Fading away? NHS Yorkshire action on financial insecurity
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?
An interesting read Mark. Certainly, we are living in very challenging times for the NHS, local authorities and third sector. The experience that I ve seen over the years suggests that NHS partners work most effectively where a clinical response is enough to resolve an issue. Whilst concepts like the wider determinants of health reveal that health is not purely a clinical issue the development of integration between health and social action and health and social care is problematic. For a variety of reasons it has historically proven very difficult to integrate clincial and social approaches to positively impact population health. There are perhaps for a variety of reasons for this. One of the my long standing concerns in this area relates to the role of Universities. Clearly, there are a wide array of medicine courses producing significant numbers of graduates with clinical expertise. What I don’t see is these courses including modules focussed on the role of the third sector, or integration practices with social care (if it is happening I suspect is not wide-spread practice or it is ineffective). Perhaps unsurprisingly, this is translated into the the development of senior leaders who appear constrained in their ability to integrate the clinical with the social and vice-versa. I guess the make up of modules for social care courses would be the same if we looked in detail of them. This then is manifested in conversations that I ve been party to with senior leaders over the years who are struggling to understand basic principles like the role of the third sector. Is it any wonder that the system is so dysfunctional when the starting position for too many future leaders working in health and social care is so unbalanced? The evidence suggests that there is much work to do in this area…
Good call Richard – I agree with you! Upstream training of clinicians and NHS leaders is a key part of the jigsaw – although I think the culture is also set by a culture of leadership from the centre – DHSC – which ends up trying to run this complex system in a way that speaks to governments need for simple soundbite analysis!
Thanks Mark. Yes, I would agree that the culture of DHSC and central government is part of the challenge here. John Seddon has written a very thought provoking book on the processes of Whitehall. This goes under the title of the ‘Whitehall Effect’ A very interesting and insightful read to help ponder the underlying processes affecting the development of public services in the UK. https://www.amazon.co.uk/Whitehall-Effect-Became-Public-Services/dp/1909470457/ref=sr_1_5?keywords=john+seddon&qid=1668598253&sprefix=john+seddo%2Caps%2C70&sr=8-5
Good read and for me it goes back to funding at a system level. If the system changed their approach so the PCNs held a budget to support people locally in certain ways, they could mobilise quicker and be more proactive to help support their local populations in cases like the cost-of-living crisis. They’re the ones that have built up the integration with VCSE/community providers, so could provide funding to their services and/or establish support groups with multiple people under one roof. Instead, if funding does come, it’s sometimes late/small or heavily restricted to what they can do with it. The system needs to be more mature and innovative to help the local population in times of need.
Thanks for this Josh – I mostly agree. At the moment GPs get some contractual funding to pay for social prescribing – but I think this is pretty ring fenced. I do think that place and sub regional commissioners still struggle to ensure that GP practice is consistent in this area … it isn’t. But in general terms I am very much in favour of devolving funding.
Hi Mark, thanks for this and interesting to know what is(n’t) happening out there. I note your last point with interest about commissioning welfare services. Many years ago there were some places doing this and if I recall rightly the evidence showed really positive effects on health, but this was pre-austerity so not sure it would be as effective now.
Thanks Karen – yes! In Sheffield our mental health service is commissioned by NHS locally – and I’m sure there are other examples elsewhere – but the NHS approach is still v reliant on individual champions and is not coherent.
Completely agree with this – ‘There is a tendency to default having ‘interesting’ discussions but failing to agree practical strategic practical 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.’
Every piece of collaborative work I’ve taken part in with ICBs, NHS Trusts etc have had this issue. IT’s very frustrating when the need to resolve the issue is urgent!
This was particularly bad with the work I did in a Long COVID Working Group that I had asked to be set up locally with representatives from public health, NHS, local council. LOTS of conversations but very little action. The communication strategy that I suggested 24 months ago is being implemented THIS MONTH. I had stressed the urgency and was told ‘that we are having these meetings is exceptional in itself, we are normally tied to set time constraints in terms of updating policy’.
I also agree with this point – ‘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
I appreciate that you wrote ‘for example’ but I would include people living with neurological diseases such as M.E/C.F.S and Long COVID (the main subset) within this list as this a very big group of people (Stripy Lightbulb CIC estimates it to be around one million people who now meet the diagnostic criteria for M.E/C.F.S in the UK. 7 research papers now state that half of Long COVID meet the diagnostic criteria for M.E/C.F.S). Too many have gone from having manageable debt as a ‘fit and healthy’ person to being unable to work during a cost of living crisis. Their only support being talking therapies and taking part in the occasional research study. Many are at the point of selling their home. They are having to seek independent advice re welfare rights/debt advice.
Really interesting article, thanks Mark.
Sally – a very affirming response – thank you! I agree completely with you – and your are right to raise other conditions – as you spotted its not an exclusive list. I am chair of citizens advice sheffield and heard today that we also provide a dedicated service to people with cystic fibrosis. I do think it is quite straightforward to develop a fairly robust framework that the NHS could use to identify services that are used by people with a long term debilitating condition that impacts on their financial security. I also think that there are very good reasons why specialist welfare rights services should be based in hospitals or surgeries alongside clinicians – it really helps having a welfare rights worker who understand the specific issues experienced by people with particular conditions. For example I suspect that people with ME or Long Covid are more likely to require (sadly) confident and skilled advocacy to enable them to access the Personal Independence Payments or Carers Allowance that they will be entitled to. Further, I think the general quality and accessibility of the clinical service will be improved through the advocacy of the welfare rights specialist who will help the clinician understand the wider challenges outside the hospitals that might be faced by the patient.
interesting read. In my opinion (from a neighbouring ICS system) there is a real lack of understanding about what Social prescribing is. to be honest something that the VCF have been doing for hunmdreds of years- just not called that. Too much emphasis on the link worker role rather than the real need to have a thriving VCF that can accept referrals eg into CAB for debt and money advice, or a wide choice for a person to really choose their own unique social networks. the same applies to mental health services. the system is bureaucratic and continues to focus on a clinical solution. Some PCN’s are great. others are treating true working with the sector as a tick box. too much talk from too many too far removed from the reality for so many people. lots of conversations with no real actions and huge delays to any solutions that may be potentially addressed. it is not a competition . the VCF sector knows through many years of experience but their evidence is still largely ignored in favour of academic research findings from universities which take far too long
Thanks Christine – really helpful comments – I agree – I am a trustee of a health focussed community anchor and one of the challenges they face is that although they get funding for the link worker there is no full cost recovery – so no funding for all the on costs which are needed to help sustain the community anchor itself. Your final comment is important too – the National Institute for Health Research is putting some funding into pilots that put communities and the VCS at the heart of research … which is sort of hopeful …. lets see!