Skip to content

How independent is the new National Academy for Social Prescribing?

November 30, 2019

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

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

The Strategic Challenge for Social Prescribing

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

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

These challenges mean that the NAfSP will need to:

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

Problems

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

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

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

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

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

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

What do you think?

We need local strategies to tackle financial insecurity and debt

October 7, 2019

 

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

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

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

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

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

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

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

Developing a more coherent story

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

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

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

Some principles

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

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

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

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

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

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

What do you think?

Declaration of interest – I am chair of Citizens Advice Sheffield

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

July 12, 2019

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

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

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

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

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

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

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

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


 

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

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

 

Cost

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

Going Forward

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

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

Acute Hospitals

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

What do you think?

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

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

May 6, 2019

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

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

Lets take a step back…..

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

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

They therefore tend to:

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

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

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

A better way?

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

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

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

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

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

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

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

What do you think?

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

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

February 24, 2019

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

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

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

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

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

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

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

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

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

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

What next?

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

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

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

What do you think?

 

 

 

 

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: