The briefings achieve the seeming impossible of being technically right and so very wrong.
We know that:
- the NHS (the acute sector in particular) has struggled to bend its service provision to respond to health inequality
- the health system as a whole has failed to consistently engage with prevention agenda
- mental health has been treated as a marginal concern and been disconnected from mainstream provision
The STP Challenge
STPs aim to do three things – improve service quality, address health inequality and save huge amounts of money – this is a big ask!
I think that history tells us that there always a drift to achieving savings and away from addressing inequality. So, we urgently need a strong, coherent framework that creates momentum for change and lays the foundation for sustainable action on inequality – step in Public Health England!
What PHE gave us
The data sets produced by Public Health England are meant to help us ensure a focus on this weakest element – health inequalities.
They show three things:
- the relationship between income and prevalence of a range of non communicable diseases
- how people on low incomes are more likely to use acute care and less likely to use elective care
- that people on low incomes do not take up screening services early enough
The problem is we know all of the above already – what the data sets do not do is help us create a platform for an evidence based dialogue that promotes the substantial system change that we need if we are to shift to stronger action on health inequalities.
Where PHE fails us
There are two areas where the briefings fail spectacularly.
Mental Illness does not exist
Frankly, I am staggered to be writing this – if you were to come to these briefings cold you would think that poor mental health does not exist in England. These briefings say nothing at all about mental illness!
Yet we know:
- the relationship between health inequalities and poor mental health.
- that health outcomes are far worse for people with mental health problems
Social Determinants are not relevant
The briefings say nothing about the social determinants of health
yet we know:
- NHS England is promoting accountable care systems that seek to pull together holistic approaches to respond to need and some Multi-Speciality Community Partnerships are developing new service models with community anchor organisations.
- There is a stated ambition for STPs to focus more on prevention
- Addressing the social determinants of health – housing and employment insecurity, low levels of income are crucial to tackling health inequalities
What PHE should have done
- There are plenty of examples of promising practice in secondary care such as the UCH Homeless pathway which build bridges between disadvantaged communities and hospital services.
- There are good health system level initiatives that focus on addressing indebtedness and improving access to welfare rights services for people with mental health problems and others experiencing inequality.
- There are a range of social prescribing, local area co-ordination and community anchor programmes that seek to redesign service to better meet the needs of the socially isolated and vulnerable.
What PHE should do
PHE should help bring the outside world and the lived experience of inequality into Sustainability and Transformation Plans.
PHE lacks the system change competence and freedom to challenge so it should commission an ongoing programme of thoughtful briefings that can be used by health inequality champions inside and outside the NHS to drive help drive local system change.
These briefings should be commissioned from two sources first – the members of the VCSE Health and Wellbeing Alliance (which they sponsor) and second leading independent organisations such as CLES, Centre for Welfare Reform, Money and Mental Health Policy Unit etc who have a track record of bringing sophisticated, independent challenge to existing local systems and the people who are trying to influence them. They should be asked to respond to the question “From the perspective of you and your stakeholders what action should STPs take to reduce health inequality?”
What do you think?