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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?

 

 

 

 

The NHS Long Term Plan and Social Prescribing

January 30, 2019

social prescribing and nhs long term plan blog

While welcomed in some quarters the NHS Long Term Plan has come in for a fair amount of criticism for its lack of strategic heft and poor  focus on the relationship that the NHS must have with external partners such as local government and the voluntary and community sector.

One of the areas where it does recognise the importance of making connections between communities, their assets and the voluntary sector is with regard to Social Prescribing.

Social Prescribing has developed a fair amount of traction in the NHS. Indeed, the term itself speaks to front line health professionals such GPs, it uses their language and it has gathered around it some significant champions such as Dr Michael Dixon who was also the founding Chair of the NHS Alliance.

This is what the NHS Long Term Plan says:

I think this means that by 2023/4 900,000 people a year will be offered Social Prescribing by the NHS. Note the commitment to 1,000 social prescribing link workers. I have allocated them by population size of CCG so for example Sheffield get 10 and Corby 1 (my full CCG list is here) of course doing it this way takes no account of inequality. The statement about NHS Social Prescribing Link workers has generated anxiety in the voluntary sector who are the main providers currently – with concern that these will be NHS employees.

At the moment there are about 59.7 million patients registered with GPs who make over 240 million appointments a year. compared to the 900,000 a year promised for Social Prescribing. This means that in 5 years time social prescribing activity will be equivalent to .38% of appointments at GPs. Here is an illustration of the scale of this.

If you are an average patient and see your GP four times a year the odds of you being offered a Social Prescribing appointment are approximately once in every 60 years!

Of course it is fairer to say that not everyone who sees a GP will need or want referral to social prescribing. It is probably more realistic to focus on people with multi morbidity. A recent study by the Department of Public Health and Primary Care at the University of Cambridge showed that over half of GP consultations are now with patients with multi-morbidity – this equates to 120m appointments a year.

The pie chart below shows how the NHS England social prescribing commitment would impact on this challenge. It is clear that the current NHSE commitment still gets nowhere near – indeed it could be said that the NHSE response is so diluted and small that it will be almost homeopathic in terms of its system level effect!

Real scale of the challenge

I mentioned in an earlier blog on Welfare Rights and Health that a joint paper produced by Citizens Advice and the Royal College of General Practice estimated that approximately 20% of GP time was spent with patients who presented with non clinical issues that would be better addressed elsewhere.

I think that this proportion is likely to be much greater with when General Practice is providing a service to disadvantaged communities who are likely to have to higher levels of multi-morbidity and a greater level of non clinical issues.

Finally there is a subsidiary point even a small target of just under a million people receiving social prescribing services will have a knock on effect to voluntary sector services. Some existing social prescribing services such as Rotherham have a degree of funding that recognises this. The NHSE 10 year plan does not seem to recognise this.

What this means

The current ambition set out in the Long Term Plan leaves social prescribing as a bit of a sideshow for the next 5 years. There is a real risk that once the magical 900,000 a year target is met that the foot comes off the gas – with little having been achieved.

  • Maybe this level of ambition matches need?
  • Perhaps only 1% of people who see GPs require social prescribing?
  • If it is only a minority interest then should more thought be given to ensure that this investment is reaching out to those who would benefit most rather than being generally available? 
  • Given the small scale of investment are there other interventions such as Local Area Coordination, Community Development and Health Trainers that might have a greater impact that should be considered by NHS England too? 

What do you think?

NHS Friends and Family Test Feedback – a distorted view?

January 9, 2019

 

I try to be cautious about big numbers – warning bells ring particularly when the first thing that you read talks about the numbers of responses rather than what the problem is and how it is being solved.

So when I looked at the Friends and Family Test (FFT) web page on the NHS England site and saw that it says that since FFT was launched in 2013 it has produced 55 million pieces of feedback and this feedback is growing at the rate of 1.2m a month I thought it was worth trying to understand this a bit more.

The Friends and Family Test was introduced in 2013 and NHS organisations are mandated to use it to provide a means for the public to give feedback about their experience of using NHS services. The review of friends and family test stated that its aims were to be:

  • A tool for local service improvement
  • Provide information to empower patient choice
  • Intra-trust performance monitoring
  • Proved comparable data to hold trusts to account

Context

The NHS sees 1.4m patients every 24 hours. So in crude terms just under 3 in every 100 (1.2m/(1.4m*30))*100 of people give feedback through the Friends and Family Test.

However when you look at the responses in more detail we also see that the rate of feedback varies according to service area.

A caveat about the data

Its’ important to see the data as illustrative – I have cobbled this together from various websites – all sources are shown. However, the figures need to be seen as indicative and as prompts for discussion.

Number of times NHS services are used each year

I have missed out maternity and community because the FFT does not pick this up in the same way. 

As you can see from the pie chart below the single biggest NHS service by use is General Practice – the table with all my figures in is here. The next largest service is outpatients followed by Dentistry and Accident and Emergency Attendance and so on.

Pie Chart One: NHS Services by number of times used a year

The next pie chart shows where Feedback from Friends and Family has come from by volume of responses. I have used the global figures – all the feedback – since Friends and Family was established (see total response rate column). The pie chart below presents a very different picture of the NHS to the service utilisation one above.

Pie Chart two: Proportion of FFT Feedback by NHS Service

So, some areas have a disproportionately high level of Friends and Family Feedback while others have a disproportionately low level of Feedback

Disproportionately Higher feedback compared to activity

  • Specialist Mental Health 10 times greater
  • Hospital Admissions 6 times greater 
  • A and E attendance 3 times greater 
  • Dentistry 1.3 times greater

About the same

  • Outpatient Appointment

Disproportionately lower feedback compared to activity

  • General practice – 3 times lower feedback compared to activity

This variation in response creates a distorted view of what the NHS is – over 70% of feedback relates to hospital provision – yet this is a small part of the NHS compared to General Practice, Community Services and Dentistry.

It does appear that the bulk of the feedback comes from services that are more transactional – in-patient, A & E, Dentist and Outpatient. Relational Services such as General Practice struggle to keep up here.

This imbalance in the data probably pulls regulators and performance managers towards hospital based services and away from community. I suspect that it is also the case that Hospitals are easier to performance manage; there are fewer of them and they are higher profile than GPs – performance management systems are able to focus on them more and are more motivated to do so given that the bulk of NHS spend is directed towards them.

Looking at the data above it is tempting to say that the focus should be on getting GPs to increase the FFT returns. I am not so sure – I wonder whether we should be asking:

  • what difference FFT has made to those services who have high rates of feedback such as A&E and In-Patients
  • whether there is a demonstrable difference in the quality of their work compared to GPs.

I will be coming back to the Friends and Family test in future blogs.

What do you think?

A bit more about the data – activity data comes from three main sources:

 

 

Noticing health inequalities and doing something about it

December 2, 2018

Making progress on tackling health inequalities is not just about getting the right evidence – it means challenging power, shifting culture and changing how we work. In order to do this we need a clear narrative – a story – that empowers champions, motivates the undecided and challenges the unconvinced.

We have struggled to do this – for example a decade ago it was a real success when we started to talk about differences in life expectancy between socio-economic groups by using examples that many people are now familiar with the such as the bus journey/bus stop analogy.

However, despite its success I think that life expectancy data was not sufficient to mobilise and sustain action at a local level. Some of the reasons for this might be that life expectancy:

  • feels very far off – it does not feel sufficiently urgent to decision makers and service providers.
  • as a measure does not reflect the profound impact that long term inequality has on health and wellbeing – it simply does not bring you into the room to feel the day to day life of living in circumstances of financial insecurity, poor housing etc.
  • a short life can still feel to be a relatively small part of someones total life years and therefore may feel as though it is not a very big deal to some people.

Health Inequalities and Multi-Morbidity – a more powerful narrative

quote from Health Foundation Understanding the Health Care Needs  of People with Multiple Health Conditions

In recent times thanks in significant part to the Institute of Health Equity and other players such as the Health Foundation we are seeing a shift to focus more on the impact of health inequality on Disability Free Life Years and multimorbidity.

This useful table from a RCGP article on  the epidemiology of multimorbidity in primary care sets out the ten most prevalent morbidities and associated comorbidities

Table from Epidemiology of Primary Care (2018) by Anna Cassell, Duncan Edwards et al.

The graph below from the Institute of Health Equity shows how people who experience socio-economic inequality are likely to have a shorter period of disability free life expectancy than people who are wealthier and to already have poor health before they reach pension age.

Talking about the relationship between socio-economic inequality and Disability Free Life years (or the very similar multi-morbidity) is helpful because it:

  • speaks directly to the NHS – in particular primary care (as is shown by this useful recent study in the British Journal of General Practice) because many of these conditions are amenable to clinical treatment.
  • motivates local commissioners because there is a relationship between multi-morbidity and use of urgent care.
  • brings a helpful focus on Mental Health particularly anxiety and depression
  • is a greater motivator to action because it affects people earlier and for longer – so it feels more meaningful and relevant
  • allows us to ask other questions such as why are people not accessing treatment or adhering to it – which drags the NHS into discussions about the social determinants of health
  • opens up a debate about the role of the social welfare system and how the NHS connects with it because they both have a role in helping people live independent lives when they experience disability and illness.

Of course focussing on multi-morbidity does not in itself solve health inequalities – however it does challenge the NHS, make it clearer what it’s contribution can be and pushes health services to make stronger connections to agencies working to address the social determinants of health.

What do you think?

The end of Clinical Commissioning Groups?

August 8, 2018

 

Disappearance 

It is beginning to look like Clinical Commissioning Groups are on the way out, the only question is how long this will take.

A key document (pages 29 to 37) is the 2017 Next Steps on the FYFV. It flags up the significant drive to create sub regional structures at a high speed using a mixture of financial incentives, creating voluntary pilot sites and through inviting local leaders to head up these initiatives.

The Next Steps report also flags up the creation of “accountable care systems” as a precursor to establishing “accountable care organisations” (see this BMJ 2018;360:k343 infographic) at a local level – bringing together providers and commissioners into one organisation.

Although there is no legislation for any of this; change has been made easier by existing flexibilities with regard to pooling budgets and austerity policies have meant that local organisations are increasingly compliant and willing to accept change if it offers the chance of additional funding.

In a very brief period of time we have been through – Sustainability and Transformation Plans which quickly led to the creation of partnership structures – initially called Accountable Care Systems through to their current iteration – Integrated Care Systems.

Some of the rationale for this feels sensible – it marks a move away from the purchaser/provider split created by the 1991 John Major Government and recognises that the artificial divide between the NHS and Local Government is unhelpful and inefficient.

Implementation has been rapid – NHS England already has a performance dashboard for first phase Integrated Care Systems. Its all a bit confusing. Even though there has been  no legislative change to create these new structures we now have new subregional (Integrated Care System) and local (Accountable Care System) boards but all the existing Governing Bodies (hospital trusts, clinical commissioning groups, local authorities) are still legally responsible for the decisions. At a sub regional level this means that comparatively obscure local structures such as Joint Overview and Scrutiny Committees have to do their best to hold these new structures to account – with no additional resource.

Resource

So, at a time when the health and care system is creaking at the seams with real delivery problems we are double running two systems – one that is legally responsible and another shadow system (with most of the same players) where decisions are made……and then have to be ratified by the legal bodies. 

This means that senior managers in the health and care system are spending time creating the new systems and running the current one. Of course NHSE has had to find new funding to employ them to do this.

For example in the South Yorkshire and Bassetlaw ICS I reckon that around 15% of top management capacity has been pulled out of local systems to create the new sub regional structure. See this July 2018 press release from the ICS Chief Executive:

Understanding the  finances is hard – but I think that the South Yorkshire and Bassetlaw ICS has access to £7m transformation funding (see page 7 of this report). This probably means that NHS England has invested about £90m in the 14 different ICS sites agreed so far. I think that this money comes from an allocation that NHSE has for transformation (page 7 again). See table below.

 

NHSE ICS Transformation Funding

Involvement and Accountability

Its not just the resource – as is often the case when new structures are created in the first phase the main players are the managers. The reason usually given is because of the need to get on with quickly creating the new system. 

This leads to a bit of a paradox. Despite a genuine desire to break the mould the new structures end up looking very much like the old ones – and I think this means that behaviours, priorities and actions do so too.

While representation is important we need to go further if we are to have a dialogue that produces a different way of working locally. More investment has to go in to voluntary sector infrastructure so they can bring their expertise and challenge to the table and serious consideration needs to be given to strong elected and lay member involvement. I do think that they need to dig out some funding to strengthen the voluntary sector voice in this new world.

Despite the ambition the approach at a sub regional level already feels a bit like the old Strategic Health Authorities with an emphasis on structures dominated by NHS managers and performance management systems that look up to NHS England rather than down to local health systems.

Meanwhile, locally the direction of travel appears to be a greater focus on Accountable Care Organisations as this clear July 2018 report from the House of Commons Library explains.

Screen Shot 2018-08-07 at 09.34.25

What do you think?

Declaration – I am a lay member of Sheffield CCG and the above piece does NOT represent the views of Sheffield Clinical Commissioning Group

Are we being too smug about the NHS at 70? Why aren’t we celebrating the abolition of the Poor Law?

July 19, 2018

All of the celebrations abut the NHS at 70 have left me a bit cold, with ceremonies across the land in Cathedrals and comments from our former secretary of state saying that the NHS:

“has come to symbolise one of the greatest advances of humanity: no matter who you are, rich or poor, young or old, in a civilised country you’ll always be able to access good healthcare”

Strangely, I have seen no celebrations of the 1948 National Assistance Act which like the NHS was created 70 years ago. Yet this important piece of legislation was a key component of the post war reforms and creation of the Welfare State following the second world war.

It worries me that we have no problem coming together across the country to celebrate the NHS but fail to acknowledge that it was only one part of a postwar settlement that aspired to create a fairer and more equal society through the creation of the welfare state. Aiming to tackle Beveridge’s  5 giant problems – Want, Disease, Squalor, Ignorance and Idleness.

Anyone in the NHS or wider public health who says that we need to focus more on ‘prevention’, get ‘upstream’ or recognise the ‘social determinants of health’ needs to take the time to understand and champion the role social welfare legislation plays – it is at least as significant to peoples health and wellbeing as the NHS.

William Beveridge and the post-war Labour Government recognised that in order to create a fairer society the welfare state had three elements:

  • A health service free at point of use
  • A social welfare system that ensured that people were protected in times of financial hardship
  • Access to good quality housing – in particular the creation of New Towns

As Wikipedia notes the 1948 National Assistance Act followed on from the 1946 National Insurance Act which required all people of working age to pay a weekly contribution in return for access to a wide range of benefits, including Orphans Allowance, Death Grants, Unemployment Benefit, Widows Benefits, Sickness Benefit and Retirement Benefit. 

The Act formally abolished the Poor Law and and established a social safety net for those who did not pay National insurance contributions (such as the homeless, the physically disabled, and unmarried mothers) and were therefore left uncovered by the National Insurance Act 1946 and the National Insurance (Industrial Injuries) Act 1946. 

It provided help to elderly Britons who required supplementary benefits to make a subsistence living, and obliged local authorities to provide suitable accommodation for those who through infirmity, age, or any other reason were in need of care and attention not otherwise available. The legislation also empowered local authorities to grant financial aid to organisations of volunteers concerned with the provision of recreational facilities or meals.

In this 70th year of the creation of the welfare state:

  • There were no celebrations in cathedrals to commemorate its anniversary – despite the significant role our benefits systems plays in keeping people well.
  • There were no commemorations of the staff who work in Job Centres and elsewhere who try their best to make an increasingly unjust system work for the benefit of people who needs its support. 

The original ambition of Beveridge and the post war government was that access to this system should not be means tested.

If we are serious about prevention and addressing the social determinants of health we need to reconnect with the principles and intellectual integrity of Beveridge and the post war government – its no good just banging on about the NHS

If you have never seen them there are two great Central Office of Information films about the establishment of the NHS and the Welfare Benefit system that were made at the time to explain both of these to the general public they are worth a look!

What do you think?

Who knows me? – Digital Marketing and Public Health

July 8, 2018

I recently ran a workshop with the National Institute for Public Health in Slovenia as part of a piece of work that I am doing with the UK Health Forum. They were interested in exploring what action could be taken to address the growth in digital marketing aimed at children and young people – particularly with regard to fast food and alcohol. This is about vulnerability – and of course could also apply to adult mental health in particular.

Slovenia is part of a WHO working group on this topic. Its challenging for a number of reasons; digital doesn’t respect borders, there are issues of vulnerability and rights, governments  are comparatively inexperienced in this field.

Capability and Strategies

Public Health is only just beginning to work out strategies that will enable it to respond effectively to digital marketing. It does seem that the default is probably to focus on legislation to reduce the scale and reach of marketing.

Other strategies include restricting the means to access social media in areas that are controlled by the state – such as banning smartphone use in schools. Of course more authoritarian countries like China or Turkey simply prevent access to some websites altogether.

Targeting and Data Harvesting

One of the the reasons that social media is so attractive is because messages can be tailored to specific populations and individuals. So, Facebook, Twitter, Instagram etc all target us with adverts that mirror our interests and buying habits – I am getting a lot of adverts for whisky, british made clothes and obscure beers at the moment!

Much of this is informed by companies harvesting and then sharing data about us – an example is Experian who hold financial information about more or less every adult and share this (for a price) with companies who are in their club. I wrote about this in 2012 here

This sophisticated approach to targeting material at individuals (to quote experian) can:

“Transform campaigns into intelligent interactions ─ where highly personalised marketing and advertising move your audiences as never before. Optimise advertising and marketing spend, boost conversion, better engage audiences and increase deployment speed.”

The public sector are off the pace here. It is still the case that most public sector digital communication is not tailored or targeted to particular communities or people. Most people who are reached are those who have made a conscious decision to join a twitter feed, facebook page or website. This means that much of the communication is with people who are already to some degree interested in the topic or organisation – for example the activity of a clinical commissioning group or a campaign to increase levels of physical activity.

Compared to the size of population and the reach of social media these interactions are small beer.

What can be done?

Build on Assets

The reason that companies use advertising and social media in particular is because they want to compensate for the fact that they do not have a strong relationship with individuals in the real world.

The strongest relationships that people should have are directly with their friends, families and communities. Counterintuitively one of the best strategies is to focus on the local. This is where agencies such as local authorities, the NHS and the voluntary and community sector have the assets and connections that can help them combat the reach of digital media providing an alternative and offering training in how to use it safely. This means that it is crucial that there is continued and greater investment in programmes such as Social Prescribing, Health Trainers, Community Health Champions and grass root community organisations.

it is interesting that the Good Things Foundation which promotes the use of digital advocates using precisely these assets which it calls “four jewels of inclusive communities” (Relationships, Participation, Independence and shared sense of place and culture) with the aim of building digital literacy and enabling people to use digital technologies to promote wellbeing.

Tailor Data to audiences

I do think that public sector agencies need to consider their position with regarded to tailored and targeted digital communications. Should they be seeking to connect more with real world organisations and their digital channels – for example mosques and churches? Should they be buying access to data from companies like Experian to produce their own tailored programmes?

What do you think?