I asked for water and you brought gasoline – Health Inequalities, STPs and Public Health England
Public Health England have just produced a set of intelligence briefings on health inequalities for Sustainability and Transformation Plans.
The briefings achieve the seeming impossible of being technically right and so very wrong.
The problem
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?
Hi Mark
A very interesting read as usual.
For me the sentence that speaks loudest was your challenge re:
‘Bringing the outside world and the lived experience of inequality into the Sustainability and Transformation Plans’.
From what I can see the current mainstream health care system really struggles to do this. The evidence would seem to indicate this is a deep and entrenched issue affecting organisational and professional culture in health care.
I would be speculating as to the reasons why this situation exists but would suspect much of this is about power, fear, and misunderstanding. There is probably an underlying tension around loss of control by involving outside, unknown influences in a climate of austerity – self-protection is a basic human instinct that could be at work here. Although I have never accessed a clinically related degree course I am concerned that concepts like ‘lived experience of inequality’ and ‘coproduction’ or ‘patient focus groups’ etc probably do not significantly feature in course content – if at all. If this is the case then surely this is another contributory factor to the culture that currently exists.
If any service provider or body responsible for influencing public service design is not willing to get close to the consumers of the service then the chances of coming up with dysfunctional solutions are surely increased? This seems to be a blight affecting much public provision in the current climate. I see parallels between the situation in health in the employability arena too – and its interesting that we now even have an evidence based film which has been released on this issue ‘I Daniel Blake’ is an interesting watch. Perhaps there is too much of a ‘command and control’ dynamic at work – there is lots of ‘top down’ developments taking place but a paucity of real lived experience filtering back up into the system as you’ve highlighted.
Might be wrong in certain areas – but these are some of the wider issues I suspect are at play here.
Concerning times.
Kind regards
Richard Hazledine
Cheers Richard – a thoughtful response – I particularly like your point about “There is probably an underlying tension around loss of control by involving outside, unknown influences in a climate of austerity”. Best Mark
Clearly if appropriate patient participation was taking place the deficits in engagement wouldn’t exist. Sadly it is the closed shop mentality that maintains the disconnect.
Thanks Hilton – agree – a stronger public voice would really help address some of these deficits. Mark
Hi Mark,
As always, enjoyed reading your article.
Your opening comment “technically right and so very wrong” nails it. We know that Service improvement, health inequality and financial pressures have been on the health agenda for years, so nothing new there. The three aims are of course interdependent. Therefore the “drift” (is that too generous a description?) to achieving economies becomes all consuming. It must be possible to achieve all three objectives by addressing the root cause of the problem rather than ignoring (at worse) or sticking an Elastoplast (at best) on vulnerable groups. Your two suggestions would seem very well placed to address this.
Best wishes – Linda
Thanks Linda – always good to hear from you – I think you have pitched this just right! All the best – Mark