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Acute hospitals need to take more action on health inequalities

June 24, 2020

I recently interviewed the board members of an integrated care system. This piece of work has challenged my ideas about how we best address health inequalities.

When it comes to tackling health inequalities I have tended to focus on those people and sectors who are most passionate and engaged with this agenda. Namely, the voluntary sector, general practice, communities themselves and local government.  I continue to think this is important. However I think that we have ended up leaving the most powerful part of the local health and care system out of the discussion – the acute hospitals. 

This has been a mistake.

Our expectations of what the acute acute sector can do with regard to health inequalities has been too narrow. When the acute hospital sector does engage it tends to  default to rather limited outward facing areas:

  • Local purchasing plans – citing the Social Value Act as an important lever (relying on the social value act is, in my view the last hope of the desperate!)
  • Local transport to and from the hospital – again this is a usually more aspiration than action
  • Local employment strategies – there are some promising examples here – for example the Leeds Teaching Hospital had a very successful local recruitment campaign in a deprived part of their patch.

All of these actions leave the most important part of hospital provision – clinical services – off the table! 

It is comparatively rare to find examples where the hospital has taken responsibility for designing and leading a service that aims to improve a patients health in the round – generally hospital services focus on delivering a specific clinical intervention that ignores the context within which people live.

When a hospital does take a more person centred approach – magically – services becomes sensitive to health inequalities! Here are three examples:

London Homeless Pathway – Pathway helps the NHS to create hospital teams to support homeless patients and in some hospitals, Pathway Care Navigators: people who were once homeless to support homeless patients.

Major Trauma Unit Sheffield Teaching Hospital – A dedicated welfare rights service provided by Citizens Advice Sheffield for patients at the major trauma unit – funded by the Sheffield Hospitals Charity.

Guys and St Thomas’ Hospital Charity – take a place-based approach, addressing a small number of complex health challenges at a time. They work with local partners in Lambeth and Southwark and share their findings with others tackling similar issues.

We need to develop a new narrative that recognises the crucial role that acute hospitals should play here. Rather than trying to develop strategies that seek to ‘pull’ funding out of the acute sector we need to recognise the role of the acute sector and expect and support them to change. 

What these examples tell us is that it is possible to work with clinicians to create a more inclusive model for good clinical practice, by recognising that the wider context of peoples lives affects their ability to engage with clinical services which then impacts on their health and how quickly they get better.

Here are some suggestions:

  • We need to engage with Acute Hospitals and work with them to develop their own Health Inequality Action Plans that link their services to the wider population and the circumstances they face.
  • The work of Guys and St Thomas charity provides insights into what this might mean but we need to go further. For example services such as Accident and Emergency should be used as a bellwether for local health systems – who uses them and why are indicators of socio-economic pressure and wider health system failure – I don’t think that local health systems use this data systematically or effectively to help shape wider strategies.
  • The examples I gave above with regard to homelessness and major trauma show that a more inclusive version of what constitutes good clinical practice is possible. Both of these examples affirm that good clinical services must recognise that a patients vulnerability and lack of personal agency can be affected by factors outside the hospital environment. These examples show that good clinical practice inside hospitals involves more inclusive actions which can improve a patients ability to use health services effectively, help their recovery and be more cost effective.

Finally, there is of course added urgency here – the over representation of people from BAME and deprived communities among those admitted to hospitals during the pandemic and who now face long periods of recovery; must provide a further spur to considering how to develop inclusive services that respond to the clinical and social needs of people who have experienced a traumatic illness.

 

What do you think?

4 Comments leave one →
  1. June 28, 2020 22:09

    Quite right Mark. Our efforts trying to get acute hospitals to do something different (provide better care for homeless patients in our case) often run straight into the language of business cases, optimisation, efficiency savings etc. Hospitals can and should play a role in helping re-balance long-term, chronic social exclusion. Allowing a bit more time, giving extra input, encouraging staff to go further, (and yes, increasing costs) for someone who has usually had very little throughout their life is not an argument that seems to convince many hospital managers or commissioners. “Would you like to improve care for homeless patients?”, often met with “That’s not really our role and not a priority”, rather then, “Of course, I work in a hospital. We care for people and we try and help the people with the highest needs the most.”

    • June 30, 2020 23:08

      Thanks Alex – and good to hear from you. To be honest your response concerns me – the Homeless Pathway has been in existence for so long now – one would have thought that the rationale behind it was now proven. I shouldn’t be surprised though, in Sheffield the Care Trust works with Sheffield Citizen Advice to provide an integrated welfare rights service to patients on the acute mental health wards. Despite a number of attempts I have struggled to generate interest in making the case that this integrated service should be seen as a standard way of responding to need in all mental health trusts. Anyway….. the battle continues.

  2. June 30, 2020 12:20

    I welcome this conversion(!). There are – fortunately – now lots of examples of trusts who see this broader role: and the connection between their outward-facing perspective (social value, civic partner, anchor) and the inward design of services and how the two are connected. If ICS’s are for anything, surely they should be for inequality reduction (after all that’s what it says integration is for in the legislation). Here are 8 things around this that the NHS can be better at to make a difference https://www.kingsfund.org.uk/blog/2018/09/health-inequalities-nhs-plan-needs-take-more-responsibility. We can learn a lot from other systems on this too, inc some progressive systems such as Montefiore in New York, and others.

    • June 30, 2020 23:00

      Thanks David – and its good to see that the Kings Fund is increasingly at the forefront of pushing for a clear framework with regard to tackling Health Inequalities and I agree with you this is precisely what the Integrated Care Systems can contribute to. Lets face it – to some degree their geography is more to do with the relationship between hospitals than local authorities. I think the Kings Fund top 8 which you link to above is definitely worth looking at. However, I do think that number 3 needs rewriting “For example, local authorities are innovating in tackling the four big risk factors that have the most impact on people’s health – smoking, excessive alcohol consumption, poor diet and lack of exercise – by developing new services that focus on addressing these risk factors together, rather than in isolation.” I don’t agree that these are the four big risk factors what happened to poor housing? financial insecurity? job insecurity? education? Local authorities are working on these important areas – in spite of government disinterest, disinvestment and sometimes opposition.

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