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Acute hospitals need to take more action on health inequalities

June 24, 2020

I recently interviewed the board members of an integrated care system. This piece of work has challenged my ideas about how we best address health inequalities.

When it comes to tackling health inequalities I have tended to focus on those people and sectors who are most passionate and engaged with this agenda. Namely, the voluntary sector, general practice, communities themselves and local government.  I continue to think this is important. However I think that we have ended up leaving the most powerful part of the local health and care system out of the discussion – the acute hospitals. 

This has been a mistake.

Our expectations of what the acute acute sector can do with regard to health inequalities has been too narrow. When the acute hospital sector does engage it tends to  default to rather limited outward facing areas:

  • Local purchasing plans – citing the Social Value Act as an important lever (relying on the social value act is, in my view the last hope of the desperate!)
  • Local transport to and from the hospital – again this is a usually more aspiration than action
  • Local employment strategies – there are some promising examples here – for example the Leeds Teaching Hospital had a very successful local recruitment campaign in a deprived part of their patch.

All of these actions leave the most important part of hospital provision – clinical services – off the table! 

It is comparatively rare to find examples where the hospital has taken responsibility for designing and leading a service that aims to improve a patients health in the round – generally hospital services focus on delivering a specific clinical intervention that ignores the context within which people live.

When a hospital does take a more person centred approach – magically – services becomes sensitive to health inequalities! Here are three examples:

London Homeless Pathway – Pathway helps the NHS to create hospital teams to support homeless patients and in some hospitals, Pathway Care Navigators: people who were once homeless to support homeless patients.

Major Trauma Unit Sheffield Teaching Hospital – A dedicated welfare rights service provided by Citizens Advice Sheffield for patients at the major trauma unit – funded by the Sheffield Hospitals Charity.

Guys and St Thomas’ Hospital Charity – take a place-based approach, addressing a small number of complex health challenges at a time. They work with local partners in Lambeth and Southwark and share their findings with others tackling similar issues.

We need to develop a new narrative that recognises the crucial role that acute hospitals should play here. Rather than trying to develop strategies that seek to ‘pull’ funding out of the acute sector we need to recognise the role of the acute sector and expect and support them to change. 

What these examples tell us is that it is possible to work with clinicians to create a more inclusive model for good clinical practice, by recognising that the wider context of peoples lives affects their ability to engage with clinical services which then impacts on their health and how quickly they get better.

Here are some suggestions:

  • We need to engage with Acute Hospitals and work with them to develop their own Health Inequality Action Plans that link their services to the wider population and the circumstances they face.
  • The work of Guys and St Thomas charity provides insights into what this might mean but we need to go further. For example services such as Accident and Emergency should be used as a bellwether for local health systems – who uses them and why are indicators of socio-economic pressure and wider health system failure – I don’t think that local health systems use this data systematically or effectively to help shape wider strategies.
  • The examples I gave above with regard to homelessness and major trauma show that a more inclusive version of what constitutes good clinical practice is possible. Both of these examples affirm that good clinical services must recognise that a patients vulnerability and lack of personal agency can be affected by factors outside the hospital environment. These examples show that good clinical practice inside hospitals involves more inclusive actions which can improve a patients ability to use health services effectively, help their recovery and be more cost effective.

Finally, there is of course added urgency here – the over representation of people from BAME and deprived communities among those admitted to hospitals during the pandemic and who now face long periods of recovery; must provide a further spur to considering how to develop inclusive services that respond to the clinical and social needs of people who have experienced a traumatic illness.

 

What do you think?

News from the front line – Corona Virus and Financial Insecurity

April 7, 2020

Two weeks ago Citizens Advice Sheffield shifted to only provide advice and support by phone and website to the people of Sheffield during this pandemic. All of this data comes from a report compiled by Citizens Advice Sheffield Chief Executive Clare Lodder.

Employment – Employment is now our 4th highest enquiry area (after benefits, universal credit and Debt) with enquiries for final quarter of the year  running at 61% above the same period in the previous year.

There has been a steep rise in people seeking help with issues to do with their employment including problems with their employer in relation to what money they have received or how the job retention scheme is applying to them or short time working.  (This has included a few employers who are confused about the scheme and unsure where to get information on this).

Sick Pay – We have also seen a spike in enquiries from the self-employed and enquiries about Statutory Sick Pay (both whether it should be paid and complaints about it not being paid).

Benefits – Problems with benefits including claiming universal credit – our Help to Claim team have a clear focus here and are able to give targeted help – but we are also helping with clients worrying about personal independence payments, particularly renewals and concerns over benefit payments.

Debts – Concern over debts, including council tax and fuel debts and an upsurge in enquiries around debt deductions from benefits and people with overpayments of Universal Credit

Destitution – People in need of help because they have no money to pay for food and/or fuel, usually because of benefit delays and the 5 week wait.

Local Collaboration

Citizens Advice Sheffield is working closely with all of the emerging support across the city including Sheffield City Council’s COVID response phone line and the local support and community hubs. It does feel that the city is now moving to a phase where there is much greater integration between voluntary sector and local government provision.

Our biggest concern

The biggest concern we have is to do with the inequalities aspect of this pandemic. Evidence from New York shows how unequal the impact of corona virus is.

People who were already on the the minimum wage – who are now finding that they have to manage on even less because they no longer have a job; people who are continuing to work because they need the income – in many cases they are providing ‘essential services’ such as public transport (this data on coronavirus deaths for public transport workers is appalling), supermarket retail, residential care, refuse collection etc.

Broadly the advice trends we are seeing are in line with the emerging picture from Citizens Advice nationally. Across the whole service in England and Wales, we are told

  • The number of cases referencing coronavirus have doubled in local Citizens Advice service, and continue to increase in the consumer service
  • Universal Credit remains the top issue for clients accessing local Citizens Advice, closely followed by employment advice
  • The national website has just seen its busiest week ever with 2.4 million page views, surpassing the previous weekly high of 2.2 million page views.

Citizens Advice nationally  has focused on rapidly updating its information on the public site.

What needs to change

Whilst Citizens Advice Sheffield have welcomed the Government’s announcements in relation to the help being provided, from the evidence from people we are helping, we believe there is more that should be done and in particular:

  • Removing the 5 week wait for universal credit to be in payment
  • Suspending all other benefit renewal action
  • Extending the limitation date from three months to six months for enforcement action against employers who have failed to pay final pay
  • Ensuring that there is a local safety net (for example by extending the scope of the local assistance scheme) to give money to people who are destitute because of benefit delays or other problems with benefits.

We also hope that some of the changes to the benefits system which have been introduced as a response to this current emergency are embedded for the future.

What do you think?

Volunteering, the NHS and Corona Virus

March 30, 2020

People are saying that things ‘won’t be the same’ after the Covid-19 pandemic is over. While I am not sure about that it is striking what has changed over the last few weeks.lambreWho would have thought that suddenly volunteers are seen as an important and integral part of the health system. Suddenly, as the population impact of COVID-19 becomes apparent and the UK government realises the scale of the challenge and the actual impact on vulnerable people and the NHS it clicks its fingers and creates over 750,000 volunteers. Indeed there has been such an interest in this that recruitment has had to be temporarily paused so that applications can be processed.

This is truly amazing. First, because so many people have put themselves forward to help, but as fundamentally because despite the efforts of some people in the NHS and many community organisations volunteering and the contribution of citizens as assets in their communities has been at best a peripheral issue in the NHS.

The most explicit reference to the ambition that NHS England had with regard to volunteers is here in the Long Term Plan which came out in January 2019.

Even here the primary focus appears to be on volunteering in the acute hospital sector, (according to the Kings Fund in 2013 there were just 78,000 volunteers in acute hospitals – 10% of the number recruited in 1 week during this pandemic!) the above extract probably exists in large part due to the work of the Kings Fund who have published quite extensively on this topic.

Aside from this and a tentative briefing aimed at  STP/Integrated Care Systems I think that NHSE main focus has been on interface issues using social prescribing as the main tool. In other words focussing on the NHS system engages with community organisations and communities and actual and potential volunteers. This strategy is set out in the NHSE document on Universal Personalised Care.

Before Covid-19

More generally volunteering works a bit like this at place level:

  • Grass roots self actualising informal groups sometimes bound together by hyper local geography – for example on my street two WhatsApp groups have sprung up in the last 2 months.
  • At community level are local Voluntary organisations who have credibility with and are connected to communities of geography or interest – for example Carers Centres, Community Anchors, Mencap and interestingly hospitals.
  • The local NHS – increasingly General Practice are developing (through Primary Care Networks) mechanisms such as Community Link Workers and Social Prescribers to connect with the two groups above. However, they are some way behind the groups in bullet point 2 above.
  • Just as importantly local authorities have with varying degrees of success been seeking to develop joint commissioning approaches with Clinical Commissioning Groups to support local voluntary organisations and also develop bridging and connecting services such as Local Area Coordination. Local Authorities do have a long history of supporting volunteering – for example through funding lunch clubs.

During Covid-19

The creation of this army of volunteers by NHSE and the Royal Voluntary Service represents both an opportunity to move the volunteering agenda more onto the mainstream agenda of the NHS in the medium and longer term but it also presents some real challenges which include:

  • While National organisations with a strong brand like the NHS can at times of crisis recruit volunteers very quickly – these only have utility if they can be connected quickly and safely with local communities and local services. It is here that local authorities and local voluntary organisations have a key role to play – they have those connections and credibility.
  • For example in Sheffield the local CVS has very quickly developed targeted volunteer recruitment and produced a map which flags up community hubs, describes roles and responsibilities flagging up community hubs in the city and the local authority has now producing a community action plan to ensure a city wide approach connecting statutory services with the local voluntary sector.

In the coming days and weeks it will be crucial that this national initiative bends to the local and also makes resources available to ensure that local organisations can respond to the scale of this offer.

After Covid-19

I think we should have high expectations that NHSE will rewrite their approach to volunteering and the role of the NHS in terms of funding the voluntary sector

What do you think?

Welfare Rights in the age of Coronavirus

March 23, 2020

I got this text over the weekend from a local decorator – over the years he has become a friend – he knows I am using this.

“Mark, I’m getting grief from family that i shouldn’t be going to work. Watching the news everything is getting really heavy now and im starting to cave. There is also the worry about getting materials as things progress – shop closures etc. Being self employed i get zip from the gov. They say universal credit, £90 @ week, is being made available but after 3 hours sat staring at the gov website and endless clicking, i have given up. They make it so infuriatingly difficult to claim. Bastards!”

Last week we made the decision to close all our offices and move Citizens Advice Sheffield – one of the largest Citizens Advice Services in England onto phone and digital. This meant  moving our 170 staff and 140 volunteers to home working. From Monday the 23rd of March we will be providing a beefed up telephone and web service. We hope that this will not only mean that we can provide a safe, accessible and resilient service but that we will also be better placed to meet greater demand. We normally help about 2,000 people a month – we hope that by providing a telephone and web service we can increase this to significantly if we need to.

Why we changed our operating model

First, as the prevalence of Corona Virus increases we could see that more and more people would be moving to self isolation. We know that businesses are closing, people are being made redundant or are facing reductions in income due to sick pay, no sick pay, or loss of income if they are self employed and horrifyingly in some cases being evicted.

This combination of factors means that people are likely to need advice with regard to employment rights, welfare rights and probably other areas such as housing and utilities but will be very reluctant to sit in waiting rooms waiting to be seen. Many will not have ever used the benefits system or will not have used it recently.

The second reason is of course because we need to ensure that our staff and volunteers are safe, so getting them to work from home and still be paid was very important to us. Of course we also hope that this will help us to continue to provide a resilient service to help those in real need over the coming months.

Health and Money

Quite rightly the focus to date has been about the health risks of COVID-19, however, as the government has begun to recognise on the 20th of March the financial impact of this virus is also tremendously important – not just to the economy but also to individuals.

For some of the most financially vulnerable they not only face a loss of income for themselves – but for their families – this at a time when children are no longer going to school and older ones will have little opportunity to work. It feels like a recipe for stress, anxiety and disorder.

Strategic Leadership at Place level

While for understandable reasons the emphasis at the moment is on the health system and to a degree on support to the vulnerable – in particular the elderly, the scale of the crisis means that government actions are having a fundamental effect on wider society.

What we do to respond to the needs of people on low income and in insecure employment will affect the effectiveness of strategies to reduce social contact. We need to quickly consider whether Local Resilience Forums should involve key frontline VCS services such as welfare rights organisations.

What do you think?

Why is NHS England counting the number of people who have been “socially prescribed”?

January 13, 2020

How do we strengthen the connection between citizens and communities and health services so that we create the best environment to improve health and wellbeing? We know we need to do it in a way that recognises peoples social and economic circumstances and builds on their strengths and the strength of their communities.

NHS England plans to meet this challenge through primary care implementing it’s strategy – Universal Personalised Care.

Central to the strategy are the groups of general practice established by NHS England – Primary Care Networks. These cover populations of 30 to 50 thousand and their role is set out in a new contract. NHSE is currently consulting on the specification for the contract.

You can comment but be quick!!! The consultation ends on the 15th of January 2020 so look and comment – here!


Part of the contract is about Social Prescribing. Before, I comment on this I want to build on my previous blog and set out the current challenges faced by social prescribing.

Social Prescribing is:

  • trying to break the barrier between clinician and community by providing a route for General Practice to connect people with other people  and resources in their community.
  • only going to be successful if GPs and their team change the way they work – to better understand how to build on personal strengths and what communities have or could have.
  • in danger of putting more pressure on poorly funded community resources and the voluntary sector.

So, if we want social prescribing to be effective we need to create a local narrative that helps us to understand what is happening in a way that:

  • helps General Practice change its culture
  • motivates GPs, citizens and community organisations to engage with it
  • brings what citizens can do for themselves or with others to the fore
  • keeps funders local and national informed about the effect that social prescribing is having on community infrastructure

This is fundamentally a local issue.

What we need to do

We therefore need to create a sophisticated but straightforward mechanism to ensure that there is feedback coming back on the difference that social prescribing is making and how it can be improved.

The primary audience for this feedback must be:

  • the GPs working in a particular network
  • the people who have used social prescribing
  • the community organisations who are working in that area
  • other voluntary organisations
  • Local Funders

What NHS England are proposing in the consultation

In the PCN Network contract specification NHS England are proposing that Primary Care Networks report on the number of people who have been ‘socially prescribed’ and that this minimum target should rise each year as follows:

20/21 – 4-8 social prescribing referrals per 1,000 weighted population

21/22 – 8-12 SPR/1,000 WP

22/23 – 12-16 SPR/1000 WP

23/24 – 16-22 SPR/1000 WP

This simple quantitative target is purely about activity it tells us nothing about where people went, what their needs were, what difference this “prescription” made to their lives and what costs the referral placed on others such as the community or the voluntary sector.

These metrics only feed Whitehall – they give an illusion of impact but only count activity.

Quantitative performance management like this is completely at odds with an initiative that aspires to change relationships and bring quality to life.

What we need

I suggest that Instead every primary care network is required to hold a yearly workshop with people who have received “social prescriptions” local community organisations and local voluntary sector. This meeting should discuss the difference that social prescribing made, the challenges that it faced and the actions that need to be taken to improve it.

The report from this meeting should go to the practices in the PCN, the CCG and to NHS England. The National Academy for Social Prescribing should be required to analyse these and produce recommendations back to DHSC and NHS England.

What do you think?

Acknowledgement – thanks to Charlotte Augst CE of National Voices for the ‘heads up’ and the inspiring conversation

How independent is the new National Academy for Social Prescribing?

November 30, 2019

At its best Social Prescribing is about trying to take a holistic strength based approach to health and wellbeing. It recognises that some of the solutions to improving health and wellbeing cannot be found in clinical interventions but instead already exist in communities, and by connecting people to these it is possible for people to build on their own strengths thereby improving their confidence and wellbeing.

NHS England has an ambitious programme of rolling out Social Prescribing Community Link Workers to all Primary Care Networks in England. Complementing this the Department for Health and Social Care has just established a National Academy for Social Prescribing (NAfSP) to foster the development of Social Prescribing in England.

The Strategic Challenge for Social Prescribing

Shifting a predominantly clinical NHS model to coproduce solutions with local communities is a significant cultural change. Some of the challenges include:

  • If social prescribing is to have a real impact on General Practice there will need to be a radical change to the primary care delivery model. Not all GPs are convinced of the model and it barely reaches the acute sector.
  • Local Government is not systematically involved in this NHSE programme (there are local examples where this has happened) developing holistic models will require multi-disciplinary engagement in neighbourhoods.
  • The relationship between social prescribing and specialist services like community development, youth work, welfare rights, advocacy, health trainers and local area coordination, needs thrashing out – otherwise people will just be referred from one service to the next – or even worse specialist services (often supporting the most needy) will continue to struggle with lack of funding because some will believe that social prescribing renders all other services unnecessary.
  • The voluntary and community sector has borne the brunt of the cuts under the Coalition and Conservative governments – it is already struggling to respond to demand – social prescribing risks overwhelming already hard pressed local communities.
  • Inequalities – to date NHS England has seen social prescribing as something that can be rolled out equally across all practices – little thought has been given to whether this is a model that should place a greater emphasis on addressing structural inequalities – both with regard to resource allocation and service design.

These challenges mean that the NAfSP will need to:

  • Gather and Share good practice
  • Influence NHS services and General Practice
  • Work as a critical friend with NHS England in the further development of personalisation
  • If necessary challenge Government with particular regard to the impact of its policies and funding on communities and local government
  • Ensure that it has strong links and some accountability to communities

Problems

Given the above challenges and actions needed to address these it is concerning that the NAfSP appears to be very reliant on the patronage of Matt Hancock the Secretary of State for Health and Social Care, who according to this FOI request has authorised:

  • the establishment of NAfSP as a private company limited by guarantee – there has been no tender or approach to any existing organisation
  • a direct initial donation of £5m of DHSC funds with the promise of more to come.
  • the appointment of a board of directors for the company – with no external recruitment of whom at least 2 are active in the Conservative Party.

It is interesting that NHS England (who have a who have a Director on the Board and appear to have provided over £.6m) accept no responsibility for the funding of or appointments to this new organisation – despite Social Prescribing being a clear part of the NHS England action plan on personalisation.

Matt Hancock has close links with the Institute of Economic Affairs a free market think tank who have a clear position on charities that are funded solely by Governments, they call them “Sock Puppets”. In other words not really independent – just mouthing the interests of Government.

Given the NAfSP fits all the IEA ‘sock puppet’ criteria – a company with all directors appointed directly by the minister with 100% funding from government it is hard to see how it is well placed to drive forward an effective change agenda that will need to achieve two things. First, make sure that attention is paid to the needs of hard pressed communities and second bring effective independent challenge to the health system, key stakeholders and of course government to help local health systems become more more person and community centred.

Between now and the new financial year the new charity will be established – it will be important to be sighted on who is on the board, will key players be involved like:

What do you think?

We need local strategies to tackle financial insecurity and debt

October 7, 2019

 

If we can’t tell the story about the scale and impact of financial insecurity and debt at a local level we won’t have the actions in place to tackle it.

Without a clear story even well intentioned local authorities and health organisations can end up taking a piece meal approach to trying to respond to need.

So, one local authority might put significant investment in welfare rights provision, another in food banks. A Clinical Commissioning Group in one place will fund welfare rights advice for people with mental health problems while another may not.

Despite government imposed austerity there is still a point to taking a more coherent approach – there are things we can do to help people access the welfare benefits they are entitled to from DWP and as importantly there is a continued to need to ensure that people are supported in resolving personal indebtedness.

I am not arguing that resolving financial insecurity and poverty is something that is solely within the gift of local players. However, there are actions that can be taken and by taking a coherent approach this exposes areas where Government Policy needs to change.

Lacking a clear narrative – lets call it a Local Financial Insecurity Strategy means that:

  • links with other issues are not made – for example local housing, health inequality and adult social care pressures.
  • money is wasted on public health prevention strategies by failing to recognise the impact of financial insecurity and debt
  • it is harder to develop inclusive strategies to support people who find it hard to access the job market such as those with mental health problems. So, these initiatives may not include wrap around provision to ameliorate job insecurity and low wages.
  • investment in supportive services at a local level are piecemeal, adhoc and naive. For example, it is easy to believe that the solution for the need for welfare advice is to invest in social prescribing without recognising that entry level benefits such as Employment Support Allowance or Personal Independence Payments often require expert, intensive and ongoing support and advocacy to help claimants fight their way through the system.

Developing a more coherent story

I am currently heading up a small piece of work which is funded by the Health Foundation which aims to develop a framework that will enable places to develop a more strategic approach to addressing financial insecurity and debt.

The programme is being coordinated by the Royal Society of Public Health in partnership with the Faculty of Public Health.

We will be working in partnership with up to three local authorities in England. We also have ONS, Public Health England, Step Change, Citizens Advice (national) and the Institute for Health Equity involved.

Some principles

First, with one exception there is no data set which provides granular and real time data on levels of financial insecurity and debt in populations. The one exception is probably Experian – currently advertised on the television by Marcus Brigstock. I wrote about Experian and their data – a couple of years ago here.

It is unlikely that we will be able to develop an approach that has this level of granularity and focus because local authorities have to pay Experian for this data.

Nonetheless there is a reasonable evidence base that might allow us to produce a framework that by using synthetic estimates might give a best possible view on the financial insecurity and debt pressures within specific populations.

Second, we tend to focus on geography – and this may be valid particularly where financially insecure populations are concentrated in particular areas of local authority.

However, it might be as good to focus on particular communities of interest who are experiencing financial stress – I wrote about people who have experienced severe trauma in a recent blog here. But this also applies to people with mental health problems, cancer, head injury etc. This approach has the potential added advantage of developing shared ownership with other systems such as the NHS.

Third, I think don’t think that we need something really exact – frankly some credible data, clarity about about population size and some true stories will be better than what we have now and will help local decision makers develop a clearer approach – this is all possible! See the blog I wrote on food banks and welfare rights.

What do you think?

Declaration of interest – I am chair of Citizens Advice Sheffield

What have acute hospitals to do with prevention and the social determinants?

July 12, 2019

I was in an Integrated Care System meeting recently and was (sadly) not surprised to be told by an Acute Hospital Chief Executive that they did not have a role to play in the prevention agenda – this rested with agencies outside hospital such as primary care, public health, local government etc.

In response I told the story of a small piece of work Citizens Advice Sheffield has been doing with the Sheffield Teaching Hospital Trust. We have been providing a targeted ward based welfare benefits advice service for the last 6 months which is specifically aimed at people who are using the major trauma unit.

These are people who are recovering from traumatic injury that may have arisen from a fall, a serious assault or road traffic accident.

As you can imagine in addition to the physical impact of trauma people have to deal with the effect this has on other parts of their lives such as their ability to work and sustain employment.

Further, they have to work their way through the benefit system – making the case for benefits they are entitled to that can include Personal Independence Payments, Carers and Attendance Allowance.

All the time they are coming to terms with their new status they run the risk of personal indebtedness as they try to stabilise their finances. For example according to MacMillan people who are diagnosed with Cancer on face an average drop of £570 in monthly income for similar reasons.

It should be clear that trying to address these issues at such a difficult time can have a negative effect on wellbeing and personal resilience which in turn can effect peoples ability to engage with and respond to treatment.

As can be seen in the table below the bulk of this pilots work focussed on benefits and tax credits, with the next largest area being employment.


 

When we look at the benefit issues some of the major areas are:

  • Personal Independence Payments
  • Help with an initial claim – I would imagine that for many people this may be their first encounter with the benefit system
  • Employment Support Allowance
  • Council Tax Reduction

 

Cost

The full cost of this service over a year is £7,000. At the moment the service is funded as a pilot by the Sheffield Teaching Hospitals Charity, but the ambition is that this will eventually receive mainstream funding.

Going Forward

The lessons provided by this service are clear. It builds on work that Citizens Advice Sheffield already does with regard to Mental Health and Cancer (of course Macmillan have pioneered welfare rights and cancer for years) where welfare rights services are aligned with and integrated into communityheath trust and acute hospital assessment and care pathways. There are plenty of other areas where there could be similar benefits – such as Stroke with degenerative illnesses like Parkinsons and Multiple Sclerosis.

The key issue is recognising that some illnesses and conditions cause a significant impact on people’s ability to control their own wellbeing and access to welfare rights and financial support has to be targeted and built into the health pathway.

Acute Hospitals

So, going back to the start of this blog – acute hospitals do have a significant role to play in prevention – and part of this is about changing the way they provide services IN hospital. As Dr Kevin Smith (Head of Healthcare at Public Health England) said at the time – we should not be led by ‘bean counting’ performance targets – the issue is how we ensure that when people are in our care we address the health and wellbeing needs of the whole person – this means addressing the social determinants of health is the responsibility of all parts of the NHS.

What do you think?

Declaration of interest – I am the chair of Citizens Advice Sheffield

We need a better model for patient experience measures in the NHS

May 6, 2019

NHS organisations usually have something like a Quality Assurance Committee which is responsible for gathering and analysing information on service quality. They do this primarily by gathering a range of data, most of which they are required to use and has been created at a national level.

However, we don’t usually consider why these measures exist in the first place – and whether they are fit for purpose. 

Lets take a step back…..

The NHS is a national service which is managed through the Government’s delivery arm – NHS England.

Many of the experience measures that local NHS organisations are required to use such as National Surveys, CQC, Friends and Family Test (I talked about these in an earlier blog here) are there primarily to give assurance to central government that organisations are delivering services that are of a good standard – they allow the government to compare one NHS trust against another.

They therefore tend to:

  • be broad brush – focussing on organisations or services rather than on specific interactions at in specific sites – eg wards.
  • place an emphasis on reaching a sample of patients which is usually at an organisation not a service level.
  • not distinguish between the views of patients and those of carers
  • be insufficiently targeted so miss out on Carers and people who struggle to have their voices heard such as those on locked wards or with a profound disability
  • not be in real time
  • provide limited opportunities for qualitative feedback
  • offer few opportunities for coproduction and relational dialogue

Nonetheless because their utilisation is performance managed by Government local NHS organisations devote a significant amount of intellectual and organisational energy to establish and maintain systems that analyse them.

I think this means that less attention is paid to questioning whether this information is useful for service improvement and what would work better.

A better way?

Local Health and Care Systems need systems that respond more sensitively to particular services and relationships and empower frontline workers to take action to improve.

Patient experience measures need to reflect the circumstances that people find themselves in and the relationship they have with health services, for example experience measures will vary according to whether:

  • its a short term relationship – going in for a fairly straightforward and one off surgical intervention
  • the depth of relationship – a relative caring for someone with Alzheimers
  • its a long term relationship – someone with a long term condition such as an ongoing mental health problem or someone with a learning disability
  • someone is a frequent User – someone with type 1 diabetes or kidney disease

There are other considerations too – at a local level NHS and Care organisations need experience measures that:

  • provide a framework that helps frontline staff feel empowered to have a dialogue with people who use their services
  • helps front line staff feel that issues that are raised with them can help them make the case for improvement.
  • builds a shared agenda between staff and patients

We need a much greater emphasis on measures that empower front line services to improve. There are examples – I do think that Care Opinion provides a useful model – it is:

  • Real time
  • service focussed – providing a platform for front line staff and managers to engage
  • patient focussed – allowing the public to tell their story in a wholistic way
  • takes dialogue out of committees and to the front line
  • provides a strategic model that allows organisations to keep tabs on quality as a whole and at the same time reflects the different relationships and concerns of different services

What do you think?

This blog is based on a talk a gave to a Care Opinion away day earlier this year

Centralising the NHS – the local Democratic Deficit at the heart of the NHS Long Term Plan

February 24, 2019

The more I read the NHS Long Term plan  the more confused I become. The source of my confusion is the following tiny paragraph lurking in Chapter 1 of the NHS Long Term Plan that sets out the deadline for establishment of the sub regional Integrated Care Systems  and by implication the end of local (local authority level or ‘place based’) Clinical Commissioning Groups.

This paragraph states that by April 2021 (just over 2 years away) Integrated Care Systems –  will cover the country and that each Integrated Care System will typically involve one Clinical Commissioning Group which will be leaner and more strategic organisations that support providers to partner with local government and other community organisations.

If my understanding is correct this will lead in most cases to the number of organisations that are responsible and accountable for making local health systems work dropping considerably – which means that accountability for system governance becomes more distant from local authorities and from local people.

In the graph below I compare the present involvement in sub regional Sustainability and Transformation Partnerships of local authorities and CCGs with what the world might look like once all Integrated Care Systems have been created – with one CCG for each ICS. My working out is all here – I have counted this manually so there will be mistakes!

As the graph shows currently the number of CCGs by NHSE region are roughly comparable with the number of local authorities – so, generally speaking the NHS and local authorities have similar governance geographies. This changes radically in the new world.

In simple terms I think the current and future governance of the local health system is a bit like this:

NHS England might say that my representation is not fair, after all they promise:

  • Place Based Plans that feed into ICS strategies – I say these are plans not accountable organisations rooted in places
  • Primary Care Networks – I say these are vehicles for the delivery of local services – which might include some coproduction
  • A wide range of mechanisms to facilitate joint provision at a local level such as local ‘alliance’ contracts, lead providers, Integrated Care Providers etc – again, I say all of these are about the integrated provision of batches of services and are not concerned with local governance and accountability.
  • Local Authority Over View and Scrutiny continues – this is true but they now also have to keep an eye on the ICS with no additional resource.
  • Local NHS Trusts continue to exist – which is true – but they are only responsible for their services.

In summary (as I flagged up in an earlier blog) I think the current plan will see a weakening of local accountability for the way in which local health systems work.  Instead there will be more of a focus on developing and delivering integrated local services with an aspiration that that these will be tailored to local need.

To some degree this dissonance is highlighted by the New Local Government Network in their challenging blog about the long term plan.

What next?

Local Authorities and Clinical Commissioning Groups have a small window to work together to create local structures that at the very least enshrine some form of local accountability at a place level for the local health system as a whole. The challenge is to do this in a way that rises above the NHS England focus on managing services and instead creates mechanisms that recognise that decisions about health and wellbeing are a compromise between clinical evidence, local ambition and social determinants.

If anyone reading this thinks I have got the direction of travel wrong please let me know.

Declaration of interest – I am a lay member of Sheffield Clinical Commissioning Group

What do you think?