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NHS England say “We have failed to tackle health inequalities and must do so much more!”

April 24, 2018

Here is a quote from a “scene setter” report on health inequalities which went to the March 2018 Board of NHS England.

“We have made positive progress in fulfilling our legal duties to reduce health inequalities and have made health inequalities a priority in implementing the NHS five year forward view”

Yet this table from the same report presents a different picture – positive progress?

Sometimes the language of bureaucracies dispirits me. We often get bland statements – that basically say – “no cause for worry we have fulfilled our legal duties” when we actually need a rallying cry…..

“we have failed to tackle health inequalities and we need to do so much more!”

This paper is a good illustration of why we lack this rallying cry.


There are two significant omissions to this report. There is no definition of what is meant by health inequalities – and following on from this there is no mention of the context within which health inequalities currently exists in the UK.

We have to come clean and say that health inequalities is avoidable disadvantage experienced as a result of peoples socio-economic status. Of course there are other disadvantages that people can experience as a result of their disability, race, gender, age etc but these equality issues are not synonymous with inequality.

A note on context – we are in the middle of a period of severe cuts to local government and other services that are intended to tackle inequality – see here (Guardian – local govt cuts),  here (JRF report)  and here (Guardian – benefit cuts).

This scene setting paper mentions none of these issues – yet it promotes integrated care systems!

Lack of a coherent narrative. 

As Mike Chitty (quoting George Monbiot) said in a recent tweet

This paper has lots of facts – its starts using an ONS classification that I was not familiar with. This breaks local authority areas down into a set of categories – supergroups – for example “services and industrial legacy” and “Business and Education Heritage Centres” etc. Later the report compares “most deprived areas”to least deprived – I think by population groups of 100,000 population. 

I know this issue is complex but I come away confused and unclear about the scale of the population affected and lack an insight into what this means at a population level.

The different approaches are confusing and risk repeating the mistakes made by the Labour Government Spearhead Programme. It focussed on local authority areas which have a high proportion of people who experienced health inequalities (a bit like the services and industrial legacy group),  however cities like Sheffield were not recognised because the proportion of people who experienced health inequalities was smaller, even though the actual number of people who experienced health inequalities was larger!

People or Conditions?

Further in the report health inequalities is described according to condition – Cancer, mental health etc.

This exemplifies the siloed approach of the NHS commissioning model. It appears as though though we are talking about different populations with regard to health inequalities – when of course we are not. This is particularly the case if we take into account the burden of disease that people who experience health inequalities carry at an earlier stage in their lives – see this blog from Peter Hoskins editor at Conservative Home!

We need something that brings all this together. Maybe a narrative path that goes something like this:

Low income and financial insecuritypoor mental health and wellbeing ➪ poor physical health 

Lack of systematic actions

It feels as though NHS England is scraping the barrel here while there are a range of initiatives mentioned it acknowledges that many of these are pilots, it mentions the Improving Access for All toolkit which I critiqued here, and Social Prescribing. Its hard to see why other initiatives such as Personal Budgets (with just 23k people on them!) are included – is NHS England saying that this is a programme specifically addressing health inequalities?

It does talk about the need to review the financial allocations formula – which is positive – however I suspect that this will take a rather long time and without a decent analysis of inequalities (see above) is unlikely to deliver.

What next?

NHS England need to work with the Local Government Assocation and key organisations such as the Institute of Health Equity, Joseph Rowntree, Citizens Advice, the Money and Mental Health Policy Institute and the Royal College of Psychiatrists to produce a coherent narrative that sets out the health inequality challenge – everything else follows from that.

What do you think?

NICE, Public Health and Local Government

March 10, 2018

Articles by Mike Kelly former Director of the Centre for Public Health at the National Institute for Clinical Excellence are always worth a read. He has just published one in the Journal of Public Health which looks at the role of evidence-based public health guidelines in local government.

One of the points that Mike makes is that councillors have a much broader view of evidence than the NICE model whose approach has its origins in evidence based medicine, peer reviewed literature etc. He notes that elected members must also take into account a range of other factors – such as their local knowledge and the views of their constituents.

Mike’s paper got me thinking – as he says –  local authorities are democratic political decision making bodies and NHS organisations are not. As I explored this a bit further it seemed to me that NICE have pulled back from their public health function in the last few of years. I think Mike left NICE in 2014

NICE guidance is still mainly for the NHS. The NHS is essentially a collection of services – and despite various attempts to make it more accountable locally it is really an aggregation of different clinical health specialisms bound together by a post war policy commitment – these are managed by NHS England on behalf of the Department of Health.

Being a collection of services – the focus is on delivery. Respective governments  have created a performance management system that focusses on individual service performance rather than their total  impact on population health.  NICE guidance works in this policy context.

In general NICE guidance focusses on one of 3 areas:

  1. technical practice with individuals,
  2. how services should work
  3. what systems should do.

Most NICE guidance focusses on areas 1 and 2; however, NICE Public Health Guidance for understandable reasons has a greater focus on areas 2 and 3. Even here emphasis is more on services rather than systems. I have looked at the 65 NICE public health guidelines of these only 13 specifically mention that the intended readership includes system leaders such as elected members, Health and Wellbeing Boards, Local Strategic Partnerships etc. My working out is here.

Most NICE guidelines are operational and conservative. By this I mean they tell us what is already known. The aim is to ensure that good practice is used consistently. It’s not surprising that elected members are largely unaware of them – most are not aimed at them and those that include them are produced infrequently.

Local Councillors head up significant local democratic institutions who use their mandate to ensure that the interests of their population are served. They are responsible for shaping what it feels like to live in that area, the local authority power of wellbeing is a recognition of this.

Many are trying to improve health and reduce health inequalities in a world that doesn’t  work according to the same rules as NICE guidelines.

It is quite understandable that local councillors have little interest in much of the guidance that is produced by NICE. Having said that I think that when it existed the Centre for Public Health at NICE must have recognised this problem because they produced a series of Local Government Briefings that attempt to speak to local authorities in their system role. While I think they still struggled with the operational nature of NICE evidence nonetheless they strike me as an attempt to reach out to system leaders like Councillors.

Unfortunately NICE is now pulling away from this innovation – see below:

Councillors are primarily concerned with strategic challenges which can include structural inequalities, access to employment, financial insecurity, social cohesion, health and care system integration etc.

Unfortunately these strategic public health issues are just not on the NICE agenda reasons include:

(Caveat – this blog has been written over a few evenings – I’m not claiming that it is a full representation of all NICE work on Public Health. Declaration of interest I used to work for the Health Development Agency)

What do you think?

The real reach and impact of the voluntary sector – what welfare rights organisations can tell us

February 11, 2018

It’s all very well talking about shifting the balance of services to community – but once it comes to resource shift the big statutory funders tend to default to trying to measure value using mechanisms that are usually variations of the ones that they use already to monitor big services like hospitals.

Frankly, having sat on a number of NHS committees over the years I am not even sure whether this high level (usually activity) information really provides much of an insight into the effectiveness of these services anyway. It certainly offers little understanding on impact on population health.

Here is an example of a report that the Sheffield Clinical Commissioning Group receives every month on performance – it is primarily fairly abstracted information on activity – it is hard to understand the relationship between this and demand and need.

What is true is that for small voluntary organisations this approach to performance data is unhelpful, not least because their contribution can look too small compared to say the number of admissions to urgent care or the number of people seen by GPs everyday.

I have been wrestling with this question for a while – because as the Chair of Citizens Advice Sheffield I want funders and other stakeholders to understand what we do and the difference it makes.

Here is our challenge.

This financial year we will probably help at least 26,000 individuals – I have made this assumption based on our half year report which is here. That sounds like a lot of people – but if you compare this against the total population of the city – some 560,000 people it looks relatively meaningless, it does not help funders and others feel confident that we are an essential service in the city.

In other words we helped approximately 5% people in the city.

However, we only actually see adults (although our advice can help their children of course) and in most cases it is one person from a household – so if we compare the number of people we see against households (229,928 – 2011 Census  )

the proportion of households we helped in the city is actually 11%.

Of course we know that people who experience different forms of inequality are even more likely to use our services. When we look at the proportion of households who use our services by council ward. (ward data from here) The picture is even more striking the table below shows   5 wards in Sheffield – four are among the most deprived and one of the wealthiest – this is what we see:


Note – as I flag up above – the figures in the table are estimated one year figures based on real 6 month utilisation data

As the table shows in the poorest parts of Sheffield one in five people use the Sheffield Citizens Advice service! This is of course shocking and concerning – compare this to the number of people who use the service in Fulwood.

Further it shows that rather than just being a worthy organisation who does good work but makes little difference – the Citizens Advice service has a population effect particularly in the most deprived parts of the city. This is a targeted and trusted service which is being used by some of the most stressed individuals and communities in the England’s 4th biggest city.

What does this mean?

If we are to see better utilisation of the voluntary sector – and particularly of their contribution to health protection then NHS England, Public Health England, Clinical Commissioning Groups and Local Authorities need to do develop better tools that capture the contribution of voluntary and community organisations. They could start by commissioning local organisations with the expertise – such as (good) councils of voluntary service and those with data handling expertise like Citizens Advice Bureau to work together to produce frameworks that capture voluntary sector data in a way that demonstrates local impact.

Of course beneath the utilisation data that Citizen Advice Bureau produce is a wealth of impact information on income increased, debts resolved and housing status secured – but there is not enough space in this blog to write about that!

What do you think?

Local Authority Funding for Welfare Rights Services is a beautiful thing

November 11, 2017

Like every one who works or is a trustee in the voluntary sector I worry about funding. It struck me recently that it not just the scale and stability of the funding that is important but what it represents.

Funding for Citizens Advice Bureau ultimately comes from two main sources. Local Government and Central Government – compared to other local voluntary organisations there is relatively little funding support from charities.

It is striking that local authority funding support has generally held up – despite the terrible  cuts to local government funding government.

In crude terms I think the difference is a bit like this:

  • Central Government – funds local Citizens Advice Services to provide Consumer Advice and Money Advice Service
  • Local Government – funds general welfare advice and also a range of infrastructure support this can include:
    • core management costs
    • Volunteer recruitment and training
    • Services tailored to particularly stressed communities such as economically disadvantaged neighbourhoods, Gypsy and Travellers, Deaf People, Migrants, people with Mental Health Problems and so on.

All of these services are important but I think there is a real difference in the focus of these two funding streams. In general central government is interested in services that are relevant to the whole population and are focussed on the relationship between the citizen and non-governmental services.

Both the Money Advice Service and Consumer Advice are good examples of this. They are primarily concerned with empowering individual members of the public to take more control of their relationship with private sector organisations, whether those are financial institutions or providers of services and goods.

Much of local authorities funding is concerned with helping people who are on low incomes and often with some degree of vulnerability to navigate their relationship with the local and national state – in particular with departments and organisations that are meant to meant to be there to help but too often make it hard to access their services.

The two screenshots below are taken from a discussion about Personal Independence Payments on the Pain Support Website

The most important aspect of this is how Citizens Advice Bureau help people access the Department of Work and Pensions or to challenge decisions about entitlement.

I now think that there is a fundamentally important distinction here. Local Authorities choose to champion and invest in local services which help people address deficits in national government policy. In this case services that are concerned with helping people to access a key national support service – the welfare benefits system which national government too often manages in a way that is designed to stop people getting the support they are entitled to.

By and large it is local authorities who are funding the services (often with a significant contribution from public health budgets) that help people access essential benefits such as:

Employment Support Allowance – 68% successful appeals

Personal Independence Payments – 65% successful appeals

Both of the above figures are for the last quarter of 2016 – source The Independent Newspaper

…and it will be local authorities that provide the funding to help the large number of people access help when they have to navigate Universal Credit.

This is why local authority funding support to Citizens Advice Bureau is so important and needs to be valued and appreciated for the beautiful thing that it is.

What do you think?

Declaration of interest – I am chair of Citizens Advice Sheffield

What has CQC to say about Inequalities and Public Engagement in General Practice?

October 5, 2017

My earlier blog looked at the recent NHS England Inequalities Resource (reducing inequality in access to general practice services) and noted how disappointing it was. As I said at least its there.

Now the Care Quality Commission have produced their three year report on the State of General Practice

I have looked at this report through the lens of Inequality and public engagement because both of these still feel:

  • Undeveloped
  • On the margins of mainstream activity
  • variable in terms of ownership and practice

The CQC report covers all England and the period 2014 to 2017 – during this time pressure on general practice has increased and the environment has changed fundamentally – not the least because now the commissioning of general practice is done jointly by NHS England and Clinical Commissioning Groups.

Health Inequalities and Public Engagement

To its credit the report does engage with both patient and public involvement and health inequalities.

It does this mainly by giving a range of case studies showing how individual practices have changed the way they work so that they are more accessible and provide relevant services often through working in a more holistic way with disadvantaged communities. Examples include GPs serving homeless people, migrants and economically disadvantaged communities – I reproduce a couple of case studies below.

Screen Shot 2017-10-05 at 22.21.03

Screen Shot 2017-10-10 at 21.14.36

A similar approach is taken with regard to patient engagement – although there are fewer case studies here:

Screen Shot 2017-10-10 at 21.18.48

What is the problem?

While case studies are always useful they are not sufficient. At their best they speak to people who are already to some degree convinced about an issue. Their strength (an example of real practice) is also their weakness – they can too easily be dismissed as not being relevant because “things are different here”.

I wonder if part of the problem rests with CQC – with their inspectorate probably not sufficiently comfortable with assessing effective practice with regard to public involvement and good practice on inequality and maybe not sufficiently convinced of the relative importance of these areas.

More importantly I think that CQC lack of theory of change here. They are sitting on a three years worth of data on every practice in England. The fact that CQC have provided case studies is a clear indication that there is variation in practice with regard to inequality and public engagement – yet CQC don’t say this! If CQC really want to help drive better practice with regard to inequality and engagement they need to use the information they hold more openly and more effectively.

It is quite different assessing the quality of mainstream services whose role is already accepted – such as the quality of primary care compared to assessing progress in implementing good practice in areas that are still to some degree on the margins – such as inequality or public engagement.

CQC need to use the intelligence they hold to challenge individual practices AND Clinical Commissioning Groups. Case Studies are not enough – organisations need to be able to see how they stand compared to their peers and understand that this information is in the public domain.

What needs to happen

  • At a CCG/local authority level it would be good to understand how PPG activity and practice compares with peers within and across health and care systems
  • We need to know how consistent good practice is across GPs serving socio-economically deprived communities and what CCGs/Accountable Care Systems should be doing to support this.
  • Finally, I think examples of bad practice (they don’t need to be named) can also be very powerful – giving evidence to show why this is not acceptable.

What do you think?


NHS England Inequalities Resource on Access to Primary Care

September 6, 2017

NHS Inequality Blog 1.jpg

Here’s the problem. Health Inequalities continue to grow (Kings Fund 2017) and many people who under the Equalities Act are described as having “protected characteristics” such as people with disabilities and mental health problems have seen little improvement in their circumstances (Being Disabled in Britain April 2017).

So, I was pleased to see the launch of the NHS England Inequalities Resource for reducing inequalities in access to general practice.

I have spent the last 4 years or so working with GP, Public Health and Voluntary sector colleagues trying to develop a stronger focus on health inequalities in primary care, problems include:

  • The challenges faced by GPs working in very disadvantaged communities are insufficiently understood and more importantly insufficiently owned at a local health system level.

  • Much guidance fails to sufficiently recognise the social and economic circumstances that affect people’s health and their ability to take control.

  • Many GPs who don’t serve communities who experience multiple disadvantage struggle to understand the complexity of the challenge and why their peers need additional resources.

In many places there are GPs who have dedicated their working career to responding to the needs of disadvantaged groups – such as the homeless, substance misusers and people with a learning disability. Many of them work in economically deprived neighbourhoods – these often have higher numbers of people with protected characteristics too.

Does this resource help?

Well, it is good that it has been produced – better something than nothing in my view – it gives us something to build on.

It is clear that a small team of people have worked hard to pull together existing knowledge into one place. Regrettably the layout is not up to the task of making this information accessible – its largely a gateway to further large and complex documents  rather than an expert analysis of this complex issue.

This document says it is for CCGs and GPs. I don’t think it is. It offers little challenge to CCGs and no coherent view about what actions CCGs should take to tackle inequalities. I think the main audience are trainee GPs and other relatively new staff working in primary care settings – there is nothing wrong with this but it does not do what it says on the tin.

Its not the fault of the authors of the document but its existence highlights where the deficits are:

  • Tackling inequality is NOT an issue that is experienced in the same way across local health systems. For GPs serving very deprived communities this is the day job – for others inequality is not a systemic issue. This disparity creates an unbalanced discourse at a local level.
  • in my view experienced GPs and their collaborators need help developing strategies to change the hearts and minds of their peers and CCG officers who are not working in disadvantaged communities and that will help challenge CCGs  and Accountable Care Systems to raise their game and their priorities.

We need to recognise that this issue exists primarily because of an imbalance in power – not because of a lack of skills and knowledge. It is a truism that services that seek to respond to the needs of people who lack power are themselves disempowered.

What we need next

We need to establish a systematic and ongoing programme of knowledge exchange – we can learn from the models of the last Labour Government – see David Bucks Kings Fund blog here  and most importantly check out Reducing Health Inequalities – System, Scale and Sustainability from Public Health England who have asked the Chris Bentley to share the learning from the Labour Government’s  National Support Team for Health Inequality.

NHS England and Public Health England needs to commission a long term  system change programme here. Its not just for General Practice to do the changing – that will be easier if we get the right leadership at a local level.

It would help to have:

  • Strategic Analysis of the local equality/health inequality challenge its scale and why it exists – at a place level.
  • Advocacy at a national level for explicit local strategies to tackle inequality
  • Clear examples of systemic models that can be used to create change

What do you think?


Access to communities: tailoring services to meet different health needs

August 27, 2017

vcs blog #2

Following my last blog on the growing interest that local health and care systems have in services that connect people with the voluntary and community sector in order to improve their health and wellbeing, I have tried to order some of my ideas into the following tables.

Please bear in mind that these are just some of my thoughts on this – I am not claiming that it is a complete picture or a completely correct one!

One of the problems with putting tables like this together is that I can justifiably be accused of having oversimplified matters – please see the tables as providing a frame for discussion not an exact representation of “what is”.

Please respond with comments suggesting how I could improve the information below and I will try to amend.


  • Social prescribing enables GPs, nurses and other primary care professionals to refer people to a range of local, non-clinical services.
  • Local Area Coordination is a long term, integrated evidence based approach to supporting people with disabilities, mental health needs, older people and their families/carers
  • Health Trainers support people to adopt healthier lifestyles through empowering them and helping them to set a personal health plan (PHP). This outlines the individual’s goals for a healthier lifestyle and a plan to achieve these goals.
  • Community health champions are people who, with training and support, voluntarily bring their ability to relate to people and their own life experience to transform health and wellbeing in their communities.
  • Advocacy means getting support from another person to help you express your views and wishes, and to help make sure your voice is heard. Someone who helps you in this way is called your advocate.
  • Welfare rights means the rights of people to be aware of and receive their maximum entitlement to state welfare benefits, and to be treated reasonably well by the welfare system
  • Community anchors are independent community-led organisations.

    They are multi-purpose and provide holistic solutions to local problems and challenges. They are there for the long run, not the quick fix. 


Table One – Different services to respond to different needs, different social conditions and differences in power.

Community Support #6.001

Table Two – Description of some of the characteristics of the above services

Community Support Model #5

What do you think?