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Lets mention inequality when we talk about welfare rights and general practice

June 28, 2018

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My last two blogs have looked at the relationship between welfare rights advice and general practice. Some respondents have drawn my attention to two recent reports:

  • The Deep End Advice Worker Project – embedding an advice worker in general practice settings produced by the Glasgow Centre for Population Health. The Deep End Group are one of the main voices for GPs serving disadvantaged communities.
  • Advice in practice – Understanding the effects of integrating advice in primary care settings produced by Citizens Advice and the Royal College of General Practice

If you only have limited time read the Deep End one   – it’s more thorough and better; this is why….

It’s positive that Citizens Advice and the RCGP have produced a joint report, hopefully there is more to come – but its conclusions and evidence are already well rehearsed – although it is good to have this information in one place.

Unfortunately, “Advice in Practice” does not mention inequality (or deprivation or disadvantage) at all!

Lets face it this is why access to welfare rights is so important. I sometimes think that national agencies are reluctant to acknowledge that inequalities exists and that addressing these requires what Michael Marmot calls proportionate universalism

As I mentioned in an earlier blog Citizens Advice Sheffield serves people from across the city but we are far more likely to be needed and used by people in poorer communities – we see 20% of households each year in the poorest wards in Sheffield compared to 3% in the wealthiest!

This is an inequality issue – the pressures faced by people on low income plays out in general practice too, there is no recognition of this at all in the report. 

As the Deep End report says:

“people who require the greatest medical support experience the greatest difficulty accessing it… this also applies to social and economic advice services where the most vulnerable experience more difficulty accessing services than their more affluent counterparts”

I think that the data in the Citizens Advice/RCGP report must be treated with caution because by giving a country average it masks what a difference in the balance of demand between practices serving wealthier communities and those serving poorer ones. It concludes that non-clinical issues take up 20% of GP time. Anecdotally I am told by Deep End GPs that this proportion is higher in practices serving poorer communities.

“Before this service was introduced (welfare rights), 50% of my workload was taken up by the socioeconomic problems of patients” – GP quoted in SROI and Co-location report.

Contrast this with the Deep End report which explicitly focusses on the relationship between poverty, welfare rights and primary care.

The Deep End service model is an embedded model – more integrated than the “co-located” one described in the Citizens Advice/RCGP report not only are advice workers on site but they have (through informed consent) access to medical records held by the General Practice. They are not only providing a service of direct benefit to patients but also have some evidence that they are reducing  GP workloads.

“It is contributing to reduced time spent by GPs on paperwork relating to benefits, it lets us get on with the job we are trained to do”

Going Forward

  • we need an explicit focus on inequalities – General Practitioners serving disadvantaged communities are under tremendous pressure this is where the need is greatest, its about time this was recognised by national bodies such as RCGP and Citizens Advice
  • Tactically focussing on the most deprived areas makes sense – it gives a clear message to commissioners that a more targeted approach is appropriate and achievable.
  • Following on from this I think that there is a growing case to be made for a different service model in disadvantaged communities for general practice which should include welfare rights provision – this will require a change in behaviour by GPs and Welfare rights agencies – the Deep End report is a useful example – particularly with regard to data sharing.
  • national bodies need to set out the arguments for how these services should be funded. To date there has been a reliance on individual commissioning champions leading to models that include public health budgets, CCGs and sometimes practices themselves. This is not systematic or sustainable.

What do you think?

With thanks to Dan Hopewell from Bromley Bow and Oonagh Robinson from the University of Glasgow for her advice.

What GPs say about DWP Medical Evidence Letters

June 20, 2018

One of the problems with responding to medical evidence letters is that GPs are not specifically paid for this work.

My last blog looked at the decision taken by the Sheffield Local Medical Committee to advise its members that they did not need to respond to requests by local Citizens Advice for help with medical evidence when people were appealing refusals by DWP to grant Personal Independence Payments or Employment Support Allowance. That blog led to some good conversations on twitter with a number of GPs. 

Here are some of the responses:

It’s an important part of the job

“I write Medical Evidence Letters everyday …. they get increasingly irritable in tone.”

Dr Charles Heatley – @drheatley

“Remember, appointments and home visits sky-rocket when people loses benefits. Wipes out Motability car, blue badge, extra money for heat/food and entitlement to carers allowance so they get sicker and can’t self care properly”

Dr Anne Murphy – @DrAnneMurphy

Dr Murphy has published a piece on her blog that sets out in straightforward terms what a GP needs to do with regards to evidence letters .

She also shared a link to a great BuzzFeed article by Emily Dugan

“It may well be the case that patients who are helped to secure PIPs are more financially secure, have better wellbeing and consult less often and in less of a crisis scenario. My experience is that certainly reduces mental health crisis presentations where we can help with money.”

Dr Tom Ratcliffe – @TomRatcliffe2

“It makes far more of a difference to most patients lives than anything we prescribe.”

“A good letter requires knowledge of the patient as a person, clinical knowledge, understanding fo the benefits system, the ability to interpret data and communicate it. But in the hierarchy of clinical practice it comes below diagnosing earwax”

Dr John Tomlinson – @mellojonny

Yes its important but its not what we are here for

“I agree the system is in a mess and horrible for people to navigate. What work should GPs not do, in order to make time to write these letters? Do the general public mind if I see 3 less patients on the days I do these letters? Or should I charge for the time?”

“…all we are doing is mitigating the action by a third party, a ludicrous inefficiency of public service, and the work we are trained to do, must suffer as a result.”

“…my skill is diagnosing and treating medical problems. Helping people fight the benefits system take me away from what I am good at – don’t get me wrong I do these letters! It saddens me that somehow, a cruel benefit system becomes a problem for doctors as well as for patients.”

Dr Simon Lennane – @SimonLennane

“I didn’t say its not worth doing, but who pays for GPs time? I would rather be at home with my kids than working until 9pm filling out forms.”

Dr Ewen Pearson – @EwenPearson2 

As a volunteer at Citizens Advice Sheffield noted:

“I just wish that there was more push-back to private health contractors like Maximus rather than an LMC swallowing their “ambassador’s” PowerPoint whole.”

Simon Landau – @Microcynicon

Thoughts

“For many patients this social administration is the most valuable thing we do, and yet we have no training, no time and no money for it. It isn’t valued in any way except by the people who matter most”

Dr John Tomlinson

It struck me how isolated GPs are – there really was a feeling that they are being left to work this issue out for themselves with little support from bodies with a wider systemic responsibility.  This certainly leaves them feeling ignored and in some cases resentful.

I think that there is a failure by the RCGP and by NHS England (and of course DWP) to recognise this is an important issue. Nothing in the GP Five Year Forward View!

I think that local Citizens Advice can make it easier for GPs by offering simple templates that are more likely to succeed at DWP tribunals.

Similarly GPs can help by giving Citizens Advice access to patient data – as Dan Hopewell from Bromley By Bow explained in his comments on my earlier blog when he drew attention to an example from the Glasgow Deep End Group.

We urgently need more collaboration here – we cannot rely on biased advice from Maximus and simply advising GPs who want to help their patients to ignore Citizens Advice requests for evidence letters – does not help GPs or their patients!

What do you think?

General Practice – Social Prescribing, Medical Evidence Letters and Personal Independence Payments

May 20, 2018

There are a number of views about the role of general practice and social prescribing. Some see social prescribing as the key mechanism for connecting primary care to communities while others are more critical seeing it as a diversion from asset based community approaches.

One of the reasons for this debate is to do with the role of general practice. Are GPs just referring patients into ‘community solutions’ at the press of a button or are they playing an active role in responding to the social circumstances that make people unwell?

I recently spoke at the launch of the Torbay FAIR project – and heard Steve Barriball CEO of Citizens Advice Exeter talk (based on their report Appealing for Common Sense ) about the experience of people who had been turned down for Personal Independence Payments and Employment Support Allowance by the DWP contractors the Centre for Health and Disability Assessments (CHDA) who are a subsidiary of Maximus.

Getting access to Personal Independence Payments and Employment and Support Allowance is a three stage process. 

GPs are important, at the appeal stage if Citizens Advice are involved they will often ask GPs to provide further medical evidence as part of building a case to demonstrate an individuals poor health.

As Exeter Citizens Advice showed the outcome of the appeal stage is more often than not positive for the claimant. The Exeter report notes that:

“With evidence nationally of around 65% of the denial of ESA and PIP claims overturned at appeal….”

Recently the Local Medical Committee where I live after taking advice from the  CHDA “GP Ambassador” produced guidance stating that GPs do not need to respond to requests for ESA Claims & Appeals (Feb18) from local Citizens Advices Services.

 

GPs are under a great deal of pressure (as are local Citizens Advice services!) and most importantly so are the members of the public who are applying for Personal Independence Payments and Employment Support Allowance. 

There is strong evidence that financial insecurity and debt affect health and wellbeing – the GP Five Year Forward View states:

“Voluntary sector organisations can also play an important role in supporting the work of general practice. For example, local models of social prescribing can enable GPs to access practical, community-based support for their patients, including access to advice on employment, housing and debt. Some areas have developed call-off services for specific groups such as carers.”

GP Evidence letters are most important at the Appeal stage and this is usually when Citizens Advice staff get involved – Citizens Advice guidance is here. As the evidence shows this appeal process is (regrettably) a necessary corrective to poor decisions made at earlier stages in the application.

In my view good practice means GPs responding positively to Citizens Advice requests – particularly at the appeal stage. From personal experience I know that there are many excellent GPs who work with disadvantaged communities who would not give a seconds thought to responding positively to such requests if they consider that access to benefits would improve a patients health, even though they are not specifically funded to do this work. In many cases receiving PIP will reduce pressure on the NHS.

This brings me back full circle to social prescribing. GPs (like Citizens Advice) are interface services. They stand on the border between statutory and professional services and individuals and communities – the place that Eileen Conn calls the Space of Possibilities. 

There is a real risk that the hard work of dedicated GPs will be pushed out of sight  (as is the case for many who experience poverty and health inequalities) unless professional bodies such as the BMA, RCGP and LMCs recognise that if we are to respond to health inequalities good practice is engaging proactively with peoples circumstances rather than just pressing a button.

I am interested to hear whether GP bodies in other parts of England take a similar approach.

What do you think?

Declaration of interest – I am chair of Citizens Advice Sheffield

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.

Context

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