The Health and Care system is so complex, the responsibilities so great, the budgets so big that it is often all too easy to think that it is the most important part of peoples lives – the glue that holds everything together. Of course it isn’t – it is really a set of services that are there as a last resort when we can no longer manage on our own.
So, the risk is that while we focus on the challenges faced by health services to meet the needs of people with mental health problems it is possible to lose focus on changes that are happening elsewhere that have the potential to make a grievous impact on the wellbeing of those same people.
Social Welfare Support and Mental Health
Just like the NHS, the social welfare system is meant to provide support to help people engage with society and take control of their own lives. One of these supportive elements is the mobility component of Personal Independence Payments (PIP) which is meant to provide funding to enable people who are unable to leave their home to do so – to go shopping, see their GP, socialise, go to training etc. Subject to assessment, people with mental health problems can either get nothing, the lower rate (£22 pw) or the higher rate (£58 pw). The Government says that people with mental health problems should only be considered for the lower rate.
In November 2016 the Government lost an Upper Tribunal ruling brought in part by Citizens Advice Sheffield which declared that in some cases people with mental health problems SHOULD be eligible for the higher rate because “overwhelming psychological distress” should be considered when assessing the descriptor. This success led to the Government trying to rush a change to the regulations to block this judgement – claiming that this was an emergency! The Government claims that if it did not do this there would be an additional cost to the treasury of £3.7bn over the next five years.
Although the Government denies that changing the regulations in this way will adversely affect people with mental health problems the House of Commons Library Research Paper – Changes to Personal Independence Payment Eligibility Criteria notes that the Governments own Equality Impact Assessment says that this change to the regulations will:
“Affect 336,500 claimants of whom 282.5000 will no longer be entitled to any mobility changes.
These changes could affect people with a wide range of conditions including learning disability, autism schizophrenia, anxiety conditions, social phobias and early dementia.”
This table – also from the Equality Impact Assessment sets out the estimated impact:
Back to the NHS
These changes will affect not only the health and wellbeing of many people with mental health problems who will find it harder to get out of their homes, will become more isolated and less able to improve their wellbeing; it will also affect NHS mental health and primary care who will have more demands placed on already stretched services.
I am concerned at how quiet key players in the health system are with regard to this issue. Despite all the rhetoric associated with the Mental Health Five Year Forward View there appears to be little coherent thinking about the need for acton to address the parlous financial circumstances of many people with mental health programmes and instead a rather superficial take on parity of esteem that gives insufficient attention to health inequalities. Regrettably this (lack of) thinking is replicated in guidance on Sustainability and Transformation Plans and on Accountable Care Systems.
I think that:
- Public Health England need to develop clear models that describe the importance of the relationship between financial security and good mental health – and the actions that need to be taken locally and nationally.
- NHS England could produce guidance and appropriate tools that set out how NHS commissioners and care trusts should connect with key agencies such as Citizens Advice Bureau. Similarly, they could produce some guidance that supports CCGS develop good practice with their GP membership on this issue.
- Finally, NHS England, Public Health England plus professional bodies like the Royal Colleges of General Practice and Psychiatry and theFaculty of Public Health could publicly advise the Department of Work and Pensions on just how damaging these plans are.
What do you think?
The graph shows the widening mortality gap for working age men over the last 75 years or so – it compares the top social class (I) with the bottom one (V). It starts in the 1930’s and ends in the 1990’s – I would be interested to know if there is a more up to date version.
Ever since I came across this graph I have been intrigued by it. This is because I think we take an ahistorical approach to tackling inequality. In part this is because every government that comes in seems to assume that we are at year zero – witness Teresa May’s address from the steps of Downing Street when she took office, but its also because most programmes and actions assume a three to five year timespan – and as the graph shows tackling health inequalities is not a 3 or 5 year project.
So lets have a look at the graph – bear in mind that the graph is comparing the gap in mortality rates for men of working age – comparing social class I (bottom line) with social class V (top line). Note there is no data for 1981 because there was a local registry officer strike that year and no records were kept.
As you can see while the mortality rates for both groups goes down – it goes down far quicker for men in social class I compared to social class V.
Here are some things that stand out for me.
- Prior to the war the gap in mortality rates is fairly narrow and pretty stable. I assume that this is because infectious disease like TB did not discriminate between social class. Nonetheless the narrowness of this gap does surprise me.
- It is after the second World War that the size of the gap really starts to grow, and it does not really stop growing. This is a bit difficult for those of us who are supporters of the NHS – because this is when the NHS was created!
- Of course it could be that without the NHS the gap might have grown faster and been even bigger; or that the NHS had no effect at all or even worse that the NHS is one of the reasons for the growth in the gap! I have toyed around with whether this might be due in part to Tudor Harts inverse care law. However, we are talking about comparisons between social classes V so I am less convinced about this.
- I have wondered whether the size of the gap is in part due to other elements of the post war social contract – such as the increased social mobility bought about by improvements in access to Higher Education.
- When I spoke about this with Chris Bentley (albeit in the pub!) – who was head of the Department of Health; Health Inequalities National Support Team he reckoned it was because the combination of socio-economic disadvantage and burden of disease in Class V since the second world war and onwards meant that many working age men in that group just did not have the wherewithal to keep pace with Social Class I. He particularly mentioned smoking – and the failure of respective government’s to reduce smoking rates among the most disadvantaged at the same rate as for wealthier people.
We are in a very difficult period of government imposed austerity. The Health Inequalities gap appears to be widening – in part because the safety net provided by the state is increasingly threadbare – we see the NHS struggling to provide a consistent and accessible service, adult social care experiencing huge cuts and welfare support diminishing – as is set out in the report by Joseph Rowntree and Dominic Harrison DPH for Blackburn. For me the lesson this graph tells us is that we need to be much better at recognising all of the systemic drivers – not just the NHS – and defending those.
By the way the answer is clearly not more targeted anti-smoking leaflets at the most worse off!
What do you think?
Over the last ten years or so there has been a huge rise in ways in which members of the public can give feedback about their experience of health and care services. This information is one of the ways in which service providers such as hospital trusts, as well as commissioners of these services can get an insight into the quality of services and what needs to improve.
These days there are a range of channels through which people can leave feedback about their experience. These have a variety of purposes:
- Complimenting or complaining about a particular service or experience that will help a service improve.
- Giving a rating that helps other potential service users to decide whether or not to use a particular service
- Creating a dialogue between a ‘customer’ and a provider which might help resolve a problem and build a relationship
- Giving commissioners an insight into how a service is performing through looking at public feedback in the round and comparing this against others.
I think there are 3 main ways in which the opinions and views of people are captured. Some of these rely on the public taking the first step and others reach out to the public.
- Provider organisations all have some way to capture comments and complaints from individuals. These are are specific to the organisation and rely on individual members of the public finding their way to them – they include in house complaints, Friends and Family, PALS services etc.
- Another channel that relies on the public finding their way to them are specialist or stand alone feedback organisations or services such as Patient Opinion, Healthwatch Rate and Review and NHS Choices – these rely on their own publicity or commissioners/providers promoting them.
- Then there are National and Local Surveys that pro-actively reach out to the public and try capture a representative sample of peoples experiences of particular services. These may be useful at a national level but their sample sizes are often quite small at a provider level.
Of course it is not quite as neat and tidy as this – for example Friends and Family is provided at an organisation or service level but there is an expectation that providers will pro-actively encourage people to use it.
Different approaches different insights
The situation is further complicated because these mechanisms vary:
Most are service specific – they focus on peoples view of for example a particular GP or a certain ward.
The one that is probably most sophisticated and different is Patient Opinion which starts in a different place – it asks people to tell the story of their issue and from this constructs and connects with various services who may be able to respond.
Patient Opinion is interesting because it tries to respond to the whole person rather than just treating someone as though they are the sum of their condition. I think this is particularly important given that local health systems are increasingly trying to develop more integrated and personalised services.
The situation is further complicated by how well signposted feedback services are. Here are examples with web links from three NHS Trusts.
This is one click from the main page of the website by clicking on the tab that says ‘your feedback’ one gets access to a range of internal feedback mechanisms.
This is also one click from the main page but a bit harder to find – its on a tab saying ‘Contact Us’ and the feedback form comes after some more administrative information.
Here the link to feedback is shouting out on the main page – although a bit confusing there are then links to internal complaints, comments and advice on how to get in touch with advocacy services.
None of the above organisations appeared to promote independent channels such as Patient Opinion or Healthwatch Rate and Review.
I think that there is inconsistency with regard to how feedback mechanisms are used across the health system. With different channels of varying utility and a wide variation in terms of how they are promoted. For example the government suggests a variety of ways in which Friends and Family information can be collected:
- There are few constraints on the technology used to collect the data, and a number of different methods would be suitable, for example:
- On-line rating: patients are given information including a web link which they can use to log on, enter a reference number and provide their feedback
- SMS/Text message: patients are given the question at the point of discharge, and are able to text their response (providing an opportunity to send follow-up questions to responders)
- Smart phone apps: patients are given details of the app, including a unique reference number, at the point of discharge
- ‘Voting booth’ kiosks or hand held devices: positioned in the location from which the patient is discharged, with ‘voting’ controlled to allow each patient to only vote once
- Telephone survey – patient is given a freephone number and a unique respondent ID to respond within 48 hours
- Postcard solutions: patients are given a postcard at discharge with an option to complete and return on site or to complete at home and post back.
This variation and the range of different feedback channels makes it harder for the public to decide which one to use and more difficult for providers and commissioners to assess the overall picture of public opinion about services.
Its interesting that Healthwatch England have now entered this area with ‘Rate and Review’. While the logic of this is clear – it brings a systematic way for them and CQC to keep in touch with public concerns it also raises more fundamental questions – in particular how they get the balance between being the provider of a feedback channel at the same time as being responsible for stress testing whether or not a system offers adequate and consistent opportunities for feedback.
I do think that there needs to be some thoughtful work done to consider what good might look like and the respective merits of different feedback systems to ensure that we don’t just gather feedback on individual experience but capture this in a way that helps us to develop more integrated local systems.
What do you think?
“Welcome back Trevor! – As Trevor Hopkins says below following his comment on my recent blog I suggested he might like me to post these as a full blog. Instead he has developed some of his arguments about Public Health England and Nudge. My personal view is that the emphasis on behavioural insights is not as strong or as self consciously planned in Public Health England as the article below might lead some to think and that behavioural insight approaches are not as powerful as we might fear. Nonetheless I think as always Trevor’s arguments are worth reading – if only so that we can be clearer about our own analysis – so read on!”
As a guest blogger can I thank Mark for this opportunity to further explore some of the issues that I raised in my recent reply to Mark’s blog ‘Public Health England, Health Trainers and Health Inequalities’.
In my reply to Mark’s excellent piece I stated that I was not surprised, “when a charity can produce a more coherent narrative on behaviour change than the government’s leading Public Health agency.” I laid much of this on PHE’s lack of a “coherent or up to date” theory of public health. As long ago as 1996 in his book, ‘Health Promotion: Philosophy, Prejudice and Practice’. Professor David Seedhouse famously described public health as a ‘magpie profession’ lacking a consistent theory for their approaches. As you observe in your blog the latest glinting object they have picked up seems to be the ‘behavioural insights’ approach.
The recent LGA publication ‘Behavioural insights and health’ (2016) traces the history of where this comes from,
“Much of the interest in behavioural insights on a policy level stems from the 2008 book ‘Nudge: Improving Decisions about Health, Wealth and Happiness’ which was written by US academics Richard Thaler and Cass Sunstein.”
It has both the look and the witty approach of one of those books on DIY personal improvement you see in airport bookshops.
“Though costumed in the guise of pop economics, complete with a cute logo – Nudge is, in fact, a manifesto for the new paternalism… don’t be fooled. Thaler and Sunstein charm their readers but they are after some very big game. This is a book that measures both the inroads psychology has made into contemporary economics, and argues a compelling brief for the new paternalism. We have ways, say Thaler and Sunstein, of making you happy!”
(from a review by Thomas C Leonard, Department of Economics, Princeton University, published online by Springer in 2008)
Behavioural insights really came to the forefront of government policy though when the coalition was formed in 2010. In fact, the coalition agreement itself made direct reference to the issue, stating that the government would be “harnessing the insights from behavioural economics and social psychology.” So this is quite clearly a Politically (with a big P) driven agenda – some would say, myself included, it looks more like ‘policy driven evidence’ than ‘evidence led practice’. The theory that “libertarianism and paternalism do not have to conflict and that the state can – and should – act as a guiding hand, ‘nudging’ citizens in the right direction.” (LGA – ibid) is highly insidious. Gone is the ineffective old-fashioned finger wagging approach to health behaviour change, in comes state sponsored behaviour change interventions that we will probably be unaware of and certainly, unlike other medical interventions, have not given our consent for.
Perhaps the biggest give-away that this is a Politically driven dogma, possibly an example of lax editing, comes in the 2010 Cabinet Office discussion paper ‘Applying behavioural insight to health’ (forward by Conservative MP Oliver Letwin) which states “The Behavioural Insights Team would like to thank in particular Department of Health Ministers and officials, whose expertise and support were vital.”
So what is ‘dispiriting’ you and me Mark is an ostensibly ’arms length’ PHE resourcing and implementing a paternalistic libertarian approach to health improvement driven by the Behavioural Insights Team based on nudge theory and clearly supported by senior Tory politicians and Civil Servants.
For Foucault the bigger problem is that this is all “predicated on our societal regime of truth, the types of discourse it accepts and makes function as true; the mechanisms and instances that enable one to distinguish true and false statements; the means by which each is sanctioned; the techniques and procedures accorded value in the acquisition of truth; the status of those who are charged with saying what counts as true.” It seems to me that PHE are making all the claims to the ‘the truth’ while ordinary people and communities remain marginalised or ignored in this discourse. In my previous reply I noted that supporters of a fifth wave of public health cited truth as a key issue in their new paradigm.
I will finish with some thoughts from my favourite post-structuralist philosopher and social theorist Michel Foucault that the truth is characterised by important traits, “It is centred on the form of scientific discourse and the institutions that produce it; it is subject to constant economic and political incitement; it is produced and transmitted under the control, dominant if not exclusive, of a few great political and economic apparatuses; finally it is the issue of a whole political debate and social confrontation.” (from an interview conducted in 1976)
To mark his death in 2002 the Journal of Epidemiological Community Health reproduced an article on Ivan Illich’s famous publication ‘Medical Nemesis’ first published in a 1974 issue of the medical profession’s house magazine The Lancet. It contained the following:
“The level of public health corresponds to the degree to which the means and responsibility for coping with illness are distributed amongst the total population. This ability to cope can be enhanced but never replaced by medical intervention in the lives of people or the hygienic characteristics of the environment. That society which can reduce professional intervention to the minimum will provide the best conditions for health. The greater the potential for autonomous adaptation to self and to others and to the environment, the less management of adaptation will be needed or tolerated.”
What do you think?