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The one rule of Social Welfare is don’t talk about Social Welfare

May 16, 2017

  • Imagine a system designed to support the most vulnerable.
  • One that is there to help people get back on their feet and take control of their lives.
  • A system that is as big as the NHS yet we barely talk about it.

I am talking about the Social Welfare system.

In 2013 in the UK the government spent approximately £126 billion on healthcare

This compares to the £215 billion we spent in 2015/16 on social welfare support (including pensions). If we take pensions out of the equation we spent some £125 billion on means tested and disability benefits.

These two systems – health and social welfare – play a crucial role in providing the infrastructure of services that allow vulnerable people to live successfully in the community and help people get through difficult periods in their lives and move on to greater independence.

The Problem

In the Health system we spend a great deal of time, energy and resources trying to work out how to make front line services more accessible to people who need services most. We have powerful population level data on who would benefit from services and who actually uses them – see the Public Health Data I wrote about in my last blog. We know which populations are most likely to have higher prevalence of cancer and coronary heart disease; which populations take up screening services and who ends up in hospital requiring emergency treatment.

With Social Welfare the situation is reversed. Local and national systems put in hardly any effort to understand level of need – for example; the  level of problematic debt among key populations. This leads to an impoverished analysis with no evidence based debate about the type of investment that is required to best meet need.

We end up with comparatively small welfare rights and debt support services such as Citizens Advice Bureau struggling to respond to people in crisis – queues and unmet need are the norm.

Tragically, this failure to take a strategic approach to ensure adequate welfare rights provision means that is more likely that vulnerable people who are already under tremendous stress will be unwell.

As well as being a personal tragedy for them this also impacts on the NHS. For example recipients of Cognitive Behavioural Therapy are less likely to benefit from this NHS service if their problematic debt is not addressed first. As well as impacting on the cost effectiveness of this service it also means it increases the likelihood that these same people will end up presenting at urgent care NHS services such as primary care and accident and emergency.

During this election period we are tripping over examples of vulnerability and pressure that stem from peoples personal financial insecurity. From Cathy Mohans challenge to Teresa May about Personal Independence Payments through to data from the Registry Trust showing that the number of people who have been served with County Court debt judgements in England and Wales has risen to to a 10 year high.

What needs to be done.

First, Leaders in local areas need to have a purposeful conversation about this. I was surprised recently when I raised this issue locally at the reluctance to engage with it. I think that we have absorbed a government message that ensuring that people get the benefits they are entitled to and need demonstrates a lack of ambition – that all we aspire to is a ‘welfare economy’. This mindset does a disservice to the millions of people – many working in low paid insecure jobs for whom access to social welfare support is essential.

Second, I think that local public health leaders must work to produce an analysis that describes the financial status of their populations and the reach of current support services. This is difficult – not least because unlike NHS England the Department for Work and Pensions produces very little useful local information to help planning.

Third, I think that key national agencies such as Public Health England and the Local Government Association should support Citizens Advice, Step Change and important think tanks like the Money and Mental Health Policy Unit to produce place based information and guidance to facilitate local action.

What do you think?

Nothing to do with the NHS? Mental Health and Personal Independence Payments

March 21, 2017

Declaration of interest – I am chair of Citizens Advice Sheffield

The Health and Care system is so complex, the responsibilities so great, the budgets so big that it is often all too easy to think that it is the most important part of peoples lives – the glue that holds everything together. Of course it isn’t – it is really a set of services that are there as a last resort when we can no longer manage on our own.

So, the risk is that while we focus on the challenges faced by health services to meet the needs of people with mental health problems it is possible to lose focus on changes that are happening elsewhere that have the potential to make a grievous impact on the wellbeing of those same people.

Social Welfare Support and Mental Health

Just like the NHS, the social welfare system is meant to provide support to help people engage with society and take control of their own lives. One of these supportive elements is the mobility component of Personal Independence Payments (PIP) which is meant to provide funding to enable people who are unable to leave their home to do so – to go shopping, see their GP, socialise, go to training etc. Subject to assessment, people with mental health problems can either get nothing, the lower rate (£22 pw) or the higher rate (£58 pw). The Government says that people with mental health problems should only be considered for the lower rate.

In November 2016 the Government lost an Upper Tribunal ruling brought in part by Citizens Advice Sheffield which declared that in some cases people with mental health problems SHOULD be eligible for the higher rate because “overwhelming psychological distress” should be considered when assessing the descriptor.  This success led to the Government trying to rush a change to the regulations to block this judgement – claiming that this was an emergency! The Government claims that if it did not do this there would be an additional cost to the treasury of £3.7bn over the next five years.

Although the Government denies that changing the regulations in this way will adversely affect people with mental health problems the House of Commons Library Research Paper – Changes to Personal Independence Payment Eligibility Criteria notes that the Governments own Equality Impact Assessment says that this change to the regulations will:

“Affect 336,500 claimants of whom 282.5000 will no longer be entitled to any mobility changes.
These changes could affect people with a wide range of conditions including learning disability, autism schizophrenia, anxiety conditions, social phobias and early dementia.”

This table – also from the Equality Impact Assessment sets out the estimated impact:

Back to the NHS

These changes will affect not only the health and wellbeing of many people with mental health problems who will find it harder to get out of their homes, will become more isolated and less able to improve their wellbeing; it will also affect NHS mental health and primary care who will have more demands placed on already stretched services.

I am concerned at how quiet key players in the health system are with regard to this issue. Despite all the rhetoric associated with the Mental Health Five Year Forward View there appears to be little coherent thinking about the need for acton to address the parlous financial circumstances of many people with mental health programmes and instead a rather superficial take on parity of esteem that gives insufficient attention to health inequalities. Regrettably this (lack of) thinking is replicated in guidance on Sustainability and Transformation Plans and on Accountable Care Systems.

I think that:

  • Public Health England need to develop clear models that describe the importance of the relationship between financial security and good mental health – and the actions that need to be taken locally and nationally.
  • NHS England could produce guidance and appropriate tools that set out how NHS commissioners and care trusts should connect with key agencies such as Citizens Advice Bureau. Similarly, they could produce some guidance that supports CCGS develop good practice with their GP membership on this issue.
  • Finally, NHS England, Public Health England plus professional bodies like the Royal Colleges of General Practice and Psychiatry and theFaculty of Public Health could publicly advise the Department of Work and Pensions on just how damaging these plans are.

What do you think?

Act on health inequalities? Learn from the past

February 19, 2017

I was recently asked to give a talk about Health Inequality and as part of it I dug out a graph that I used to use a lot when I worked for the Department of Health.hi-blog-2017-iii

The graph shows the widening mortality gap for working age men over the last 75 years or so – it compares the top social class (I) with the bottom one (V). It starts in the 1930’s and ends in the 1990’s – I would be interested to know if there is a more up to date version.

Ever since I came across this graph I have been intrigued by it. This is because I think we take an ahistorical approach to tackling inequality. In part this is because every government that comes in seems to assume that we are at year zero – witness Teresa May’s address from the steps of Downing Street when she took office, but its also because most programmes and actions assume a three to five year timespan – and as the graph shows tackling health inequalities is not a 3 or 5 year project.

So lets have a look at the graph – bear in mind that the graph is comparing the gap in mortality rates for men of working age – comparing social class I (bottom line) with social class V (top line). Note there is no data for 1981 because there was a local registry officer strike that year and no records were kept.



As you can see while the mortality rates for both groups goes down – it goes down far quicker for men in social class I compared to social class V.

Here are some things that stand out for me.

  • Prior to the war the gap in mortality rates is fairly narrow and pretty stable. I assume that this is because infectious disease like TB did not discriminate between social class. Nonetheless the narrowness of this gap does surprise me.
  • It is after the second World War that the size of the gap really starts to grow, and it does not really stop growing. This is a bit difficult for those of us who are supporters of the NHS – because this is when the NHS was created!
  • Of course it could be that without the NHS the gap might have grown faster and been even bigger; or that the NHS had no effect at all or even worse that the NHS is one of the reasons for the growth in the gap! I have toyed around with whether this might be due in part to Tudor Harts inverse care law. However, we are talking about comparisons between social classes V so I am less convinced about this.
  • I have wondered whether the size of the gap is in part due to other elements of the post war social contract – such as the increased social mobility bought about by improvements in access to Higher Education.
  • When I spoke about this with Chris Bentley (albeit in the pub!) – who was head of the Department of Health; Health Inequalities National Support Team he reckoned it was because the combination of socio-economic disadvantage and burden of disease in Class V since the second world war and onwards meant that many working age men in that group just did not have the wherewithal to keep pace with Social Class I. He particularly mentioned smoking – and the failure of respective government’s to reduce smoking rates among the most disadvantaged at the same rate as for wealthier people.

Why this is relevant nowhi-blog-2017-ii-1

We are in a very difficult period of government imposed austerity. The Health Inequalities gap appears to be widening – in part because the safety net provided by the state is increasingly threadbare – we see the NHS struggling to provide a consistent and accessible service, adult social care experiencing huge cuts and welfare support diminishing – as is set out in the report by Joseph Rowntree and Dominic Harrison DPH for Blackburn. For me the lesson this graph tells us is that we need to be much better at recognising all of the systemic drivers – not just the NHS – and defending those.

By the way the answer is clearly not more targeted anti-smoking leaflets at the most worse off!

What do you think?

Who is afraid of the big bad Sustainability and Transformation Plan?

January 11, 2017


In South Yorkshire and Bassetlaw we are busy thinking about the next phase of discussion on our Sustainability and Transformation Plan (STP). There is a useful and serious group of CCG engagement leads, the voluntary sector and local Healthwatch who are collaborating on developing a shared approach to deepening discussion with the public this year.

These discussions have led me to revisit our STP a number of times – simply because I cannot retain in my mind what it says the problem is and what it is trying to achieve.

I now think that my difficulty in grasping this is only in part due to my failing memory and limited intelligence- its also to do with the fact that STPs claim to be something that they are not.

I think that STPs are represented as THE overarching strategic plan for sub-regional health systems. However, if we look closely at them – the actions that stand out relate to plans to make specific NHS services – usually hospital based more effective and (hopefully) more efficient. There is nothing particularly threatening or wrong about this – in a number of cases these plans existed before STPs were thought of.

Of course STPs also try describe a wider vision and set of principles for local health systems – care closer to home, greater emphasis on prevention, tackling inequality etc. Here the actions are not clear – largely because STPs are NHS documents and this is a world where the NHS has less responsibility and influence. Again, nothing particularly new here – we have been concerned about these issues for some time …. and failed to make a great deal of progress.

The theory is that STPs will join these two issues up – greater efficiencies in hospital care will lead to greater investment in community, prevention etc – its an optimistic scenario.

Trusting STPs.

Its difficult to have faith in a plan that many people believe is primarily concerned with implementing cuts to health systems. In my experience STPs represent the projected funding shortfall (in South Yorkshire and Bassetlaw this is some £571 million) as being due to rising demand and inefficiency – when we know it is largely due to a government policy decision to restrict NHS funding and cut funding to local government.

The Funding Gap

Second, STPs run the risk of assuming that the NHS can produce plans that will of themselves solve societal and socio-economic problems.

Many of the heath and wellbeing problems that people face are caused by factors that have nothing to do with the NHS – poor quality employment, reduction in social welfare support, low wages, cuts in adult social care etc. All of these create demand on one of the few parts of the public sector that has been relatively protected and is not rationed – the NHS.

There is a real danger that if we are not clear about the actual challenges facing the health and well being of the population and why these impact on the NHS that we will have a distorted discussion about the future shape and role of NHS services.

Three things we need to do:

First – lets be honest about:

Second – local discussions must start from peoples experience of what health and wellbeing means to them. We have to talk about the whole experience here not just the NHS bit. Our starting point should be the whole journey not specific services such as General Practice. For example in an earlier blog I wrote about a video I had helped produce about a man who received excellent treatment in hospital for his stroke – but was then left on his own to cope with – social isolation, physical disability, lack of role, access to benefits – not surprising he became depressed and needed help from a range of NHS services that he should never have needed in the first place.

Finally – Lets be honest about what STPs can realistically achieve – otherwise we risk people feeling threatened and anxious about what they claim to be – seeing a lack of detail as an indication of secrecy rather than what it actually is – a collection of practical plans to improve hospital services and some rather vague ambitions to contribute to the development of a more integrated health and care system.

I am more hopeful about the “place based plans” which in theory underpin STPs. In Sheffield’s case they are Shaping Sheffield and sister documents such as the  Primary Care Strategy These come much closer to joining up community and prevention, not least because they have a stronger connection with local government – albeit one that still needs further development.

What do you think?

Through a glass darkly – inequalities, public health and NHS data on mental health

November 27, 2016



The NHS 5 Year Forward View gives a clear call for a re-balanced approach to prevention, clinical services, and community support and notes how important this is to help us tackle health inequalities and poor mental health.

But….those of those who are involved locally know that its all very well having the analysis and the aspiration – translating this into action is something else.

I want to focus on how our use of data shapes our approach to mental health and how this determines what we commission and provide – I think that this tends to leads us in one direction only – towards clinical solutions for social problems. We can see this in the report of the Independent Task Force on Mental Health to the NHS in England – although it recognises poverty as a significant driver for poor mental health its focus on inequalities is almost exclusively on ensuring equal access to clinical services – not on the social circumstances in which people with mental health problems live..

Lets look at the national data – because these set the tone for how we use data locally.

Problem One

The Public Health England Public Health Profiles do include mental health indicators – but they only have two. These are for quite specific issues – incidence of suicide and deaths from drug misuse. There is nothing on broader issues such as anxiety and depression.

Problem Two

We know about the relationship between poor mental health – anxiety, depression and inequalities but most of the measures that pick up on inequality in the Public Health Profiles do so at a county/borough/city level – so the extent of inequality is masked by those who are better off.

Problem Three

There are more detailed mental health indicators that are produced by Public Health England. Two that are particularly helpful are the Common Mental Health Disorders and the Severe Mental Illness Profiles.

There is a tremendous amount of detail in both of these – with an overwhelming emphasis on data from statutory clinical health services. However once again they fail to locate the incidence of anxiety and depression within the wider socio-economic context of a particular district. There is a section on ‘Risk Factors’ which is deprivation related. But I think that the scale of the issue here is masked by a wider population effect.

Problem Four

As I have said almost all the data in the mental health datasets looks at the performance of the Health and Care mental health system. This means that there is a constant pull back towards clinical interventions.

Yet as the APHO 2007 report “indications of public health in the english regions 7 mental health” notes we need to focus on the needs of those who experience inequality most – this means focussing on:

  • Housing Insecurity
  • Problematic Debt
  • Low wage and insecure employment
  • Take up of welfare rights support
  • Social Isolation

While some of this data sit in a background document to the Mental Health profiles (cmhd indicator list v5 march-2016) each indicator is presented in isolation and so does not give a coherent picture of the negative social factors that people with mental health problems experience.

This failure to present a coherent narrative about the relationship between mental health and inequality means that local health and care systems lack the evidence that will help  them make the significant changes that are needed to rebalance services to focus more on prevention and community support.

What needs to happen

  • PHE and NHS England need to start to produce a data set that describes the scale of the risk factors that are faced by populations of people with poor mental health AND data sets that focus on the risk factors faced by people in the bottom 20% of the population by income – compared to those in the top 20%
  • More work needs to be done to bring key voluntary sector data into these profiles. There is plenty of data out there – for example voluntary sector and social landlords have good data on housing insecurity, Citizens Advice and Stepchange have excellent data on incidence of indebtedness and so on.

The recent report “The Missing Link” from the Money and Mental Health Policy Institute notes that:

“The IAPT recovery rate for people experiencing both depression and financial difficulty is likely to be just 22%, compared to 55% for people without financial difficulties. For anxiety, the IAPT recovery rate is likely to be just 38% among those with financial difficulties, while over half of patients without financial difficulties recover through IAPT.

We found that an intervention on financial difficulty boosts the likelihood of recovery for an individual with depression and financial difficulties from 22% to 48% and for an individual with anxiety and financial difficulties the likelihood of recovery increases from 38% to 50%.

What do you think?

The confusing world of NHS patient feedback

September 21, 2016


Over the last ten years or so there has been a huge rise in ways in which members of the public can give feedback about their experience of health and care services. This information is one of the ways in which service providers such as hospital trusts, as well as commissioners of these services can get an insight into the quality of services and what needs to improve.

These days there are a range of channels through which people can leave feedback about their experience. These have a variety of purposes:

  • Complimenting or complaining about a particular service or experience that will help a service improve.
  • Giving a rating that helps other potential service users to decide whether or not to use a particular service
  • Creating a dialogue between a ‘customer’ and a provider which might help resolve a problem and build a relationship
  • Giving commissioners an insight into how a service is performing through looking at public feedback in the round and comparing this against others.

I think there are 3 main ways in which the opinions and views of people are captured. Some of these rely on the public taking the first step and others reach out to the public.

  • Provider organisations all have some way to capture comments and complaints from individuals. These are are specific to the organisation and rely on individual members of the public finding their way to them – they include in house complaints, Friends and Family, PALS services etc.
  • Another channel that relies on the public finding their way to them are specialist or stand alone feedback organisations or services such as Patient Opinion, Healthwatch Rate and Review (this is NOT a Healthwatch England initiative, but used by some local Healthwatch) and NHS Choices – these rely on their own publicity or commissioners/providers promoting them.
  • Then there are National and Local Surveys that pro-actively reach out to the public and try capture a representative sample of peoples experiences of particular services. These may be useful at a national level but their sample sizes are often quite small at a provider level.

Of course it is not quite as neat and tidy as this – for example Friends and Family is provided at an organisation or service level but there is an expectation that providers will pro-actively encourage people to use it.

Different approaches different insights

The situation is further complicated because these mechanisms vary:

Most are service specific – they focus on peoples view of for example a particular GP or a certain ward.

The one that is probably most sophisticated and different is Patient Opinion which starts in a different place – it asks people to tell the story of their issue and from this constructs and connects with various services who may be able to respond.

Patient Opinion is interesting because it tries to respond to the whole person rather than just treating someone as though they are the sum of their condition. I think this is particularly important given that local health systems are increasingly trying to develop more integrated and personalised services.

The situation is further complicated by how well signposted feedback services are. Here are examples with web links from three NHS Trusts.

Guys and St Thomas NHS Foundation Trust

This is one click from the main page of the website by clicking on the tab that says ‘your feedback’ one gets access to a range of internal feedback mechanisms.

Universities Hospital Bristol

This is also one click from the main page but a bit harder to find – its on a tab saying ‘Contact Us’ and the feedback form comes after some more administrative information.

Northumbria NHS Foundation Trust

Here the link to feedback is shouting out on the main page – although a bit confusing there are then links to internal complaints, comments and advice on how to get in touch with advocacy services.

None of the above organisations appeared to promote independent channels such as Patient Opinion or Healthwatch Rate and Review.


I think that there is inconsistency with regard to how feedback mechanisms are used across the health system. With different channels of varying utility and a wide variation in terms of how they are promoted. For example the government suggests a variety of ways in which Friends and Family information can be collected:

  • There are few constraints on the technology used to collect the data, and a number of different methods would be suitable, for example:
  • On-line rating: patients are given information including a web link which they can use to log on, enter a reference number and provide their feedback
  • SMS/Text message: patients are given the question at the point of discharge, and are able to text their response (providing an opportunity to send follow-up questions to responders)
  • Smart phone apps: patients are given details of the app, including a unique reference number, at the point of discharge
  • ‘Voting booth’ kiosks or hand held devices: positioned in the location from which the patient is discharged, with ‘voting’ controlled to allow each patient to only vote once
  • Telephone survey – patient is given a freephone number and a unique respondent ID to respond within 48 hours
  • Postcard solutions: patients are given a postcard at discharge with an option to complete and return on site or to complete at home and post back.

This variation and the range of different feedback channels makes it harder for the public to decide which one to use and more difficult for providers and commissioners to assess the overall picture of public opinion about services.

Its interesting that Healthwatch England have now entered this area with ‘Rate and Review’. While the logic of this is clear – it brings a systematic way for them and CQC to keep in touch with public concerns it also raises more fundamental questions – in particular how they get the balance between being the provider of a feedback channel at the same time as being responsible for stress testing whether or not a system offers adequate and consistent opportunities for feedback.

I do think that there needs to be some thoughtful work done to consider what good might look like and the respective merits of different feedback systems to ensure that we don’t just gather feedback on individual experience but capture this in a way that helps us to develop more integrated local systems.

What do you think?