Commissioning to tackle Cancer and the Social Determinants of Health

My last post focussed on the importance of local leaders driving needs assessments and commissioning through using commissions to ask the tricky and difficult strategic questions that systems need to address.

I want to focus on another example of effective commissioning to address the Social Determinants of Health – this time from an organisation which has its roots in clinical support to people with cancer – Macmillan Cancer Support.

One of the challenges in tackling the social determinants of health is in convincing local commissioners that a particular service or intervention is worth investing in.

The response from commissioners – particularly in the NHS – is usually something like “show us the evidence that this works and we will consider investing in it”. This response, particularly in these straightened times is usually sufficient to send us scuttling away to our burrows – to try to address the often impossible task of demonstrating the causual link between a social determinant, health outcomes and savings to the NHS……….we rarely re-emerge.

Those of us who have been involved in this field know that once we hit the social determinants of health – out in the real world – it is really hard to identify the causal relationship between a social determinant of health and its specific impact on populations in a way that satisifies a local commissioner – this is because outcomes are often long term and multi-factoral.

I think that one of the reasons that we face this problem is because of the divide between commissioning and provision that successive governments have promoted over the years. This has been driven by:

• an attempt to bring greater scrutiny and accountability into how public funding is used.
• a concern that providers cannot be trusted to make decisions that are always in the best interests of the public – this has become a bigger issue as services have become privatised and therefore cannot always be assumed to working in the public interest.

The key point is that the driver for the commissioner/provider split is not actually ensuring quality of provision – it is instead a rather poor attempt at ensuring accountability for how public money is spent.

The purchaser/provider split means that commissioners have had to increasingly rely on proxies for experience – quantitative data and evidence generated through research – to help them make decisions. This is because the needs of the public and their experience of service delivery is not something that commissioners are directly exposed to. This is of course one of the reasons that is given by the Department of Health for the creation of CCGs – GPs will be both providers and commissioners of services.

The lived experience of people with Long Term Conditions

Arguably the biggest challenge that the NHS faces is how best to respond to the needs of people with Long Term Conditions – 2/3 of the NHS budget is spent on this area (Patient Involvement and Public Accountability NHS Future Forum p3).

So I was interested to read an article recently in the Guardian written by Jan Morgan who had experienced a severe stroke. What is striking about this powerful and moving story is how her quality of life and wellbeing was most affected by her access (or lack of access) to the financial support that she was entitled to. Her difficulties in getting this support had a huge impact on her recovery and wellbeing – and hence on her utilisation of NHS services.

One of the key services that helps people with Long Term Conditions navigate the complex and off-putting government social welfare system are welfare rights services.

Yet it remains very hard to convince the Department of Health and the NHS of their central importance for the reasons that I have explained at the beginning – the response is still too often – show us the evidence!

Macmillan Cancer Support

Macmillan Cancer  Support (quoting them) “improve the lives of people affected by cancer. One in three of us will get cancer, We are all affected by cancer. We can help. We are Macmillan.”

In 2011 Macmillan spent £106 million on services for people affected by cancer. They supported 1.7 million people with cancer and 640,000 carers. Of these they supported over 500,000 people through their Macmillan nurses and healthcare professionals who include nurses, doctors, consultants, radiographers, dietitians, clinical psychologists and others.

This is an organisation that has strong roots in providing comprehensive clinical health services to patients – a bit like the NHS really!

But in addition to their health and social care Macmillan also offer a range of financial help and support services. They know that 70% of people with cancer experience a drop in income or increased costs. In addition to grants they provide and commission a wide range of welfare rights services – many in partnership with their national strategic partner – Citizens Advice.

In 2011 together they helped almost 118,000 people and leveraged £200 million in benefits for them.

Why does Macmillan place more importance on commissioning services to tackle the social determinants of health than the NHS?

I think that there are two main reasons for this.

First – Macmillan does not have to account to Government for its spending. 98% of its income is generated through fundraising. This means that it is not tied to activities that are determined by government or by the (very limited and clinically dominated) evidence base.  Instead Macmillan has to be able to convince its independent funders that the people who rely on its services value them.

Second – Macmillan is directly in touch with the people who receive its services and it listens to what people with cancer say they need. Through this Macmillan knows that access to financial support is key to the wellbeing of people with cancer, their families and their carers. This is sufficient evidence to give them the confidence to invest in welfare support services AND to give approximately 9% of their income directly in grants to people with cancer and their carers.

Implications for Commissioners.

• How do you recognise the impact of long term conditions on peoples wellbeing – and in particular the social determinants of health like income?

• Do the organisations you commission take responsibility for the whole person or are they only interested in them as site of a clinical illness?

• How much flexibility do you give to provider organisations? Do you prescribe the interventions and services that provider organisations should deliver – or do you block fund them and hold them to account for their expertise and their relationship with the people who depend on their services?

What do you think?