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Where are health Inequalities, Communities and the Voluntary Sector in the NHS England General Practice Forward View?

May 16, 2016

GP Forward View

The General Practice Forward View is an important document, it sets out how NHS England proposes to support the development of general practice through to 2020/21. It is therefore important for all of those working in primary care and communities to understand the opportunities it presents and how it to access them.

Health Inequalities and Communities

Screen Shot 2016-05-15 at 22.23.12
As the graph above shows it was disappointing to see that with the exception of social prescribing there appears to be little recognition given to the context within which General Practice works. So, there is little mention of inequalities and of deprivation and indeed of the voluntary sector.

This is concerning. In Sheffield we have started an exciting piece of work with practices who serve the poorest parts of the city. We recently invited Professor Graham Watt down from the Glasgow Deep End Group. Their work as is shown by the graph below (Scottish data) shows that practices serving the poorest communities are likely to receive less funding yet face much greater demands than practices serving wealthier areas.

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Nonetheless the GP Forward View does present opportunities – not least because there are a range of commitments including one to revisit the GP funding formula to better reflect deprivation and rurality as well as a promise of more funding (£2.4bn more by 2020/1).

There are a number of levers for us to use – they include influencing the development of the Sustainability and Transformation Plans which will include £508m over the next five years to strengthen practice resilience (£56m), grow the medical and non medical workforce (£206m) and support practice redesign (£246m) and a development programme for practices (£30m). Similarly it will be important to ensure that CCG commissioning strategies for primary care include clear actions with regard to health inequalities and the role of the voluntary and community sector.

Here are three suggested actions.

  • Data – any local authority/CCG area needs to be able to describe the particular challenge faced by practices serving the most deprived populations. The Glasgow Deep End Group focusses on the practices working in the 100 most deprived populations in Scotland. We need a similar hard edged focus. It is surprising difficult to re-create the graph above in a CCG area – but we need data on funding, health inequality and activity if we are to produce a robust evidence base that underpins actions.
  • Service Models – It is the case that many GPs have developed hopeful productive working relationships with voluntary and community sector organisations. The current buzz word is Social Prescribing – but many of these relationships predate this. There is often a strong link to a neighbourhood organisation – or community anchor, many of these are members of Locality. This is important because service models and relationships will vary depending on the community. In Sheffield the recent neighbourhood based approach – People Keeping Well – based on populations of roughly 30,000 begins to recognise this level of organisation. Again, the CCG is currently undertaking a piece of work to capture different service models developed by 4 of these GP/Community Anchor partnerships. These service models should help us develop a more systematic approach to promoting ways of working that foster local partnerships with communities.
  • Alliances – I know that this appears obvious. But in this case it is crucial to get General Practice staff, Active Citizens, VCS organisations and other allied services such as Pharmacy and Optometry to come together to design local service models. This is not just about consultations. This has to be an ongoing process of shared enquiry and requires different skills to the ones that NHS Commissioners have traditionally relied on. Again, we can learn from the Deep End model here who use a process of ongoing dialogue which continually spins off briefing papers and reviews. These have the potential to influence local strategies. The methodology is a bit similar to the Rapid Review approach that I referenced in an earlier blog.

What do you think?

Local Healthwatch – Getting Strategic and punching above its weight

May 4, 2016

HW Punch

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?

Getting value from local voluntary organisations

April 5, 2016

blog contracts

You can’t buy long term relationships with short term contracts

The growing recognition of the importance of relationships, user experience and public voice highlights the urgent need for commissioners to look more closely at their culture and behaviour.

Although there are exceptions it too often feels as though the main mechanism for ensuring value with small voluntary sector organisations is through using 3 year contracts (sometimes with a roll over year) at the end of which commissioners go back to the market and tender again. I think this is often destructive and fails to capitalise on the opportunities presented by ‘local’.

Its not as if there were no other examples:

  • Its quite usual for an NHS hospital to have at last a 5 year contract to deliver a particular service agreed with a Clinical Commissioning Group
  • Most GPs have no fixed contract period
  • Academies are offered 125 year leases on local authority schools and land for a token amount
  • Commissioning organisations like Clinical Commissioning Groups work have no specific length to their existence or roles

All of the above are subject to a range of measures, performance systems, inspections, challenges etc that are used to ensure quality and value for money – the main mechanism is not market testing.

Short contract periods are often used because they are believed to be cost effective methods that can be used to assure the public that value has been achieved.

This is quite different from actually achieving value!

I worry that:

  • A reliance on market testing and 3 year contracts takes responsibility away from commissioners of services to engage and foster collaboration with providers to ensure value.
  • Is often used unthinkingly for local relational services – like Healthwatch – which rely on time to build relationships with members of the public and local organisations
  • It does not take account of the strategic role of key smaller services such as Healthwatch confusing size of investment with strategic relevance and therefore allow system leaders to pass responsibility for quality assurance to comparatively junior contract managers who lack the position and strategic position to adequately assess competence.

The balance is of course shifting once again with a greater emphasis on localism and on new structures such as Accountable Care Organisations that seek to build relationships across different providers and with communities. Nonetheless, there is a risk that the emphasis here will be on relationships between the big players – leaving smaller voluntary organisations at the mercy of cruder mechanisms like fixed term contracts and tendering to ensure value.

Solutions?

Evidence and Collaboration

The work we have been doing with Healthwatch England starts to go some of the way to trying to address – using a 360º stakeholder survey that the contract manager/commissioning lead can use (in partnership with local healthwatch) to capture the views of wider players at both an operational and strategic level and then get a system level discussion going that generates a shared view of actions that can be taken to increase effectiveness not just by the local local Healthwatch but by all health and care organisations in the local system.

This sort of model can be used to gather a more sophisticated view of similar small VCS organisations whose role is complex, multi-sectoral and relational. For example community anchor organisations whose contribution is often ‘chunked up’ and defined by separate contracts that fail to capture the relationships, processes and added value. Its important to note that the Scottish Government is moving ahead on making core grant aid infrastructure funding available directly to Community Anchors.

Contract and Grant Aid – theory and models

There remains a crying need for local government and Clinical Commissioning Groups in particular to develop a more sophisticated view to how to best to ensure performance and value. There needs to be an urgent review of funding and performance levers that considers the respective roles of:

  • Small and larger grants
  • When fixed term contracts work and what length they should be
  • What skills and capabilities local systems need to have in place to drive transformation and value

What do you think?

Is that all there is? – Five Year Forward View for Mental Health

March 7, 2016

5yFV MH Task Force

When a system is under pressure a natural tendency is to focus inward at precisely the time it needs to be looking outwards. So its not surprising that this report focusses almost exclusively on the NHS.

The Independent Mental Health Taskforce to the NHS in England report is a determined attempt to raise the profile of mental health services and in particular contribute to action that drives parity of esteem for mental health.

The foreword says:

“we have placed a particular focus on tackling inequalities. Mental health problems disproportionately affect people living in poverty, those who are unemployed and who already face discrimination. For too many, especially black, Asian and minority ethnic people, their first experience of mental health care comes when they are detained under the Mental Health Act, often with police involvement, followed by a long stay in hospital. To truly address this, we have to tackle inequalities at local and national level. ”

The problem is when I look through the report I cannot find this ‘particular focus’.

Inequality

The report does say that inequality is a major cause of poor mental health:

  • People with mental health problems are overrepresented in high turnover, low pay and often part time or temporary work.
  • Children from low income families are are 3 times more likely to be at risk.
  • Children living in poor housing have increased chances of experiencing stress, anxiety and depression
  • People in marginalised groups are at greater risk – especially people from black and minority ethnic communities
  • As many as nine out of ten people in prison have a mental health, drug or alcohol problem

System Failure

The report does make the case for system failure:

  • Three quarters of people with mental health problems receive no support at all
  • There is wide variation in access to services such as IAPT – with waits of 6 to 124 days
  • 20% of people on the Care Programme Approach have not had a formal review in the previous 12 months
  • Mental Health accounts for 23% of all NHS activity but spending on secondary mental health services is equivalent to just half of this.

An argument for funding for NHS providers

The recommendations largely miss out on the root causes of inequality and primary prevention and instead focus on the system at the end of the line – the NHS – social care is poorly represented in the report.

There are almost 60 recommendations. With the majority concerned with local operational matters – how services are delivered, yet the report speaks primarily to NHSE rather than local health and care systems.

I am not saying that this huge wodge of recommendations are bad – but I think the commission ended up not seeing the wood for the trees – it has produced a plan that is about operational change rather than system transformation.

Missing the point

Inequality – The report is unclear about inequality – there is no challenge to how government policy risks exacerbating inequality. Although many of the examples it gives in the introduction are about how societal inequality increases the likelihood of poor mental health. The few actions that explicitly reference inequalities focus on the unequal way in which people who have mental health problems are treated and how some groups of people with mental health problems such as some minority ethnic communities and people who have been in prison are not treated equally.

Community – Locally the role of community organisations, social prescribing etc is increasingly understood yet the VCS barely scrapes into the report – I spotted one explicit reference with regard to navigators.  It is unfortunate that the important contribution that local Healthwatch are increasingly making as positive disruptors in local systems is not affirmed. If there is one area of social policy that needs strong ongoing disruption it is mental health. The need for public and user experience is briefly recognised but needs to be much stronger if real and sustainable change is to occur.

Social Determinants – When the social determinants of health are mentioned it is only within the context of secondary prevention – supported housing and employment support. Of course this is important but we know that the NHS and Social Care are increasingly being used to pick up the fall out from wider government policy attacks on the vulnerable – particularly with regard to changes in the benefit system and housing provision. There is no mention of the prevalence of indebtedness among people with a psychosis despite the strong evidence base to support this.

Money – Others are more expert than me here – but I am not convinced that the £1bn asked for and apparently promised by the Government is close to being sufficient. Tactically the report should at least have called for more funding than it thought the government was likely to give!

What next

  • Local Health and Care systems must ensure that the recommendations and focus of this report are understood to be only a small part of the discussion they need to have locally. It is crucial that the role of Housing Providers, Citizens as advocates, Social Care, Employment Support, Access to Education and communities themselves is also included.
  • There remains an urgent need for a more holistic mental health strategy that recognises the crucial role of the social determinants of health

What do you think?

Asking or Telling? NHS England Planning Guidance

January 25, 2016

Blog 5YFV Guidance

Interested in localism, citizenship and communities? Then read and take a position on the latest NHS England Planning Guidance. Unlike previous planning guidance although NHS England is calling the shots this is issued jointly with Public Health England, Monitor, Care Quality Commission, Health Education England, NICE and the NHS Trust Development Authority.

This planning guidance follows on from the 5 Year Forward View – which I broadly welcomed here.

Changing Relationships

I think that there is a change of tone compared to the original mandate that NHSE received from Government. We we see a toughening up of Government expectation – with greater direct control and performance management – this is fairly typical behaviour for 2nd term Governments.

At the same time NHSE continue to promote (an albeit imperfect) localism as is shown through their impending devolution of commissioning of General Practice to CCGs.

What I think this means – Simon Stevens continues to push the line that local solutions are the way to address the 3 big challenges highlighted in the guidance (equitable health outcomes, quality of services and financial savings), however, NHSE will be more closely monitored on this approach and held to account (blamed?) if this does not succeed.

Producing local health system Sustainability and Transformation Plans (STPs)

“We are asking every health and care system to come together, to create its own ambitious local blueprint for accelerating its implementation of the Forward View. STPs will be subject to formal assessment”

What I think this means – These proposals seek to accelerate system level action on integration, to some degree they can be read as a belief that Health and Wellbeing Boards have lacked the impetus and capability to do this by themselves.

Those of you who are long in the teeth will remember local Health Improvement Plans (HIMPs) which were a similar intervention brought in by the Labour Government and more recently Joint Health and Wellbeing Strategies – no mention of them in the guidance!

Carrot and Stick

NHSE has to ‘ask’ – it cannot tell local government what to do. However, there are different ways of asking.

“The STPs will become the single application and approval process for being accepted onto programmes with transformational funding for 2017/18 onwards. The most compelling and credible STPs will secure the earliest additional funding from April 2017 onwards”

So this is tough love from NHSE to drive transformation locally. The principles that it sets out with regard to what a STP should involve are hopeful:

“(i) the quality of plans, particularly the scale of ambition and track record of progress already made. The best plans will have a clear and powerful vision. They will create coherence across different elements, for example a prevention plan; self-care and patient empowerment; workforce; digital; new care models; and finance. They will systematically borrow good practice from other geographies, and adopt national frameworks;

(ii) the reach and quality of the local process, including community, voluntary sector and local authority engagement;

(iii) the strength and unity of local system leadership and partnerships, with clear governance structures to deliver them”

Implications

First, NHSE is moving into wider territory seeking to engage with and influence – some might say control areas of social policy that it is not directly responsible for – social care and the broader prevention agenda.

Second, it has set local health and care communities a real challenge – to develop a joint strategic approach that brings together NHS Commissioners, Providers, Local Government and to some degree the VCS. Many of the structures that delivered these have been weakened or dismantled – such as Local Strategic Partnerships. In addition dominant market and Westminster cultures have not fostered the culture and skills to make this sort of local collaboration work. Some Health and Wellbeing Boards are still not mature or inclusive enough to be fit for purpose to respond to this challenge.

Finally, NHSE has a managerial culture and staff establishment that lacks the ability to adequately assess, support and engage with the ambition described here, so there is a real risk that it will fail to establish the processes needed to determine what a good STP is. See my recent experiences of engaging with NHSE here.

Actions

Despite the above caveats I think there is a real opportunity for those of us who believe that if any solution to unmet need, fairer and better services exists in the current policy environment it has to be a local one.

The ambitions require a response from more than the usual suspects. We urgently need to develop local approaches that establish relationships to jointly solve systemic challenges rather than just protect organisations or services this means:

  • Coherent approaches to engaging with and supporting citizens who are already or want to be involved in their communities
  • Building on the work that some GPs and community anchor organisations have been doing creating neighbourhood services that often have some element of social prescribing.
  • Ensuing that the big NHS Trusts are ‘asked’ to engage with this whole system agenda rather than just focussing on the concerns of their own organisation

What do you think?

What do people think about local Healthwatch and why?

December 7, 2015

Blog HW QS

At the moment we (Leeds Beckett University) are doing some work for Healthwatch England developing ways in which local Healthwatch and their stakeholders can understand how effective a local Healthwatch is.

It is challenging to come to a view about the effectiveness of a small organisation with a very big remit whose impacts are often long term and therefore hard to measure.

One of the tools we are testing is to gather views of a wide range of local stakeholder organisations through a 360º process using the Healthwatch England Quality Statements (we developed these earlier in the year in partnership with local Healthwatch) to produce an analysis which is then considered at a facilitated workshop.

Gathering and analysing a wider stakeholder view should help contract managers (who are usually middle managers) have a more effective relationship with local Healthwatch.

What is clear is that the opinions of all stakeholders are shaped by the context they work in. Here are some thoughts:

It depends on where you sit

Organisational stakeholder’s perceptions are to some degree influenced by the position and role that they occupy, for example:

  • Managers of services may have experienced local Healthwatch through being subject to an investigation or having sight of a report that may relate to their service. So, they will have a good and detailed knowledge of that specific interaction but may not be aware of the broader range of services that local Healthwatch provide or the other roles they perform at a more strategic level. It is also the case that a service that has been investigated by local Healthwatch will have to account for any criticisms they may receive to senior figures in their own organisation – this may feel uncomfortable.
  • Leaders such as Cabinet Members, Directors and members of Governing bodies generally have a different experience of local Healthwatch. They are more likely to be aware of the broader scope of Local Healthwatch activities and may have a more personal relationship with local Healthwatch senior officers and board members through formal and informal strategic meetings.
  • Different sectors perspectives vary. For example it could be argued that health providers have a view that is focused on the services that they are funded to provide. Local Authorities and NHS providers are large organisations and it is unlikely that all staff will have a shared understanding of a small organisation like Local Healthwatch, while a CCG with fewer staff and a broad health scope may have a more rounded view of local Healthwatch – but within the context of NHS commissioning.

It depends how you talk

There is evidence that the way that large organisations such as local authorities and NHS bodies are organised means that there is an emphasis on understanding the world primarily through analysis of quantitative data (demographic and performance) and evidence from research.

This is not the way in which citizens and communities operate where much more emphasis is placed on personal experience and the stories that describe them. Local Healthwatch operates in between these two constituencies, part of its added value is reflected in its ability to bring the public ‘into the room’ in a way that is understood and accepted by these large organisations.

Remember the history

Local Authorities and many health providers can often trace a continuous history going back over 100 years. It is very easy in the highly pressured environment of health and care to forget that local Healthwatch are actually very small and new organisations. Their effectiveness relies heavily on relationships, with the public and with stakeholder organisations. Local Healthwatch have been in existence for less than three years, they are still developing their expertise and their relationships with citizens and communities.

Moving Forward

So, any analysis of effectiveness cannot just rely on a totting up ratings and opinions – these are important – but there also has to be some account taken of the context that respondents are working within and it needs to be understood that the effectiveness of a local Healthwatch while ultimately its responsibility can be improved by bigger players in the system helping; actions could include:

  • Including an explanation of the Healthwatch role in all induction for new staff
  • Briefing middle managers on the role and current activities of their local Healthwatch
  • Agreeing what good practice should be when working with local Healthwatch on an investigation

What do you think?

With thanks to Healthwatch Dorset and Leicester, the local authorities of Poole, Bournemouth and Dorset and of course, Jennie Chapman

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