    They are multi-purpose and provide holistic solutions to local problems and challenges. They are there for the long run, not the quick fix. 

 

Table One – Different services to respond to different needs, different social conditions and differences in power.

Community Support #6.001

Table Two – Description of some of the characteristics of the above services

Community Support Model #5

What do you think?

The welfare benefit system is a public health system

June 25, 2017

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This blog is based on a talk I gave at the recent Faculty of Public Health Conference  – reacting to the Ken Loach film I Daniel Blake.

In a recent blog I set out how public health has struggled to recognise the important contribution that the benefits system makes to wellbeing and tackling health inequalities. We need to think of the benefit system as a public health service.

Nonetheless, we are in a position where this crucially important Public Health Service is increasingly difficult to access and where it is even hard to have a discussion at a local level about how we can ensure that vulnerable populations make best use of it.

A reminder – the NHS budget is just over £100 billion a year and the social welfare spend is £126 billion – not including pensions.

In fact as the figure below from Simon Duffy (Centre for Welfare Reform) shows the actual cost of social welfare to the state is considerably less than this.

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When it comes to public health strategies and practice at a national level we look to two agencies to scope the landscape – Public Heath England and NICE. Between them they would argue that they describe the strategic public health challenges and actions needed to improve population health and tackle health inequalities.

At the conference we heard that this is not the case. Both agencies work within the constraints of Government Policy – Public Heath England strategic focus has to be consistent with the government agenda – not only does it not publicly challenge DWP actions – the only time it mentions welfare payments in its strategies is with regard to actions that will reduce their take up! It also does not offer strategies and actions to ensure that the benefit system is used to its best effect.

PHE Welfare Payments

NICE works to a shopping list of priorities signed off by Government – again this list does not include welfare benefits.

This means that we must not accept that the Public Health England Strategy includes all the issues we need to address and the actions we can take or that it even includes the most important ones! In fact the Public Health England strategy is based on a mixture of evidence and a government ideology.

Local Action

Luckily, local Public Health teams have a degree of autonomy from central government. However there are challenges here too. It is quite difficult to have a system level conversation about access to the welfare benefit system – I think that this is for three reasons:

  • Poisoned Minds – Local leaders find it difficult to engage with an issue that has been represented by large elements of the press and respective governments as being about scroungers and layabouts.
  • Pot of gold – Partly for the reason above local decision makers would rather focus on creating employment and getting people off benefits which is of course commendable. However, there are many unable to work, low paid jobs rely on benefit top up and there is some evidence that people with good financial security through appropriate welfare support are likely to find employment more quickly than those ‘incentivised’ through punitive benefit regimes.
  • Welfare Economy – I suspect that some local leaders worry that a focus on improving access to the benefit system will lead to accusations that they lack ambition and are building an economy that is dependent on ‘handouts’.

Actions

Five actions for local Public Health.

  • Narrative and Conversation – have a strategic conversation at an appropriate level which considers what is known about need, levels of financial insecurity and demand on benefits services (this is difficult because DWP release little local data). Data sources could include StepChange, Citizens Advice, Insolvency Judgement trends, Public Health funeral (Paupers Funeral) trends, local Food Bank data etc. Organisations like the Centre for Welfare Reform and the Money and Mental Health Policy Unit can offer analysis.
  • Investment – consider the current level of investment in welfare rights services – what stories do providers tell of the strategic picture? Too often their data is kept at contract manager level in local systems rather than being used to develop strategies.
  • Focus – Often local Citizens Advice Services are left to get on with it – there is plenty of demand out there. Local commissioners need to understand the whole population effect – in particular are services targeted on the most vulnerable? For example:
    • People with mental health problems such as those receiving IAPT or on the Care Programme Approach
    • People with progressive long term conditions such as Cancer – Macmillan has done tremendous work here
    • Families in poverty especially those who are expecting new children
  • Collaboration – Local Public Heath teams can help by pulling together welfare rights providers and NHS provider and commissioners to consider how to strengthen the contribution of welfare benefits to people with long term conditions.
  • Evidence – local Citizens Advice services have a long track record of translating issues faced by their clients into evidence to challenge policy (I gave a Sheffield example here) local Public Health Teams need to consider how they can strengthen this.

What do you think?

Does Return on Investment help improve Public Involvement in the NHS?

June 14, 2017

 

I recently gave a talk at the annual NICE (National Institute for Health and Care Excellence) conference on a review Leeds Beckett University did of the Bradford District Care NHS Foundation Trust public engagement strategy ‘Involving You’.

NICE has published an account of our work here. Our full report is here.

As I went in to the workshop with my co-presenter Cathy Woffendin (Deputy Director of Nursing at the Trust) I noticed that the sub title to the workshop was “Demonstrating the Return on Investment of patient and public involvement” I should probably have clocked this earlier! When the workshop kicked off I made it clear that we were not going to be looking at this, instead we were going to talk about how we reviewed the actions the Trust was taking to strengthen their relationship with the public and what actions they had taken after our report.

After our presentations one of of the audience asked whether a Return on Investment approach would help decision makers in health take public engagement more seriously.

At the time I was unconvinced by this argument – on the basis that I think we should expect that leaders of NHS organisations have a value base that emphasises the importance of individual and collective relationships with members of the public.

Nonetheless it is perfectly possible to argue that there are financial benefits to having a strong relationship with the public – these include:

  • reducing cost of delays to proposed changes or innovations due to public challenge
  • added value arising from patient/public ideas about how services could be improvement
  • increase in reputation due to being seen as a good responsive health organisation
  • Accountability to local people – strengthening quality of governance

After the conference and prompted by the question I did do a bit of searching and came across a good paper titled Patient and public involvement: how much do we spend and what are the benefits? published in 2015. This is a thoughtful review of current state of play and I recommend that people read it.

The paper recognises the position that I and others have taken:

“Many PPI practitioners are sceptical about any attempt at ‘valuing’ participation practice and see economic and monetary analysis of the costs and benefits as reductions or simplistic”

Nonetheless, the paper’s premise is that it important to measure the cost of Patient and Public Involvement (PPI) with a view to determining its added value.

I remain unconvinced for three reasons – which are all to do with context.

If its small we must measure it!

It seems to me that innovative and low cost activities are too often subject to the greatest demand for evidence on impact and cost. They have to prove their value in a way that mainstream parts of the health infrastructure do not. For example I suspect that more is invested in Quality Assurance teams in Clinical Commissioning Groups than in Patient and Public Engagement – yet there is no call to demonstrate their Return on Investment.

The system is not listening

Sometimes it is too easy for health systems to say that PPI produces little added value – when the reason for this is actually because the health system has not framed its engagement in a way that allows the public to contribute in an effective or powerful way, or even worse when the system lacks the ability or will to respond to challenge from the public.

Deliberative Democracy

Finally, PPI is about deliberative democracy. The UK is a democracy – talking with the public is part of our culture –  we do not need to prove that this brings a ‘Return on Investment’ in order to do it.

Where next

The paper concludes with some ideas about how to measure the cost of PPI. Its a useful list – because it gets us thinking – although I am not sure how practical it is.

Actions

I think that local health organisation should consider:

  1. What is our vision for building our relationship with the public?
  2. What are the actions we are taking to move towards our vision and what resources (number of staff, their grade) we put into this?
  3. How are we changing our organisational culture in order to make it easier for the the public to work with us?

What do you think?

 

The one rule of Social Welfare is don’t talk about Social Welfare

May 16, 2017

  • Imagine a system designed to support the most vulnerable.
  • One that is there to help people get back on their feet and take control of their lives.
  • A system that is as big as the NHS yet we barely talk about it.

I am talking about the Social Welfare system.

In 2013 in the UK the government spent approximately £126 billion on healthcare

This compares to the £215 billion we spent in 2015/16 on social welfare support (including pensions). If we take pensions out of the equation we spent some £125 billion on means tested and disability benefits.

These two systems – health and social welfare – play a crucial role in providing the infrastructure of services that allow vulnerable people to live successfully in the community and help people get through difficult periods in their lives and move on to greater independence.

The Problem

In the Health system we spend a great deal of time, energy and resources trying to work out how to make front line services more accessible to people who need services most. We have powerful population level data on who would benefit from services and who actually uses them – see the Public Health Data I wrote about in my last blog. We know which populations are most likely to have higher prevalence of cancer and coronary heart disease; which populations take up screening services and who ends up in hospital requiring emergency treatment.

With Social Welfare the situation is reversed. Local and national systems put in hardly any effort to understand level of need – for example; the  level of problematic debt among key populations. This leads to an impoverished analysis with no evidence based debate about the type of investment that is required to best meet need.

We end up with comparatively small welfare rights and debt support services such as Citizens Advice Bureau struggling to respond to people in crisis – queues and unmet need are the norm.

Tragically, this failure to take a strategic approach to ensure adequate welfare rights provision means that is more likely that vulnerable people who are already under tremendous stress will be unwell.

As well as being a personal tragedy for them this also impacts on the NHS. For example recipients of Cognitive Behavioural Therapy are less likely to benefit from this NHS service if their problematic debt is not addressed first. As well as impacting on the cost effectiveness of this service it also means it increases the likelihood that these same people will end up presenting at urgent care NHS services such as primary care and accident and emergency.

During this election period we are tripping over examples of vulnerability and pressure that stem from peoples personal financial insecurity. From Cathy Mohans challenge to Teresa May about Personal Independence Payments through to data from the Registry Trust showing that the number of people who have been served with County Court debt judgements in England and Wales has risen to to a 10 year high.

What needs to be done.

First, Leaders in local areas need to have a purposeful conversation about this. I was surprised recently when I raised this issue locally at the reluctance to engage with it. I think that we have absorbed a government message that ensuring that people get the benefits they are entitled to and need demonstrates a lack of ambition – that all we aspire to is a ‘welfare economy’. This mindset does a disservice to the millions of people – many working in low paid insecure jobs for whom access to social welfare support is essential.

Second, I think that local public health leaders must work to produce an analysis that describes the financial status of their populations and the reach of current support services. This is difficult – not least because unlike NHS England the Department for Work and Pensions produces very little useful local information to help planning.

Third, I think that key national agencies such as Public Health England and the Local Government Association should support Citizens Advice, Step Change and important think tanks like the Money and Mental Health Policy Unit to produce place based information and guidance to facilitate local action.

What do you think?