“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?
In an earlier blog I mentioned some of the good practice being developed by local Healthwatch with regard to engaging with and influencing Quality Accounts.
The NHS Choices website states that there is a statutory responsibility for all healthcare providers over a certain size to produce a Quality Account and to seek the views of local Healthwatch who if they wish may send a written response. This is affirmed in the Healthwatch England Guidance.
The logic is clear – a bit of local voice based on the experience of the public can provide a reality check, foster engagement and bring a bit of informed challenge to this annual statement.
This mechanism could become more important as we move to more devolution, integrated care and co-production with the public as local health and care systems respond to the ambitions set out in the Five Year Forward View.
Whats the problem?
When we compare the approach taken by NHS Trusts to the private sector in particular there is a striking contrast. While the private sector does produce Quality Accounts their quality is more variable and they often do not appear to seek the views of local Healthwatch or the local Overview and Scrutiny Committee.
A quick scan of a couple of private hospitals in Sheffield shows that only one mentions engagement with their local Healthwatch.
- Thornbury Hospital Quality Account – no mention
- Claremont Hospital Quality Account – asked for comments
The problem gets worse when you look at some of the big players in this field who operate across the country.
For example Partnerships in Care have around 60 sites across the country and specialise in providing services to some of the most vulnerable people (people with a learning disability, people with a head injury and people with a mental health problem). They produce one Quality Account for the whole service and it has no comment from a Healthwatch – although it does have a comment from one ex service user who now works for Rethink he also commented in the previous Quality Account.
Service user comments are very important – and a number of private sector Quality Accounts have these – however, I think the views of an organisation such as a local Healthwatch are qualitatively different – they have a duty to consider a Quality Account when asked and are accountable for the views they express in a way that individuals are not, in the case above I don’t think that the comment reflects the views of Rethink.
I could not find many examples of where a private sector provider has sought the views of a local Healthwatch and that Healthwatch has responded – but there are some.
Care UK in their 2014/15 Quality Account include comments from Healthwatch in South Gloucestershire and in Bristol. Also since writing the blog Sian Balsom from Healthwatch York has said that the Ramsay Clifton Park Hospital in York have asked them to comment on their Quality Account for the last two years. However, Ramsay have a network of 22 acute hospitals and their practice does vary – for example there is no mention of Healthwatch in the Ramsay Berkshire Independent Hospital Quality Account.
I could find no mention of local Healthwatch in the Quality Accounts that I looked at from:
Circle Group – for example see Bath and Nottingham
BMI General Healthcare – see for example the Priory Hospital Birmingham and Clementine Hospital
Spire Healthcare produce a national Quality Account – again no mention of Healthwatch in their Quality Accounts
Priory Group who are an acute mental health provider – who also produce one Quality Account
This national issue does not just apply to private sector providers – have a look at the one produced by Marie Stopes – again no mention of local Healthwatch.
Where this leaves us
Advice from NHS Choices is as follows
There is considerable variation with regard to how independent providers use Quality Accounts and what they expect from them. It does seem as though many independent providers are working in a parallel world where they have a much narrower view of the purpose of Quality Accounts and their relationship with local Healthwatch than NHS Trusts.
- Some big national independents produce one Quality Account for all their sites.
- Others produce a quality account for each site.
- A minority seek the views of local Healthwatch – most don’t appear to.
- There is a wide variation in the quality and accessibility of the Quality Accounts produced.
What should be done?
- Local Healthwatch with the support of Healthwatch England should develop an explicit strategy for engaging with the Quality Accounts of the big national providers.
- Clinical Commissioning Groups should take a more robust approach to challenging private sector providers on the content and quality of their Quality Accounts – some of the ones I looked at above are inaccessible and uninspired.
- Finally, I think that NHS Improvement need to produce some clear guidance for non NHS providers stating clearly why producing accessible and engaging Quality Accounts is important and why local Healthwatch must be involved in commenting on them.
What do you think?
I recently attended a discussion organised by the Galileo Group which considered the above question.
The title comes from a statement by Conservative peer Lord Hodgson, a member of the All-Party Parliamentary Group on Charities and Volunteering, who stated ‘what planet are these people on’? When he heard that one of the largest charities did not want to pay £15,000 to set up the new Fundraising Regulator.
Since this discussion the Charity Commission Report “Public Trust and Confidence in Charities” notes that the level of trust and confidence in charities has fallen to 5.7/10 compared to 6.7/10 in 2012 and 2014.
The temptation is for the Charity Sector to accept the analysis of Lord Hodgson and of the Charity Commission and focus inwards on improvement. I am not convinced that there is any evidence that the sector as a whole has witnessed a deterioration in standards of practice.
The sector is being criticised in a number of ways:
- its independence and legitimacy to campaign
- the strategies they use to fundraise
- the competence of its governance
There have been cases where some charities have not been as good as we have the right to expect. However, I see no evidence that the current performance of the charitable sector is any worse now than it has been in the past. In fact the growth of an executive function and the diminution of the role of trustees has ironically probably led to greater organisational competence.
It is therefore disappointing when organisations like the Charity Commission fail to provide wider evidence of the competence of the sector and instead produce reports which tell us that the public have lost confidence in the sector because the media and government tell them that the sector is behaving badly.
If you look at other sectors (Banking – various miselling scandals), Service Sector (G4S, SERCO, A4E), High Street Retail (BHS etc), NHS Trusts (Mid Staffs) and judge them on the above criteria there are much stronger grounds for being concerned about their legitimacy, fundraising strategies and governance rather than that of big national charities.
I think that the current highly critical environment exists (there is a good summary in the Morning Star here) – not because the sector is failing – rather the reverse – its actually rather successful despite government imposed austerity. I think this relative success exposes the national voluntary sector to attack because there is:
- dislike of independent challenge to government
- concern that the charity model of service delivery is a direct challenge to that offered by private sector corporates who are fishing in the same pond for government contracts.
- belief that large charities are a redoubt of the left of centre professional class
I have some sympathy for national charities (I am on the board of one – Citizens Advice) they have responded to the marketisation of public sector funding and the move away from grant funding – in some cases quite successfully. This must be galling to private sector providers who are keen to get access to the lucrative public sector market.
I think that the sector needs to develop a more strategic response here.
- Evidence – there needs to be a clear evidence based view of the competence of the sector. If the Charity Commission cannot do this (and in my view it should) then other players like NCVO need to step up and do the work – we urgently need a robust and clear view of the sector which challenges this moral panic.
- Governance – it is too easy to portray many charities as the mouthpiece of the professional ‘charitariat’, it may feel frustrating for some to to give some power over to members and trustees but strong accountability and roots into the communities we serve is essential to charities survival and is an important way of keeping true to founding values – avoiding a drift to social enterprise or business.
- Challenge – national charities must see the gagging legislation as giving them a mandate for evidence based challenge rather than a restriction. Part of all charities business plans should be to raise funds to ensure that they can lobby appropriately to represent the interests of the people who rely on their services.
- Government – finally the sector should have the confidence to challenge government. A number of the problems here rest with government behaviour. From the sweetheart deals that were done by ministers with Kids Company, through to the way in which lobbying from some charities and private sector companies is condoned while charities are attacked – we need a coherent challenge that places these issues in the wider context of policy influence and access to markets.
What do you think?
Remember the Department of Health Responsibility Deal? It emerged in the early days of the Coalition Government, well, I think its gone. I cannot find any official announcements but articles in the Daily Mail and The Grocer around December 2015 signal its demise – although the word used is ‘pause’.
The Responsibility Deal (RD) was Andrew Lansleys attempt to establish a public-private partnership between industry, government, public bodies and voluntary organisations in England. Organisations involved made voluntary ‘pledges’ on various areas, including alcohol, which are designed to improve public health and hence avoid trying to drive health improvement through regulation. Initially it was aimed at traditional targets – principally the alcohol and food industries but it developed to pick up on other areas notably mental health and health in the workplace.
I have documented some of its struggles in earlier blogs:
- Who cares about the Department off Health Responsibility Deal (2012) – this looked at its impact
- A lack of Interest – Mental Health and Responsibility Deal (2013) this explored the lack of traction of the Mental Health element of the Responsibility Deal
Its not our fault guv’
Evidence that the deal is dead is scattered around the web – this includes
- the home page of the Responsibility Deal which now has a very definite start and finish date and a statement that says that “this content was published under the 2012 to 2015 Coalition Government.” In other words its not our fault guv’.
- no mention of the public health Responsibility Deal in the latest government public health strategy produced by its agency Public Health England although the 2013/4 strategy did commit to work on the Mental Health in the Workplace Pledge – clearly not very successfully if you look at the link to on the next bullet point on registrations.
- No new registrations in 2016 and a significant drop off in 2015.
Of course the Government has to say that it was a tremendous success – just look at the evidence based (not!) statement below by Parliamentary Under Secretary of State for Public Health Jane Ellison MP this was given as part of her Responsibility Deal Presentation in March 2015.
I would imagine that some of the 776 organisations who have signed up to the pledges might be a tad upset that the Government has walked away from this.
Similarly some special interest groups might also be a bit irritated at the time lost by this diversion from real policy change and activity. In my view this applies particularly to mental health in the workplace – where there is precious little activity taking place anyway.
What can be learnt
We do need to learn from this. Most importantly – and I realise this will fall on deaf ears – the Government needs to learn from this process and share this learning. Here are some thoughts:
- First – there has got to be a realistic view about when regulation is required. The main reasons for key interest groups in the public health world resigning or refusing to engage was because they were concerned that the Responsibility Deal was an inappropriate mechanism for influencing the behaviour of powerful lobby groups in the food and alcohol industries. In a number of cases (smoking, sugar) it turned out that legislation was the only mechanism that would work.
- Second I do think that voluntary processes that seek to validate the good and motivate the inadequate are a useful driver for change. Local Authorities in particular use this as way to drive improvement. However, the way the RD was set up – its crude infrastructure, vague pledges, cumbersome website, poor communications and failure to share learning meant that it was impossible to understand how meaningful a pledge was, how much traction it had in a sector and whether it was being adhered to or not. It was far too much about spin as Jane Ellison’s presentation shows.
- Finally, it is worth listening a bit more to the professional bodies. If they say that they cannot be involved because they have don’t have confidence in the model – they are probably worth listening to!
At the end of the day the level of its impact can best be measured by the deathly silence from all the organisations who signed up – that is the sufficient indication of its irrelevance.
What do you think?
In our work with local Healthwatch it struck me is that one of the challenges that local Healthwatch face is operating at both an operational and strategic level.
The default for understandable reasons tends to be towards the operational – not least because I suspect this is what they are performance managed on by their commissioner. In other words there is a focus on the delivery of services. In Healthwatch terms this might be:
- Providing information and advice
- Undertaking a set of investigations in areas where there is concern – for example on provision of urgent care or dentistry or a programme of enter and view.
All of this is clearly important – a local Healthwatch has no credibility if it cannot demonstrate that it has a clear programme of practical actions developed in response to concerns raised by members of the public.
However, this is not enough – they need to be able to bring their influence to bear at a system level too.
In the Quality Statements that we developed for Healthwatch England last year local Healthwatch identified that one of the most important areas by which their effectiveness should be measured was that concerned with how they manage strategic relationships – their relationship to their local health and care system as a whole.
In order to do this effectively local Healthwatch need to go further than just using their positional power on the Health and Wellbeing Board. From our work I have seen examples of where local Healthwatch are doing this successfully. Here are some examples.
Making Quality Accounts Meaningful
Following a report we wrote on with Healthwatch Leeds on the relationship between Quality Accounts (and Local Accounts) and local Healthwatch – Healthwatch Leeds have continued to develop work in this area. This year they are holding two workshops – the first held earlier this year gave Quality Account leads from across the system (big hospital trusts, hospices, community NHS trusts, the local authority) the chance to share progress they had made to address some of the challenges they identified in the Quality Accounts last year. The second workshop will allow a joint discussion on their draft Quality Accounts for this year.
This friendly, collective discussion achieves the following:
- Sharing of good practice – its interesting that some of the work that the two Hospices were doing was of particular interest to the much larger NHS trusts.
- Breaking down silos – this is one of the few places in the local system that brings organisations together to look at how they connect and work together to meet the health and care needs of people in Leeds.
A shared approach to engagement
Healthwatch Leeds pulls together a “Public Voices Group” a regular bi-monthly meeting of engagement leads from across the health and care system – provider and commissioner. This forum provides an opportunity to:
- Share information on emerging consultations
- Discuss good practice
- Jointly publicise activity
- Undertake joint work – the group recently asked us to undertake a quick survey which looked at how different health and care organisations in the city used membership databases to connect with the public.
Advice and Information
This is an emerging area. In our work across the country it has been striking that the area where the work of local Healthwatch is least understood is that to do with Information, Advice and Signposting for individual members of the public. I don’t think this is surprising for two reasons:
- First, local Healthwatch are very small – in most cases there contribution to information and advice provision when compared to a large hospital trust, a local authority or welfare rights service is very small. This does not mean that it is not important. A local Healthwatch may be the last port of call for people who have struggled to get advice and information anywhere else.
- Second, in most local authorities areas no one has a handle of the level of advice and information provision in the health and care world and I have seen no evidence that anyone has an analysis of what good might look like.
I think that this could be an area where local Healthwatch has a role to advocate for a strategic review advice and information provision – who is being missed out and what good might look like.
What do you think?