Skip to content

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?

Lets mention inequality when we talk about welfare rights and general practice

June 28, 2018

fullsizeoutput_145b

My last two blogs have looked at the relationship between welfare rights advice and general practice. Some respondents have drawn my attention to two recent reports:

  • The Deep End Advice Worker Project – embedding an advice worker in general practice settings produced by the Glasgow Centre for Population Health. The Deep End Group are one of the main voices for GPs serving disadvantaged communities.
  • Advice in practice – Understanding the effects of integrating advice in primary care settings produced by Citizens Advice and the Royal College of General Practice

If you only have limited time read the Deep End one   – it’s more thorough and better; this is why….

It’s positive that Citizens Advice and the RCGP have produced a joint report, hopefully there is more to come – but its conclusions and evidence are already well rehearsed – although it is good to have this information in one place.

Unfortunately, “Advice in Practice” does not mention inequality (or deprivation or disadvantage) at all!

Lets face it this is why access to welfare rights is so important. I sometimes think that national agencies are reluctant to acknowledge that inequalities exists and that addressing these requires what Michael Marmot calls proportionate universalism

As I mentioned in an earlier blog Citizens Advice Sheffield serves people from across the city but we are far more likely to be needed and used by people in poorer communities – we see 20% of households each year in the poorest wards in Sheffield compared to 3% in the wealthiest!

This is an inequality issue – the pressures faced by people on low income plays out in general practice too, there is no recognition of this at all in the report. 

As the Deep End report says:

“people who require the greatest medical support experience the greatest difficulty accessing it… this also applies to social and economic advice services where the most vulnerable experience more difficulty accessing services than their more affluent counterparts”

I think that the data in the Citizens Advice/RCGP report must be treated with caution because by giving a country average it masks what a difference in the balance of demand between practices serving wealthier communities and those serving poorer ones. It concludes that non-clinical issues take up 20% of GP time. Anecdotally I am told by Deep End GPs that this proportion is higher in practices serving poorer communities.

“Before this service was introduced (welfare rights), 50% of my workload was taken up by the socioeconomic problems of patients” – GP quoted in SROI and Co-location report.

Contrast this with the Deep End report which explicitly focusses on the relationship between poverty, welfare rights and primary care.

The Deep End service model is an embedded model – more integrated than the “co-located” one described in the Citizens Advice/RCGP report not only are advice workers on site but they have (through informed consent) access to medical records held by the General Practice. They are not only providing a service of direct benefit to patients but also have some evidence that they are reducing  GP workloads.

“It is contributing to reduced time spent by GPs on paperwork relating to benefits, it lets us get on with the job we are trained to do”

Going Forward

  • we need an explicit focus on inequalities – General Practitioners serving disadvantaged communities are under tremendous pressure this is where the need is greatest, its about time this was recognised by national bodies such as RCGP and Citizens Advice
  • Tactically focussing on the most deprived areas makes sense – it gives a clear message to commissioners that a more targeted approach is appropriate and achievable.
  • Following on from this I think that there is a growing case to be made for a different service model in disadvantaged communities for general practice which should include welfare rights provision – this will require a change in behaviour by GPs and Welfare rights agencies – the Deep End report is a useful example – particularly with regard to data sharing.
  • national bodies need to set out the arguments for how these services should be funded. To date there has been a reliance on individual commissioning champions leading to models that include public health budgets, CCGs and sometimes practices themselves. This is not systematic or sustainable.

What do you think?

With thanks to Dan Hopewell from Bromley Bow and Oonagh Robinson from the University of Glasgow for her advice.

What GPs say about DWP Medical Evidence Letters

June 20, 2018

One of the problems with responding to medical evidence letters is that GPs are not specifically paid for this work.

My last blog looked at the decision taken by the Sheffield Local Medical Committee to advise its members that they did not need to respond to requests by local Citizens Advice for help with medical evidence when people were appealing refusals by DWP to grant Personal Independence Payments or Employment Support Allowance. That blog led to some good conversations on twitter with a number of GPs. 

Here are some of the responses:

It’s an important part of the job

“I write Medical Evidence Letters everyday …. they get increasingly irritable in tone.”

Dr Charles Heatley – @drheatley

“Remember, appointments and home visits sky-rocket when people loses benefits. Wipes out Motability car, blue badge, extra money for heat/food and entitlement to carers allowance so they get sicker and can’t self care properly”

Dr Anne Murphy – @DrAnneMurphy

Dr Murphy has published a piece on her blog that sets out in straightforward terms what a GP needs to do with regards to evidence letters .

She also shared a link to a great BuzzFeed article by Emily Dugan

“It may well be the case that patients who are helped to secure PIPs are more financially secure, have better wellbeing and consult less often and in less of a crisis scenario. My experience is that certainly reduces mental health crisis presentations where we can help with money.”

Dr Tom Ratcliffe – @TomRatcliffe2

“It makes far more of a difference to most patients lives than anything we prescribe.”

“A good letter requires knowledge of the patient as a person, clinical knowledge, understanding fo the benefits system, the ability to interpret data and communicate it. But in the hierarchy of clinical practice it comes below diagnosing earwax”

Dr John Tomlinson – @mellojonny

Yes its important but its not what we are here for

“I agree the system is in a mess and horrible for people to navigate. What work should GPs not do, in order to make time to write these letters? Do the general public mind if I see 3 less patients on the days I do these letters? Or should I charge for the time?”

“…all we are doing is mitigating the action by a third party, a ludicrous inefficiency of public service, and the work we are trained to do, must suffer as a result.”

“…my skill is diagnosing and treating medical problems. Helping people fight the benefits system take me away from what I am good at – don’t get me wrong I do these letters! It saddens me that somehow, a cruel benefit system becomes a problem for doctors as well as for patients.”

Dr Simon Lennane – @SimonLennane

“I didn’t say its not worth doing, but who pays for GPs time? I would rather be at home with my kids than working until 9pm filling out forms.”

Dr Ewen Pearson – @EwenPearson2 

As a volunteer at Citizens Advice Sheffield noted:

“I just wish that there was more push-back to private health contractors like Maximus rather than an LMC swallowing their “ambassador’s” PowerPoint whole.”

Simon Landau – @Microcynicon

Thoughts

“For many patients this social administration is the most valuable thing we do, and yet we have no training, no time and no money for it. It isn’t valued in any way except by the people who matter most”

Dr John Tomlinson

It struck me how isolated GPs are – there really was a feeling that they are being left to work this issue out for themselves with little support from bodies with a wider systemic responsibility.  This certainly leaves them feeling ignored and in some cases resentful.

I think that there is a failure by the RCGP and by NHS England (and of course DWP) to recognise this is an important issue. Nothing in the GP Five Year Forward View!

I think that local Citizens Advice can make it easier for GPs by offering simple templates that are more likely to succeed at DWP tribunals.

Similarly GPs can help by giving Citizens Advice access to patient data – as Dan Hopewell from Bromley By Bow explained in his comments on my earlier blog when he drew attention to an example from the Glasgow Deep End Group.

We urgently need more collaboration here – we cannot rely on biased advice from Maximus and simply advising GPs who want to help their patients to ignore Citizens Advice requests for evidence letters – does not help GPs or their patients!

What do you think?

General Practice – Social Prescribing, Medical Evidence Letters and Personal Independence Payments

May 20, 2018

There are a number of views about the role of general practice and social prescribing. Some see social prescribing as the key mechanism for connecting primary care to communities while others are more critical seeing it as a diversion from asset based community approaches.

One of the reasons for this debate is to do with the role of general practice. Are GPs just referring patients into ‘community solutions’ at the press of a button or are they playing an active role in responding to the social circumstances that make people unwell?

I recently spoke at the launch of the Torbay FAIR project – and heard Steve Barriball CEO of Citizens Advice Exeter talk (based on their report Appealing for Common Sense ) about the experience of people who had been turned down for Personal Independence Payments and Employment Support Allowance by the DWP contractors the Centre for Health and Disability Assessments (CHDA) who are a subsidiary of Maximus.

Getting access to Personal Independence Payments and Employment and Support Allowance is a three stage process. 

GPs are important, at the appeal stage if Citizens Advice are involved they will often ask GPs to provide further medical evidence as part of building a case to demonstrate an individuals poor health.

As Exeter Citizens Advice showed the outcome of the appeal stage is more often than not positive for the claimant. The Exeter report notes that:

“With evidence nationally of around 65% of the denial of ESA and PIP claims overturned at appeal….”

Recently the Local Medical Committee where I live after taking advice from the  CHDA “GP Ambassador” produced guidance stating that GPs do not need to respond to requests for ESA Claims & Appeals (Feb18) from local Citizens Advices Services.

 

GPs are under a great deal of pressure (as are local Citizens Advice services!) and most importantly so are the members of the public who are applying for Personal Independence Payments and Employment Support Allowance. 

There is strong evidence that financial insecurity and debt affect health and wellbeing – the GP Five Year Forward View states:

“Voluntary sector organisations can also play an important role in supporting the work of general practice. For example, local models of social prescribing can enable GPs to access practical, community-based support for their patients, including access to advice on employment, housing and debt. Some areas have developed call-off services for specific groups such as carers.”

GP Evidence letters are most important at the Appeal stage and this is usually when Citizens Advice staff get involved – Citizens Advice guidance is here. As the evidence shows this appeal process is (regrettably) a necessary corrective to poor decisions made at earlier stages in the application.

In my view good practice means GPs responding positively to Citizens Advice requests – particularly at the appeal stage. From personal experience I know that there are many excellent GPs who work with disadvantaged communities who would not give a seconds thought to responding positively to such requests if they consider that access to benefits would improve a patients health, even though they are not specifically funded to do this work. In many cases receiving PIP will reduce pressure on the NHS.

This brings me back full circle to social prescribing. GPs (like Citizens Advice) are interface services. They stand on the border between statutory and professional services and individuals and communities – the place that Eileen Conn calls the Space of Possibilities. 

There is a real risk that the hard work of dedicated GPs will be pushed out of sight  (as is the case for many who experience poverty and health inequalities) unless professional bodies such as the BMA, RCGP and LMCs recognise that if we are to respond to health inequalities good practice is engaging proactively with peoples circumstances rather than just pressing a button.

I am interested to hear whether GP bodies in other parts of England take a similar approach.

What do you think?

Declaration of interest – I am chair of Citizens Advice Sheffield