Skip to content

Fading away? NHS Yorkshire action on financial insecurity

November 15, 2022

In my previous blog I looked at the response of the three Integrated Care Systems (ICS) in Yorkshire to the growing financial insecurity faced by many people in this region. Each Integrated Care Board (ICB) received a paper which set out the context, rationale and in the case of two ICS made a number of recommendations for action.

As I said in the blog – it is so important to come up with quick practical actions that will make a material impact on people who are most effected by a toxic combination of poor health,  financial insecurity and a reliance on NHS services between now and the next two years at least.

It is important that ICBs recognise that local government and the VCS are under terrible financial pressure and their situation is likely to get worse. So just referring more people through social prescribing to welfare rights and debt advice is worse than passing the buck – it is irresponsible unless funding for these services is found.

I have now looked at the minutes of each ICS which captures the discussions in response to the papers. A summary of all the minutes is available here

The big danger is that after an initial flurry the financial insecurity crisis will be largely ignored as NHS systems default to focussing on the very real demand and quality issues in the health system – ignoring the feedback loop between health and poverty and forgetting their ambitions to take a ‘population health management’ approach in an ‘integrated care system’.

There is a tendency to default having ‘interesting’ discussions but failing to agree practical strategic actions. If any board is commissioning work try to understand the problem’ or is hunting for ‘evidence of what works’, it’s a sign that they have avoided taking action.

West Yorkshire minutes

Chair reminded the ICB that the Integrated Care Partnership (WYPB) asked for a response in relation to alleviating poverty.

Recognition that the ICB had two potential roles – for staff and for citizens in West Yorkshire.

Practical examples such as Winter warmth investment and link to tackling inequalities.

Call for development session for ICB

Recognition that work was going ahead in each place and it would be helpful to have oversight and assurance for this work

Actions

Board members invited to contact the Chair and Chief Executive to join a Task and Finish Group to take forward actions identified in recommendations.

Humber and North Yorkshire

Actions

A letter has been drafted by the Chair and Vice Chair (not in public domain) which will describe actions that are taking place and setting out best practice with regard to impact.

The ICB is looking to secure clear evidence in terms of impact and is working with local universities with regard to this.

It is expediting the approach to social prescribing and work with regard to workforce and recruitment.

South Yorkshire 

Noted a fast change environment and worsening situation with regard to inflation. Concerns raised with regard to impact on cost of prescriptions, need for signposting to debt advice by NHS, impact on winter planning. 

Concerns re NHS workforce impact with 40,000 earning less than £25k, focus on areas of deprivation not sufficient – eg people with learning disability, impact on local economy.

Concern that leadership on this is not clear – view expressed that ICB role is not about dictating or providing answers but contributing to solutions. Important to learn from COVID. Importance of working in collaboration with VCS.

Actions

Place directors to consider practical responses and report to October development meeting – I think this means a private meeting.

My conclusions

ICS responses to the growth of financial insecurity in their populations is unclear. There is a real risk that instead of meaningful strategic actions we will see a default to traditional pathways that appear to involve action but make little difference to population health.

The red RAG ratings to watch out for are – an over emphasis on:

  • Role of NHS as Economic Anchor
  • Focus on staff pay and conditions rather than wider population actions
  • Focus on Social Prescribing to the exclusion of welfare rights services
  • The awful OHID guidance aimed at making NHS staff more poverty aware

Actions we need to see

First, identifying populations who are using the NHS and at risk of financial insecurity and commissioning integrated welfare rights/debt advice to run alongside clinical services for example:

  • Major Trauma
  • Head Injuries
  • Motor Neurone Disease
  • Cancer
  • Muscular Dystrophy
  • Multiple Sclerosis
  • People with acute mental illness

Second, commissioning of sessional welfare rights/debt advice services to run alongside GPs serving the most deprived populations in each place.

What do you think?

What Integrated Care Systems are saying about financial insecurity in Yorkshire

October 26, 2022

 

We are in for a very tough time over the next couple of years … and it will be the poorest who carry the greatest personal burden.

This is the time when the NHS needs to be looking hard at how it provides services so that they are delivered in a way that recognises the terrible financial pressures that people face.

I have had a look at the three Integrated Care Boards (ICB) in Yorkshire and was heartened to see that each had a paper which is specifically about the impact of financial insecurity on the health of the populations they serve.

Actions

Two of the papers – WYICP alleviating poverty report and Humber and North Yorkshire ICS had been discussed at the wider Integrated Care Partnership (ICP) too – this feels right, because the wider voluntary and community sector and local government already have a track record here.

The South Yorkshire  paper has only been to the ICB so far – it’s more of a discussion paper – without specific recommended actions.

The other two papers suggest actions that include:

  • We need to better at bringing population based data that is relevant to the ICS specifically on inequality and financial insecurity.
  • NHS and care staff need to be provided with training and support about the impact of financial insecurity on their patients so that they can signpost and advise.
  • Thought needs to be given to how access to welfare advice and support is given within key pathways.
  • The role of the NHS providers as key economic anchors needs to be utilised 
  • NHS and Social Care staff who are experiencing financial insecurity need to be helped

Leadership

West Yorkshire and Humber and North Yorkshire recommend establishing strategic groups to keep a grip on this agenda and to be accountable for a response. Humber and North Yorkshire ICB has used their helicopter view to provide an appendix summarising approaches being taken in each place and by each NHS organisation. This is helpful although there is no overarching analysis of this.

What do I think?

The papers help, although they default too easily to rather grand system change ideas rather than focussing on actions that address the immediate crisis. For example talking about the role of the NHS as an economic anchor is fine but ain’t going to address current challenges. The reasons why the NHS needs to step up here is better explained by organisations outside the NHS such as Macmillan and the Money and Mental Health Policy Institute.

I think the NHS needs to focus primarily on practical actions that health systems can take now that will improve peoples financial insecurity and benefit the NHS. This will require cultural change and modernising what we think good clinical practice is.

Calls for more work on understanding population data better is probably a distraction. It is perfectly possible to establish a framework based on health impact/need for NHS services/financial vulnerability that can play to the strength of NHS clinical delivery models – by focussing on particular conditions and defined populations. The generally rather bland Kings Fund think piece has a good example of this below. I have written extensively on this using examples such as the Cancer, Major Trauma, Mental Health, Progressive Illnesses etc.

There is money

There is funding out there available to help people. The online advice service ‘entitledto’ produce a yearly analysis of how much benefits are unclaimed each year. Their estimate for 2022 is £15bn across the UK. This equates to roughly £1.2bn available for people in Yorkshire. I challenge any NHS ICS to propose an alternative course of action that would help people as significantly as enabling people to access these unclaimed benefits.

The reality is that vulnerable people experiencing traumatic health conditions need expert help to access the benefits they are entitled to.

I think that the NHS has a key role to play in helping get this money into peoples pockets by funding dedicated welfare rights services. There are too few examples of this – in Sheffield the NHS funds a welfare rights service specifically for people experiencing acute mental health problems.

Actions

We need an action plan which:

  • is informed by services on the front line who are tackling financial insecurity and health. Such as national ones like Macmillan and the Money and Mental Health Policy Institute and local ones such as Local Citizens Advice.
  • is about impact over the next 2 years
  • invests NHS funding directly into welfare rights services that are integrated into key clinical services – not distractions such as social prescribing
  • focuses on areas where the toxic combination of a significant health problem and financial insecurity impact on NHS utilisation and personal recovery.

 

  • What do you think?

Disclosure – I am Chair of Citizens Advice Sheffield

Waiting for the South Yorkshire Integrated Care Partnership

October 4, 2022

UPDATE – 24th October 2022

Since I published this blog on the 3rd of October the original South Yorkshire and Bassetlaw ICS website has been updated. It now appears to be the platform for the new Integrated Care Partnership. 

3 months after the NHS restructured we are still waiting for the South Yorkshire Integrated Care Partnership to be formally launched.

Quick Explainer

Since July 2022 Integrated Care Systems (ICS) are the way the NHS is organised. England has been divided into 42 sub regions each with an Integrated Care Board (ICB) – mainly focussed on the NHS and an Integrated Care Partnership (ICP) – with a broader strategic remit including local government and the voluntary sector.

ICPs are responsible for producing the Integrated Care Strategy for the ICS.

It’s the Integrated Care Partnerships that puts the ‘I’ in ‘ICS’

Integrated Care Partnerships are important, but there seems to be significant variation in the progress being made to establish this basic infrastructure that is part of Integrated Care Systems.

Lets have a look at Yorkshire (population 5.4 million)

In Yorkshire there are 3 ICS. Two appear to have an Integrated Care Partnership up and running with clear links to it via the Integrated Care Board these are West Yorkshire and Humber and North Yorkshire.

3 months into the creation of the new health structures the only mention that I can see of the South Yorkshire Integrated Care Partnership is an announcement that the South Yorkshire Mayor has been appointed Chair. There appears to have nothing up at the moment that the public can see – not even a note on the website saying that this is a work in progress, watch this space etc etc.

I think the resources and responsibility to establish the partnership rest with the Integrated Care Board not the Mayoral Combined Authority (MCA) … although it would be refreshing if the SYICB were to pass the resources for coordinating the Integrated Care Partnership over to the MCA.

Here are the screenshots from the three Integrated Care Boards showing how we can find out what the Integrated Care Partnership is doing, who is on it etc.

West Yorkshire

 

Humber and North Yorkshire

South Yorkshire

Meanwhile in South Yorkshire

I have heard informally it that the South Yorkshire Integrated Care Partnership had a private meeting in the week starting the 28th of September, and that Oliver Coppard the Mayor for South Yorkshire has been confirmed as Chair

However, at the moment it is not possible to know:

  • Who is on this partnership
  • What its agenda is
  • What its forward plan for meetings are

Does any of this matter?

The government guidance is clear:

“The integrated care partnership MUST involve in the preparation of the integrated care strategy: local Healthwatch …. and people who live and work in the area.” 

“In order to influence the first 5 year joint forward plans the integrated care partnership would have to published an initial strategy by December 2022”

In South Yorkshire we have less than two months for the public and communities to get there head around what an Integrated Care Partnership is let alone to then engage and comment on the strategy.

Current Position

This is how I rank the three Integrated Care Systems with regard to how they publicise the role of the Integrated Care Partnership

First – West Yorkshire

  • a clear accessible website – that shouts their values.
  • The website also makes it easy to click on the ICP pages – one click away!
  • There are also clear links to the agendas and minutes of previous meetings. It is easy to find out who the partners are – with logos to each organisation that click through to the relevant website.

Second – Humber and North Yorkshire

  • website nice & friendly
  • it does take 2 clicks to get to the ICP pages
  • the ICP link is a bit hidden in the Integrated Care Board Page.

Third – South Yorkshire

  • nothing to see here!

I would be very interested to hear from people living in other ICS areas outside Yorkshire. How easy is information about your Integrated Care Partnership to find? Who is on it?

What do you think?

South Yorkshire Integrated Care Board Strategy and a Barnsley Chop

July 25, 2022

As a resident of Sheffield I was keen to have a look at the newly launched “Start With People”  strategy, which was approved at the first public meeting South Yorkshire Integrated Care Board (ICB). It sets out how the ICB will work with people and communities . Here are some thoughts.

The strategy is  strong on principles – particularly with regard to the aspirations that the ICB has with regard to developing strong and trusted relationships with the public in South Yorkshire.

I was surprised but pleased to see a photograph of Dean in the strategy. Dean is the butcher I go to every Saturday down at the Moor Market. So when I popped down for some home cured bacon (which I strong recommend) and a couple of Barnsley Chops I showed Dean his photograph. Both Dean and his wife were surprised to see him in the strategy – they knew nothing about it and had not been approached for their permission. To be honest as I said to him, I was surprised too – I know that he has an excellent reputation for a finely cut piece of sirloin – but I was not aware that he had strong views on collaboration and co-design in the NHS.

There is a serious point here – if you say that your NHS strategy puts the relationship with the public at the heart of your work then you need to live by that. The photographs in this strategy are of real South Yorkshire people – yet it feels as though they have been used as stock images to bring a bit of local colour to give the report authenticity. That is not right.

Moving on….to inequalities

The strategy identifies a range of areas that the ICB will be focussing on here and references the NHSE Core20PLUS5 framework. However it is not possible to understand how the actions that are set out here relate to these. It is also hard to understand the relative ambition with regard to scale and impact here. These feel like a disparate collection of projects that have been hoovered up into this space.

What is lacking is an analysis that tells us what the problem is, its scale and the actions that the NHS will be taking to address it.

I think part of the reason for this deficit lies in the very simplistic “Theory of Change’ that the ICB is using – this is listed on page 38 of the report – and I show it below.

Most theories of change start by analysing the problem that needs solving – and then considering what the goal should be with regard to addressing this problem. Many – particularly when addressing complex whole systems problems also recognise that a key early step is to consider who needs to be involved, influenced or engaged in order to take effective action.

The (uncredited) theory of change in this strategy does none of these things. Sadly, I do think the NHS has history here – tending to default to project delivery planning tools when trying to achieve system change.

There are more appropriate theories of change – check out the United Nations one or closer to home – NESTA. Both have an upfront analysis of what the problem is – which for a new organisation with ambitions to be accountable and transparent would seem like an essential thing to do.

Finally! … a real problem

For me the most important paragraph in the whole document is tucked away at the end of the section on the Voluntary and Community Sector – page 9 – which states:

When I read this paragraph my thought were:

  • Is this really the case?
  • Why do communities distrust the NHS?
  • Which communities distrust the NHS?
  • What does this mean for the health of populations?
  • What does this mean for the way that NHS are provided?
  • What actions need to be taken to change this perception?
  • And most importantly has the lack of trust maybe got something to do with inequalities?

So, coming full circle – yes, it is really important to be upfront about principles – but communities will not trust us if they feel that we are just playing lip service to how we represent and involve them and present unconvincing strategies to address the real problems they and the health systems faces.

WHAT DO YOU THINK?

 

 

 

 

 

 

 

 

 

 

Talking about Community Anchor Organisations

May 19, 2022

At Leeds Beckett University we undertook a piece of work called Space to Connect which was funded by the department for Digital Culture Media and Sport and the CooP Foundation.

The programme was meant to look at how community anchor organisations could develop physical spaces to improve sustainability and services.

We had just started work when the Pandemic hit!

So instead we worked with these organisations looking at what they did during the pandemic to respond to the needs of isolated and vulnerable people in their communities. Many of us saw how community anchors pivoted and were among the first organisations to respond to need.

At the time there was a lot of hopeful talk about how this experience would represent a shift (some say a ‘left shift’) in how the local voluntary sector was perceived, funded and collaborated with by the NHS in particular. I think it is fair to say that there is still some way to go!

One of the products we produced was a discussion tool that can be used in a meeting or a workshop to begin an action focussed conversation within NHS organisations or an ICS about Community Anchor Organisations. The idea being that just having a conversation in a meeting would represent a useful step forward.

There is a blog on the Leeds Beckett website about this – which you can access here

If you would like to look at the discussion tool the link is here – ignore the first page – it is just the standard format used by Leeds Beckett when reports are stored on the website – it is much more attractive than that!

Finally, what was really important was our joint work with Locality which is the national organisation representing Community Anchors. The link to the Locality website is here

Do feel free to get in touch if you would like to know more.

Inequality and Left Behind Neighbourhoods

May 4, 2022


I recently spoke at the All Party Parliamentary Group Inquiry into Levelling Up  which is focussing on ‘left behind neighbourhoods and feeds into the development of the Governments Levelling Up White Paper.

Here are a three things I learnt.

Unclear Actions

The best analysis I have seen is the one done by they Institute for Government,  it’s nice and short and concludes ‘broad ambitions but … lacks focus’.

Money – this won’t touch the sides on the way down!

The Levelling Up white paper is full of commitments to funding and some of it sounds like quite big sums but its really hard to work out how real any of it is.

When I try to understand funding I ask the following:

  1. Is it new funding?
  2. Is it recurrent or one off?
  3. How much is it worth once it has been divided up into 151 unitary local authorities in England?
  4. How does the funding match up with what has been cut from local authorities in the last 10 years
  5. How does it compare to current local authority budgets

An example – the White Paper refers the creation of the  £2.6bn UK Shared Prosperity Fund to be used to ‘restore local pride across the UK focusing on investment in improving communities and place, people and skills and supporting local business’.

£2.6bn sounds like a real statement of intent – this feels like big money! But when we look at the allocations we can see how small this fund actually is. Over the three years of the fund South Yorkshire will receive £46,132439. 

If this fund were divided by population for the four local authority areas this equates to approximately £6.4m per year for Sheffield – for 3 years. 

This still sounds like a tidy sum – but Sheffield Council is now spending £211m less every year due to government cuts over the last 10 years.

Despite the paper talking about the importance of local decision making even this small fund is not in the gift of local decision makers. 16% has already been  allocated to the Department for Educations Multiply Programme which focusses on on local skill development for adults – specifically numeracy. The remainder then has to be allocated across three huge areas:

  • Community and Place, 
  • Supporting Local Business
  • People and Skills. 

This funding is barely going to touch the sides on the way down! 

Local Context and Decision making

One of the biggest challenges that the White Paper and the focus on ‘left behind neighbourhoods’ does not acknowledge is the local context. If we are going to create fairer places we need those with resources to behave more fairly and maybe even give up some of their funding to help hard pressed communities.

The problem is that those who are relatively better resourced are also under pressure! Look at the NHS – which is usually a bit better off than Local Government.

Dentistry – in some parts of the country it is increasingly difficult to access NHS dentists.

Here is what Healthwatch England  and CQC say.

General Practice faces an increase in demand and a decline in recruitment and retention – here is what the BMA says.

Waiting Times for elective services have increased – here is what the BMA says.

What this means for inequalities and levelling up

We are in a position where about 30% of the population experience substantial health inequalities. If we are to take action at a local level this means reallocating resources within an area because the funding made available through the levelling up white paper is not  sufficient.

If the whole of the local system is under pressure it will be extremely difficult to persuade key stakeholders within the local NHS such as GPs, Dentists and Hospitals to reallocate some of the general ‘whole population’ resources to focus on those experiencing the greatest degree of health inequality.

What can we do?

This might feel a bit wet – but I think it is really important that we ensure that  local decision makers are honest and describe clearly how much resources are actually available for ‘levelling up’ this means using frameworks such as my 5 questions above – this particularly applies to the NHS commissioners and Integrated Care Systems.

What do you think?

VIRTUAL WARDS – Will this increase in NHS capacity widen Inequalities?

March 30, 2022

The NHS Operational and Planning Guidance for 2022/3 sets out a significant target for the system level roll out of virtual wards.

Here is the target

“By December 2023 to have completed the comprehensive development of virtual wards towards a national ambition of 40-50 virtual beds per 100,000 population.”

According to my maths – England has a population of 56 million which equates to (560*45) the creation of a minimum of 25,200 virtual beds in England. According to the Kings Fund, England has experienced a significant decline in acute hospital beds and currently has just over 100,000.

So this proposal equates to a 20% increase in beds – assuming that actual hospital beds are not reduced further.

Here is the money

NHSEI has allocated a total of £200m in 2022/3 and £250m in 2023/4 subject to targets being met (pp23/4 of operational planning guidance).

This £450m is transition funding only, and the second tranche of £250m has to be match funded by local systems in order to be released. This means that after 2023/4 local health systems will have to manage costs of running 20% plus beds from within their own resources.

The implementation costs equate to £450m/25200 = £17,900 per new virtual bed.

What is a virtual ward?

According to the NHS Supporting Information virtual wards:

“Support patients who would otherwise be in hospital to receive the acute care, remote monitoring they need in their own home or usual place of residence (I assume this means a care home).

..provide acute clinical care at home for a short duration (up to 14 days) as an alternative to care in hospital. 

…are suitable for …. People with respiratory problems, COVID-19, heart failure or acute exacerbations of a frailty led condition”

What’s not to like?

I think there are two areas to be concerned about – which need more thought and action.

Inequality and Equality

The supporting information document I mention above is prefaced by a standard NHS statement – see below.

However the subsequent document makes no mention of why equality and inequality are relevant to this agenda and what actions might need to be taken with regard to the implementation of virtual wards.

Here are some suggestions:

The government has an ambition that 20% of acute beds will be provided at home in Communities. We know that:

  • people with multi-morbidities are over represented in poorer areas
  • Many people who experience health inequalities (core20plus5 group are more likely to live in poor quality housing, have low income and experience greater financial security
  • The virtual ward model places a strong emphasis on digital connectivity -yet there is good evidence that disadvantaged communities lag behind with regard to access to digital technologies.

If we are to develop virtual wards in a way that does not widen inequality we need to consider how these will impact on people whose ‘virtual ward’ experience may be significantly worse than someone with a secure income, decent housing and good digital connectivity.

This leads me on to my second point…..

Integrated Health and Care systems

The current proposal feels like lifting and shifting a clinical model from a hospital to a community setting. Just because it is not in a hospital does not make it any more of a community based service – unless it is integrated into the local voluntary and community sector.

The ‘virtual ward’ patient is likely to require greater support from family or other carers, may require access to welfare rights and housing assessments etc. All of these can be addressed through a stronger funded connection with local voluntary organisations and local government etc. 

What needs to happen

The NHS talks about the need to have a stronger focus on inequality and about shifting investment towards community and the voluntary sector, the virtual ward process needs to have: 

  • robust measures to understand the impact on inequalities
  • have an explicit focus on capturing examples of good practice that address inequality and involve collaboration with the voluntary sector – this Leeds example looks interesting
  • Costed plans to address the needs of patients living in poor conditions with fragile incomes
  • Costed plans to ensure that the potential of the local formal and informal voluntary and community sector is utilised.

What do you think?

Talking and Learning about Patient Experience

January 18, 2022

In November last year I gave a lecture on Patient Experience to District Nurses, Health Visitors and School Nurses who are training at the Leeds Beckett School of Health.

I was lucky enough to be able to develop this in collaboration with the excellent Sarah Neill who heads up patient experience at Sheffield Clinical Commissioning Group.

Here are some of the things that I learnt and some information about a symposium we are planning for the 2nd of March this year.

We need to be clearer about what we mean by patient experience and why it is useful.

Finding out about how people feel about a service they received is generally seen to be a ‘good thing’. In the wider world of e-commerce leaving comments is increasingly understood as being useful. For businesses it can help them improve and promote their products, for customers it helps them avoid a bad service, find good ones and provides a way to ‘give something back’.

Yet, in the world of the NHS the use of patient experience feedback still feels to be inconsistent and its role poorly understood. I think this is for a number of reasons:

Top down

Many of the official or statutory methods for capturing patient experience feel as though they have little relevance to front line provision. In a number of cases this is because the perception is that these measures are really there to assure distant decision makers at the top of organisations or government that they know what is going on. Further, the relatively low number of respondents at a service or GP level can lead front line staff to feel that these are merely the views of an unrepresentative minority.

Resources

Health and care services are under unprecedented demand and have experienced real reductions in funding and a reduction in the rate of growth ever since the austerity imposed by the Coalition Government in 2008. For many clinicians there is a view that there is insufficient time and resource to develop patient experience while they are struggling to provide front line services.

Clinical training

I do think that some clinicians feel (after devoting years to professional training and ongoing CPD)  that the reported experience of patients provides little added value to their practice.

The added value of patient experience

Despite the above challenges I think that systematically listening to the experience of patients is really important for the following reasons:

Validation and empowerment

Getting feedback on a specific action can be empowering. Most feedback to the NHS is positive. In the tough times we are experiencing with the pandemic, made worse by the actions of some of the press and government ministers it is so important that front line practitioners get to hear a different and often more positive view from people who actually use their services

Understanding the pressures that people face.

This quote is from a manager in an NHS Care Trust 

“Can we look at the more social side of peoples lives – housing, isolation which may be the cause of or at least exacerbate a mental health problem. To understand experience properly do we need to understand it in the context of peoples lives?”

As we move to yet another reorganisation of the NHS one of the key words is integration – if we are to move to an integrated approach to service provision we need people to help us to understand how the social determinants of health impact on their health and there ability to use services.

The two quotes below come from a piece of work that Macmillan initiated to try to better understand what people with cancer were most concerned about.

From Local Benefits and Advice Service – Macmillan Cancer Care – Impact Brief 2016 https://www.macmillan.org.uk/_images/local-benefits-advice-services_tcm9-283178.pdf

Advocacy

Many NHS front line staff are working with defined populations of people (parents, a geographic community, people with a specific condition such as HIV or motor neurone disease etc). Understanding how this population collectively experience services and how these fit into the context of their lives can empower clinicians by providing them real stories of their patients. Clinicians can use these to advocate for service improvement and development in their organisations and with colleagues.

Join us!

As part of a wider piece of work Leeds Beckett are collaborating with the Patient Experience Library, with the support of NHS England and NHS Improvement to develop more training and support for people responsible for Engagement and Experience in the NHS and local Health and Care Systems. We are starting this work with a national symposium on the 2nd of March.

To register for the symposium follow this link here.

Why the NHS should be concerned about Poverty

April 16, 2021

The impact of inequality and poverty on health is increasingly recognised both within the NHS and among think tanks and policy makers.

It is important to catch this wave – this focus and interest is unlikely to last so we must make gains now to lay foundations for lasting change.

The new report by the Kings Fund on the NHS role in tackling poverty is an example of this. Over the last few years the Kings Fund has shown a growing interest in this area – although it still feels like a comparatively marginal activity in its work.

Their report is based on gathering together examples of existing practice in the NHS. This take us so far – but it misses some key elements that are essential for change to be long lasting. I wonder if the structure of the report has been constrained by contractual requirements from NHS England?

The biggest section that is missing in this report is asking and answering this simple question:

Why should the NHS be concerned about poverty?

If this is not addressed confidently and explicitly then we have not created a framework to have this debate within the NHS…… and a debate needs to happen.

The idea that clinical practice should be informed by the experience of poverty is still seen as irrelevant or at best a side issue by too many clinicians and directors of services

It is the Health Foundation who are doing the heavy lifting here.

The graphic below is from a Health Foundation article that sets out some of the reasons why the NHS should be interested in poverty. In essence it summarises some of the points made by Marmot in particular.

Money and Resources – Health Foundation 2018

I think that there are three reasons why the NHS should be concerned about poverty

  • if you are experiencing poverty you are more likely to be unwell and have multiple morbidities
  • poverty means that you will find it harder to access services because they are too often allocated unfairly or are provided in a way that does not make it easy for you to use them because of where or how you live.
  • a significant health problem creates financial insecurity and means that you need to use health services as effectively as you can – yet your poverty will make it hard to focus on getting well because you will be having to tackle financial problems such as debt or housing insecurity at the same time as trying to use NHS services effectively.

I summarise this in the poisonous Venn diagram below.

Poverty and Poor Health create Vulnerability – Mark Gamsu April 2021

Over the years on this blog I have given examples of how a catastrophic health problem such as Cancer, Major trauma, Psychosis brings together this toxic mixture of financial insecurity, need for health services and difficulty in using them.

This combination is much more likely to make tough and resilient people vulnerable – it affects them AND it affects NHS services effectiveness. Here are two really good examples of work on this North East and Cumbria NHS – Poverty Proofing Health Settings and the Money and Mental Health Policy Institute.

From The Missing Link – How tackling financial difficulty can increase recovery rates in IAPT – MMHPI 2016

I think we need to have a more systematic focus across health services generally, asking the question:

“where are some of the most vulnerable people in our hospitals and communities and do our clinical services reflect this need?”

Two final points.

It is dispiriting to see yet another report on poverty that devotes almost half of its suggested actions to the role of the NHS as an economic anchor. Yes, the NHS could do more on its role as a local economic engine – but putting it in this report is a mistake for two reasons.

First, the primary function of the NHS is its clinical responsibilities – giving this much space to the economic role takes attention away from this – imagine how barren this report would have been without this section? Frankly, we need that absence just to demonstrate how much further the NHS needs to travel here.

Second, we need a more considered analysis of the impact that economic anchors have on poverty. How much effect do they really have? Are there solid examples of where they have directly contributed to reducing or stemming poverty? It is too easy to get excited by the big money numbers without thinking … how much of this money actually ‘trickles down’ to those experiencing poverty.

Finally, we really do need to start talking more clearly about the role different parts of the NHS have with regard to the poverty agenda. We tend to default to just talking about community based services like General Practice and not give enough attention to the acute sector.

What do you think?

Reorganising the NHS (again) a failure of ambition, understanding and imagination?

December 28, 2020

Here we go again. NHS England are now in the final stages of reorganising the NHS along the lines that they flagged up in the 5 year forward view some 4 years ago. The report Integrating Care – Next steps to building strong and effective integrated care systems across England offers two options:

Either – make the current sub regional ICS partnerships statutory with a single CCG in each sub region

OR

Get rid of CCGs entirely and make the Integrated Care System a statutory organisation responsible for managing the allocation of funding at place (local authority level)

The second option is the one NHSEI want.

As usual the solution the NHS takes to wider societal and policy problems is to ……reorganise.

I am not going to spend the rest of of this blog complaining about the decision. I want to focus on the deficit at the centre of these proposals. During the pandemic one of the most important lessons that emerged is the primacy of place. This report recognises this – it talks a lot about ‘subsidiarity’, primacy of ‘place’ and ‘neighbourhood’. 

However, the report does not appear to understand why this is important. It is locked into a simplistic and old fashioned view that the NHS is a bundle of services that are packaged up to be delivered at local authority, neighbourhood and subregion – it assumes that the challenge is one of technical delivery – rather than a negotiated relationship with all local stakeholders including the public.

No understanding is shown as to why local accountability, scrutiny or co-production is essential.

The reality is and should be that places have to make the tough decisions which requires local accountability. For example, in Sheffield there was an extensive consultation by the CCG on reorganisation of the Urgent Care system – which mobilised many groups in the city – mainly in opposition. This included regular lobbying of the CCG Governing Body. This pressure lasted for months – and was a constant reminder and challenge to the CCG that its analysis of the problem, the actions it was proposing and the way it communicated them was not good enough. At the end of this process this accountability and engagement ensured that the CCG listened and took a more thoughtful approach with regard to this agenda.

I am not convinced that the NHSE model – creating provider partnerships at place level provides the relationships, the longevity or the accountability that a corporate body with a board discussing difficult issues in public does. 

Partnerships are not an effective mechanism for public accountability.

We only have to look at the current ICS model (where accountability rests with each member) to see how hard it is for the public to engage and influence Integrated Care Systems and Sustainability and Transformation Partnerships, yet this seems to be the model proposed for partnerships at place level.

What can we do?

  • First, in order to make better decisions local NHS provider organisations must create a budget to fund a local independent function that will test and challenge local health and care decisions. This will be crucial – not least by providing resources to citizens who will want to engage with local decisions and with those of their ICS. This independent function could sit in local Healthwatch, Local Government scrutiny services or even with an academic institution.
  • Second, provider organisations at a local level need to invest in a collective approach to building citizen voice to ensure that the way in which patient and public experience of health services is heard is significantly strengthened. This must include investing in VCS organisations who work with communities of geography and interest particularly those who are easily ignored.
  • Third, we need an honest assessment of how Primary Care Networks are going to connect with communities. Mechanisms such as Patient Participation Groups have had very little impact – if PCNs are to be the point of connection with communities we need to be clear about how much of this local relationship building can actually be done by Primary Care Networks.
  • Fourth we need to build robust strategic structures embedded in local authorities where membership includes councillors, supported by senior officers, NHS leaders and public voice membership (lay members). These need to control significant proportions of NHS and local government spend – for example in Sheffield the Joint Commissioning Committee is in charge of the £.5bn Better Care Fund allocation.

We will need to build these mechanisms not only to make better decisions locally but also to ensure that a stronger place based voice is heard in public at ICS level.

What do you think?