Why the NHS should be concerned about Poverty
The impact of inequality and poverty on health is increasingly recognised both within the NHS and among think tanks and policy makers.
It is important to catch this wave – this focus and interest is unlikely to last so we must make gains now to lay foundations for lasting change.
The new report by the Kings Fund on the NHS role in tackling poverty is an example of this. Over the last few years the Kings Fund has shown a growing interest in this area – although it still feels like a comparatively marginal activity in its work.
Their report is based on gathering together examples of existing practice in the NHS. This take us so far – but it misses some key elements that are essential for change to be long lasting. I wonder if the structure of the report has been constrained by contractual requirements from NHS England?
The biggest section that is missing in this report is asking and answering this simple question:
“Why should the NHS be concerned about poverty?“
If this is not addressed confidently and explicitly then we have not created a framework to have this debate within the NHS…… and a debate needs to happen.
The idea that clinical practice should be informed by the experience of poverty is still seen as irrelevant or at best a side issue by too many clinicians and directors of services
It is the Health Foundation who are doing the heavy lifting here.
The graphic below is from a Health Foundation article that sets out some of the reasons why the NHS should be interested in poverty. In essence it summarises some of the points made by Marmot in particular.
I think that there are three reasons why the NHS should be concerned about poverty
- if you are experiencing poverty you are more likely to be unwell and have multiple morbidities
- poverty means that you will find it harder to access services because they are too often allocated unfairly or are provided in a way that does not make it easy for you to use them because of where or how you live.
- a significant health problem creates financial insecurity and means that you need to use health services as effectively as you can – yet your poverty will make it hard to focus on getting well because you will be having to tackle financial problems such as debt or housing insecurity at the same time as trying to use NHS services effectively.
I summarise this in the poisonous Venn diagram below.
Over the years on this blog I have given examples of how a catastrophic health problem such as Cancer, Major trauma, Psychosis brings together this toxic mixture of financial insecurity, need for health services and difficulty in using them.
This combination is much more likely to make tough and resilient people vulnerable – it affects them AND it affects NHS services effectiveness. Here are two really good examples of work on this North East and Cumbria NHS – Poverty Proofing Health Settings and the Money and Mental Health Policy Institute.
I think we need to have a more systematic focus across health services generally, asking the question:
“where are some of the most vulnerable people in our hospitals and communities and do our clinical services reflect this need?”
Two final points.
It is dispiriting to see yet another report on poverty that devotes almost half of its suggested actions to the role of the NHS as an economic anchor. Yes, the NHS could do more on its role as a local economic engine – but putting it in this report is a mistake for two reasons.
First, the primary function of the NHS is its clinical responsibilities – giving this much space to the economic role takes attention away from this – imagine how barren this report would have been without this section? Frankly, we need that absence just to demonstrate how much further the NHS needs to travel here.
Second, we need a more considered analysis of the impact that economic anchors have on poverty. How much effect do they really have? Are there solid examples of where they have directly contributed to reducing or stemming poverty? It is too easy to get excited by the big money numbers without thinking … how much of this money actually ‘trickles down’ to those experiencing poverty.
Finally, we really do need to start talking more clearly about the role different parts of the NHS have with regard to the poverty agenda. We tend to default to just talking about community based services like General Practice and not give enough attention to the acute sector.
What do you think?
Reorganising the NHS (again) a failure of ambition, understanding and imagination?
Here we go again. NHS England are now in the final stages of reorganising the NHS along the lines that they flagged up in the 5 year forward view some 4 years ago. The report Integrating Care – Next steps to building strong and effective integrated care systems across England offers two options:
Either – make the current sub regional ICS partnerships statutory with a single CCG in each sub region
OR
Get rid of CCGs entirely and make the Integrated Care System a statutory organisation responsible for managing the allocation of funding at place (local authority level)
The second option is the one NHSEI want.
As usual the solution the NHS takes to wider societal and policy problems is to ……reorganise.
I am not going to spend the rest of of this blog complaining about the decision. I want to focus on the deficit at the centre of these proposals. During the pandemic one of the most important lessons that emerged is the primacy of place. This report recognises this – it talks a lot about ‘subsidiarity’, primacy of ‘place’ and ‘neighbourhood’.
However, the report does not appear to understand why this is important. It is locked into a simplistic and old fashioned view that the NHS is a bundle of services that are packaged up to be delivered at local authority, neighbourhood and subregion – it assumes that the challenge is one of technical delivery – rather than a negotiated relationship with all local stakeholders including the public.
No understanding is shown as to why local accountability, scrutiny or co-production is essential.
The reality is and should be that places have to make the tough decisions which requires local accountability. For example, in Sheffield there was an extensive consultation by the CCG on reorganisation of the Urgent Care system – which mobilised many groups in the city – mainly in opposition. This included regular lobbying of the CCG Governing Body. This pressure lasted for months – and was a constant reminder and challenge to the CCG that its analysis of the problem, the actions it was proposing and the way it communicated them was not good enough. At the end of this process this accountability and engagement ensured that the CCG listened and took a more thoughtful approach with regard to this agenda.
I am not convinced that the NHSE model – creating provider partnerships at place level provides the relationships, the longevity or the accountability that a corporate body with a board discussing difficult issues in public does.
Partnerships are not an effective mechanism for public accountability.
We only have to look at the current ICS model (where accountability rests with each member) to see how hard it is for the public to engage and influence Integrated Care Systems and Sustainability and Transformation Partnerships, yet this seems to be the model proposed for partnerships at place level.
What can we do?
- First, in order to make better decisions local NHS provider organisations must create a budget to fund a local independent function that will test and challenge local health and care decisions. This will be crucial – not least by providing resources to citizens who will want to engage with local decisions and with those of their ICS. This independent function could sit in local Healthwatch, Local Government scrutiny services or even with an academic institution.
- Second, provider organisations at a local level need to invest in a collective approach to building citizen voice to ensure that the way in which patient and public experience of health services is heard is significantly strengthened. This must include investing in VCS organisations who work with communities of geography and interest particularly those who are easily ignored.
- Third, we need an honest assessment of how Primary Care Networks are going to connect with communities. Mechanisms such as Patient Participation Groups have had very little impact – if PCNs are to be the point of connection with communities we need to be clear about how much of this local relationship building can actually be done by Primary Care Networks.
- Fourth we need to build robust strategic structures embedded in local authorities where membership includes councillors, supported by senior officers, NHS leaders and public voice membership (lay members). These need to control significant proportions of NHS and local government spend – for example in Sheffield the Joint Commissioning Committee is in charge of the £.5bn Better Care Fund allocation.
We will need to build these mechanisms not only to make better decisions locally but also to ensure that a stronger place based voice is heard in public at ICS level.
What do you think?
Levelling up our Communities – the paper Boris Johnson commissioned
Anybody interested in communities, citizens and their relationship with local systems must read Danny Kruger’s report “Levelling Up Our Communities” which came out in September. Danny is the conservative MP for Devizes – and has a track record of working in this area. I got to know him a bit because he was one of the people involved in the development of “A better way” a couple of years ago.
His experience and the fact that he appears to have the ear of the Prime Minister means that this report is worth a read.
The report like the Teresa May Government’s Civil Society Strategy (Danny was one of the architects of this) is a mixed bag and like that strategy contains too many little actions, lacks a clear theory of change with little clarity about the end point, priority actions and timescale.
Danny is honest about some of some of the policy challenges and failures:
- He recognises the scale of inequalities and the disproportionate effect that this has on communities and that ‘social safety nets that help people in crisis are fraying’.
- He acknowledges the lack of traction of Cameron’s Big Society initiative
- He notes the relative lack of success of the NHS Volunteering scheme to connect willing volunteers to meaningful activity.
If you would like to see positive if equivocal responses to this report there is a good summary here. While the report is full of ideas, I will focus on three areas that worry me – Local Government, Sound bites for the PM and investment.
The lack of focus on local government fatally weakens this report
The most important enabler – Local Government is barely mentioned, yet the report recognises that some local authorities have led the way with place based approaches that foster community volunteering.
I strongly recommend reading the latest excellent paper from New Local (Think Big Act Small) which does a good job recognising the crucial role of local government.
In fairness I suspect that Kruger has not focused on local government because of plans for a White Paper on the future of Local Government. Nonetheless, this absence sits uneasily with his suggestion of a Community Power Act which aims to ‘affirm the right of ordinary people to affect change in their neighbourhoods.
Recommendations the Prime Minister would like
There are some actions that I think will land well with a prime minister who likes big ideas and populist statements. Some of these include:
- A ‘Neighbour Day’ bank holiday
- Establishment of a ‘National Volunteer Reserve’
- Creation of a ‘Volunteer Passport’
- A Kickstart programme to pay young volunteers
All of these make nice headlines but I am not convinced that they are of strategic importance.
Where is the money?
The paper acknowledges the financial stress that the local voluntary and community sector have experienced. However the report feels constrained by an ideological view that the state should not be a long term or substantial funder of the voluntary and community sector. There is a contradiction here – given that the government has no ideological problem pumping large amounts of tax payers money into the private sector often with little scrutiny (See here, here, here). Further – local government (see earlier point) has a long tradition of funding the local voluntary and community sector through contracts and grant aid.
So, the report offers a patchwork of proposals which primarily see the government as an enabler not a funder – they include:
- Selling off public sector assets – is this seriously a long term plan?
- Persuading the wealthy to give more – good luck with that!
- Using the National Fund to create a Community Recovery Fund – currentl value about £.5billion. However, this is still only half the size of the Health Foundation – which while big is very small in terms of the scale of the challenges faced.
- Using dormant insurance accounts – value £2bn – is this really a long term funding source?
- Encouraging the faith sector to raise more money through fundraising – with a promise that this will lead to closer collaboration with government. I did a double take with this one. First, I thought that Government’s role is to work with citizens anyway (although the faith based Trussell Trust may disagree); second, is the paper seriously proposing that if an interest group raises lots of money they will get more influence on government policy?
What Next
Credit to Danny Kruger for setting out his ideas – he does want to strengthen citizen activism and assets – and he sets out an approach informed by his own experience, values and analysis of what is possible.
I think that those of us who are concerned about this need to respond to the opportunity created by this report; build on his analysis but also offer up alternatives to some of his proposals – there is a better way!
What do you think?
While we have our heads down in the pandemic NHS England is pressing ahead with its plans to reorganise the local NHS landscape. It looks like this involves getting rid of place based Clinical Commissioning Groups and creating sub-regional Integrated Care Systems and locality based Primary Care Networks. Much of this is in line with a blog I wrote 16 months ago.
NHSE has been held back because abolition of CCGs requires a change in legislation – which has been delayed by Brexit and COVID.
Nonetheless NHSE and the Government still appear to be keen to progress this – so instead they are using changes that do not require legislation retaining CCGs but reducing their number through mergers, with the aim of eventually creating a single CCG function that is co-terminus with Integrated Care Systems.
The current state of play is set out in this presentation which includes two examples from Norfolk and Kent showing how CCGs have CCGs have managed the politics of this change with local government and the public.
Although NHS England and the Department of Health and Social Care have said that choosing to merge is a voluntary process and will by decided by local CCGs it is of course possible to ‘encourage’ this by changing the wider environment through a mixture of incentives and pressures – for example:
- Require CCGs to reduce management costs by 20% by 20/21
- Claim that CCGS are volunteering to merge into sub regional ICS – in fact many mergers were due to CCGs wanting to become co-terminus with local authorities eg Leeds from 5 to 1 and Bradford from 3 to 1 etc
- Trying to create single Accountable Officer positions in charge of multiple CCGs on an ICS footprint – which is in effect a precursor to merger.
All of the changes above – taken by themselves can be seen as reasonable and only of internal concern to the NHS, which means that there has been little discussion of the direction of travel outside the NHS with local authorities, the VCS etc. The risk is that a series of much more important questions are left unasked and unanswered such as:
- What are the challenges facing local health and care systems?
- What are the best ways to mobilise a range of diverse stakeholders (the public, NHS, local government the private sector and the Voluntary Sector) to work together to address these challenges?
- What is best done at a neighbourhood, place, sub-regional and national level?
- What is the best way to hold these different stakeholders to account in order to bring supportive but critical challenge?
Why is any of this important?
There seems to be two assumptions within the NHS England/Government plans
That running the health service is best done at a sub-regional level with an implied belief that delivery of the health services is fundamentally about the management of standardised services rather than co-design of health and wellbeing systems to fit places. There also seems to be a belief that accountability to NHS England or Government is more important than accountability to places.
One of the examples in the presentation claims a range of benefits such as being better at tackling inequalities to justify mergers. This is a dog whistle argument – mention the right areas – but don’t present the evidence for why this is the case. This direction of travel – moving to get rid of place based CCGs to sub regional ones shows a failure to understand the contribution that local governance makes to collaboration and the development of integrated working.
In my experience the involvement of CCG Governing body members (Executive, GPs and Lay members) are key to connecting with the VCS, Health and Wellbeing Boards, Healthwatch, Joint Commissioning Committees and local authorities. This diversity of stakeholders has helped to build relationships, sensitise plans and strategies on difficult areas such as inequality, public voice and provided leadership in public meetings connecting citizens and communities to plans.
Second building on the CCG role at place level means that there is a good fit with local authority structures and accountabilities – this is how we do local democracy. It’s not perfect – but it is certainly better than moving everything up to sub-regions. As the paragraph below from the report of the Governments Public Accounts Committee in 2019 in 2019 on CCGs notes:
A similar and wider range of concerns has also been expressed by the British Medical Association in their 2019 guidance here.
What next?
Place based CCG Governing Bodies have either spent the last 7 years or so messing about or have (sometimes painfully) provided an important contribution to the development of local health systems – I think it is the latter! We need to:
- Set out with our local partners why place based governance of the NHS is important.
- Engage with their Integrated Care Systems – and ask the sort of system questions that I sketch out in bullets above.
- Where it does not already happen CCGs, Healthwatch and Local Government should be demanding that Integrated Care Systems have active representation from Local Government and the Voluntary and Community Sector – a good example of this is West Yorkshire and Harrogate Integrated Care System
What do you think?
Declaration of interest – I am a lay member on Sheffield CCG
I recently interviewed the board members of an integrated care system. This piece of work has challenged my ideas about how we best address health inequalities.
When it comes to tackling health inequalities I have tended to focus on those people and sectors who are most passionate and engaged with this agenda. Namely, the voluntary sector, general practice, communities themselves and local government. I continue to think this is important. However I think that we have ended up leaving the most powerful part of the local health and care system out of the discussion – the acute hospitals.
This has been a mistake.
Our expectations of what the acute acute sector can do with regard to health inequalities has been too narrow. When the acute hospital sector does engage it tends to default to rather limited outward facing areas:
- Local purchasing plans – citing the Social Value Act as an important lever (relying on the social value act is, in my view the last hope of the desperate!)
- Local transport to and from the hospital – again this is a usually more aspiration than action
- Local employment strategies – there are some promising examples here – for example the Leeds Teaching Hospital had a very successful local recruitment campaign in a deprived part of their patch.
All of these actions leave the most important part of hospital provision – clinical services – off the table!
It is comparatively rare to find examples where the hospital has taken responsibility for designing and leading a service that aims to improve a patients health in the round – generally hospital services focus on delivering a specific clinical intervention that ignores the context within which people live.
When a hospital does take a more person centred approach – magically – services becomes sensitive to health inequalities! Here are three examples:
London Homeless Pathway – Pathway helps the NHS to create hospital teams to support homeless patients and in some hospitals, Pathway Care Navigators: people who were once homeless to support homeless patients.
Major Trauma Unit Sheffield Teaching Hospital – A dedicated welfare rights service provided by Citizens Advice Sheffield for patients at the major trauma unit – funded by the Sheffield Hospitals Charity.
Guys and St Thomas’ Hospital Charity – take a place-based approach, addressing a small number of complex health challenges at a time. They work with local partners in Lambeth and Southwark and share their findings with others tackling similar issues.
We need to develop a new narrative that recognises the crucial role that acute hospitals should play here. Rather than trying to develop strategies that seek to ‘pull’ funding out of the acute sector we need to recognise the role of the acute sector and expect and support them to change.
What these examples tell us is that it is possible to work with clinicians to create a more inclusive model for good clinical practice, by recognising that the wider context of peoples lives affects their ability to engage with clinical services which then impacts on their health and how quickly they get better.
Here are some suggestions:
- We need to engage with Acute Hospitals and work with them to develop their own Health Inequality Action Plans that link their services to the wider population and the circumstances they face.
- The work of Guys and St Thomas charity provides insights into what this might mean but we need to go further. For example services such as Accident and Emergency should be used as a bellwether for local health systems – who uses them and why are indicators of socio-economic pressure and wider health system failure – I don’t think that local health systems use this data systematically or effectively to help shape wider strategies.
- The examples I gave above with regard to homelessness and major trauma show that a more inclusive version of what constitutes good clinical practice is possible. Both of these examples affirm that good clinical services must recognise that a patients vulnerability and lack of personal agency can be affected by factors outside the hospital environment. These examples show that good clinical practice inside hospitals involves more inclusive actions which can improve a patients ability to use health services effectively, help their recovery and be more cost effective.
Finally, there is of course added urgency here – the over representation of people from BAME and deprived communities among those admitted to hospitals during the pandemic and who now face long periods of recovery; must provide a further spur to considering how to develop inclusive services that respond to the clinical and social needs of people who have experienced a traumatic illness.
What do you think?
Two weeks ago Citizens Advice Sheffield shifted to only provide advice and support by phone and website to the people of Sheffield during this pandemic. All of this data comes from a report compiled by Citizens Advice Sheffield Chief Executive Clare Lodder.
Employment – Employment is now our 4th highest enquiry area (after benefits, universal credit and Debt) with enquiries for final quarter of the year running at 61% above the same period in the previous year.
There has been a steep rise in people seeking help with issues to do with their employment including problems with their employer in relation to what money they have received or how the job retention scheme is applying to them or short time working. (This has included a few employers who are confused about the scheme and unsure where to get information on this).
Sick Pay – We have also seen a spike in enquiries from the self-employed and enquiries about Statutory Sick Pay (both whether it should be paid and complaints about it not being paid).
Benefits – Problems with benefits including claiming universal credit – our Help to Claim team have a clear focus here and are able to give targeted help – but we are also helping with clients worrying about personal independence payments, particularly renewals and concerns over benefit payments.
Debts – Concern over debts, including council tax and fuel debts and an upsurge in enquiries around debt deductions from benefits and people with overpayments of Universal Credit
Destitution – People in need of help because they have no money to pay for food and/or fuel, usually because of benefit delays and the 5 week wait.
Local Collaboration
Citizens Advice Sheffield is working closely with all of the emerging support across the city including Sheffield City Council’s COVID response phone line and the local support and community hubs. It does feel that the city is now moving to a phase where there is much greater integration between voluntary sector and local government provision.
Our biggest concern
The biggest concern we have is to do with the inequalities aspect of this pandemic. Evidence from New York shows how unequal the impact of corona virus is.
People who were already on the the minimum wage – who are now finding that they have to manage on even less because they no longer have a job; people who are continuing to work because they need the income – in many cases they are providing ‘essential services’ such as public transport (this data on coronavirus deaths for public transport workers is appalling), supermarket retail, residential care, refuse collection etc.
Broadly the advice trends we are seeing are in line with the emerging picture from Citizens Advice nationally. Across the whole service in England and Wales, we are told
- The number of cases referencing coronavirus have doubled in local Citizens Advice service, and continue to increase in the consumer service
- Universal Credit remains the top issue for clients accessing local Citizens Advice, closely followed by employment advice
- The national website has just seen its busiest week ever with 2.4 million page views, surpassing the previous weekly high of 2.2 million page views.
Citizens Advice nationally has focused on rapidly updating its information on the public site.
What needs to change
Whilst Citizens Advice Sheffield have welcomed the Government’s announcements in relation to the help being provided, from the evidence from people we are helping, we believe there is more that should be done and in particular:
- Removing the 5 week wait for universal credit to be in payment
- Suspending all other benefit renewal action
- Extending the limitation date from three months to six months for enforcement action against employers who have failed to pay final pay
- Ensuring that there is a local safety net (for example by extending the scope of the local assistance scheme) to give money to people who are destitute because of benefit delays or other problems with benefits.
We also hope that some of the changes to the benefits system which have been introduced as a response to this current emergency are embedded for the future.
What do you think?
Volunteering, the NHS and Corona Virus
People are saying that things ‘won’t be the same’ after the Covid-19 pandemic is over. While I am not sure about that it is striking what has changed over the last few weeks.lambreWho would have thought that suddenly volunteers are seen as an important and integral part of the health system. Suddenly, as the population impact of COVID-19 becomes apparent and the UK government realises the scale of the challenge and the actual impact on vulnerable people and the NHS it clicks its fingers and creates over 750,000 volunteers. Indeed there has been such an interest in this that recruitment has had to be temporarily paused so that applications can be processed.
This is truly amazing. First, because so many people have put themselves forward to help, but as fundamentally because despite the efforts of some people in the NHS and many community organisations volunteering and the contribution of citizens as assets in their communities has been at best a peripheral issue in the NHS.
The most explicit reference to the ambition that NHS England had with regard to volunteers is here in the Long Term Plan which came out in January 2019.
Even here the primary focus appears to be on volunteering in the acute hospital sector, (according to the Kings Fund in 2013 there were just 78,000 volunteers in acute hospitals – 10% of the number recruited in 1 week during this pandemic!) the above extract probably exists in large part due to the work of the Kings Fund who have published quite extensively on this topic.
Aside from this and a tentative briefing aimed at STP/Integrated Care Systems I think that NHSE main focus has been on interface issues using social prescribing as the main tool. In other words focussing on the NHS system engages with community organisations and communities and actual and potential volunteers. This strategy is set out in the NHSE document on Universal Personalised Care.
Before Covid-19
More generally volunteering works a bit like this at place level:
- Grass roots self actualising informal groups sometimes bound together by hyper local geography – for example on my street two WhatsApp groups have sprung up in the last 2 months.
- At community level are local Voluntary organisations who have credibility with and are connected to communities of geography or interest – for example Carers Centres, Community Anchors, Mencap and interestingly hospitals.
- The local NHS – increasingly General Practice are developing (through Primary Care Networks) mechanisms such as Community Link Workers and Social Prescribers to connect with the two groups above. However, they are some way behind the groups in bullet point 2 above.
- Just as importantly local authorities have with varying degrees of success been seeking to develop joint commissioning approaches with Clinical Commissioning Groups to support local voluntary organisations and also develop bridging and connecting services such as Local Area Coordination. Local Authorities do have a long history of supporting volunteering – for example through funding lunch clubs.
During Covid-19
The creation of this army of volunteers by NHSE and the Royal Voluntary Service represents both an opportunity to move the volunteering agenda more onto the mainstream agenda of the NHS in the medium and longer term but it also presents some real challenges which include:
- While National organisations with a strong brand like the NHS can at times of crisis recruit volunteers very quickly – these only have utility if they can be connected quickly and safely with local communities and local services. It is here that local authorities and local voluntary organisations have a key role to play – they have those connections and credibility.
- For example in Sheffield the local CVS has very quickly developed targeted volunteer recruitment and produced a map which flags up community hubs, describes roles and responsibilities flagging up community hubs in the city and the local authority has now producing a community action plan to ensure a city wide approach connecting statutory services with the local voluntary sector.
In the coming days and weeks it will be crucial that this national initiative bends to the local and also makes resources available to ensure that local organisations can respond to the scale of this offer.
After Covid-19
I think we should have high expectations that NHSE will rewrite their approach to volunteering and the role of the NHS in terms of funding the voluntary sector
What do you think?
Welfare Rights in the age of Coronavirus
I got this text over the weekend from a local decorator – over the years he has become a friend – he knows I am using this.
“Mark, I’m getting grief from family that i shouldn’t be going to work. Watching the news everything is getting really heavy now and im starting to cave. There is also the worry about getting materials as things progress – shop closures etc. Being self employed i get zip from the gov. They say universal credit, £90 @ week, is being made available but after 3 hours sat staring at the gov website and endless clicking, i have given up. They make it so infuriatingly difficult to claim. Bastards!”
Last week we made the decision to close all our offices and move Citizens Advice Sheffield – one of the largest Citizens Advice Services in England onto phone and digital. This meant moving our 170 staff and 140 volunteers to home working. From Monday the 23rd of March we will be providing a beefed up telephone and web service. We hope that this will not only mean that we can provide a safe, accessible and resilient service but that we will also be better placed to meet greater demand. We normally help about 2,000 people a month – we hope that by providing a telephone and web service we can increase this to significantly if we need to.
Why we changed our operating model
First, as the prevalence of Corona Virus increases we could see that more and more people would be moving to self isolation. We know that businesses are closing, people are being made redundant or are facing reductions in income due to sick pay, no sick pay, or loss of income if they are self employed and horrifyingly in some cases being evicted.
This combination of factors means that people are likely to need advice with regard to employment rights, welfare rights and probably other areas such as housing and utilities but will be very reluctant to sit in waiting rooms waiting to be seen. Many will not have ever used the benefits system or will not have used it recently.
The second reason is of course because we need to ensure that our staff and volunteers are safe, so getting them to work from home and still be paid was very important to us. Of course we also hope that this will help us to continue to provide a resilient service to help those in real need over the coming months.
Health and Money
Quite rightly the focus to date has been about the health risks of COVID-19, however, as the government has begun to recognise on the 20th of March the financial impact of this virus is also tremendously important – not just to the economy but also to individuals.
For some of the most financially vulnerable they not only face a loss of income for themselves – but for their families – this at a time when children are no longer going to school and older ones will have little opportunity to work. It feels like a recipe for stress, anxiety and disorder.
Strategic Leadership at Place level
While for understandable reasons the emphasis at the moment is on the health system and to a degree on support to the vulnerable – in particular the elderly, the scale of the crisis means that government actions are having a fundamental effect on wider society.
What we do to respond to the needs of people on low income and in insecure employment will affect the effectiveness of strategies to reduce social contact. We need to quickly consider whether Local Resilience Forums should involve key frontline VCS services such as welfare rights organisations.
What do you think?
Why is NHS England counting the number of people who have been “socially prescribed”?
How do we strengthen the connection between citizens and communities and health services so that we create the best environment to improve health and wellbeing? We know we need to do it in a way that recognises peoples social and economic circumstances and builds on their strengths and the strength of their communities.
NHS England plans to meet this challenge through primary care implementing it’s strategy – Universal Personalised Care.
Central to the strategy are the groups of general practice established by NHS England – Primary Care Networks. These cover populations of 30 to 50 thousand and their role is set out in a new contract. NHSE is currently consulting on the specification for the contract.
Part of the contract is about Social Prescribing. Before, I comment on this I want to build on my previous blog and set out the current challenges faced by social prescribing.
Social Prescribing is:
- trying to break the barrier between clinician and community by providing a route for General Practice to connect people with other people and resources in their community.
- only going to be successful if GPs and their team change the way they work – to better understand how to build on personal strengths and what communities have or could have.
- in danger of putting more pressure on poorly funded community resources and the voluntary sector.
So, if we want social prescribing to be effective we need to create a local narrative that helps us to understand what is happening in a way that:
- helps General Practice change its culture
- motivates GPs, citizens and community organisations to engage with it
- brings what citizens can do for themselves or with others to the fore
- keeps funders local and national informed about the effect that social prescribing is having on community infrastructure
This is fundamentally a local issue.
What we need to do
We therefore need to create a sophisticated but straightforward mechanism to ensure that there is feedback coming back on the difference that social prescribing is making and how it can be improved.
The primary audience for this feedback must be:
- the GPs working in a particular network
- the people who have used social prescribing
- the community organisations who are working in that area
- other voluntary organisations
- Local Funders
What NHS England are proposing in the consultation
In the PCN Network contract specification NHS England are proposing that Primary Care Networks report on the number of people who have been ‘socially prescribed’ and that this minimum target should rise each year as follows:
20/21 – 4-8 social prescribing referrals per 1,000 weighted population
21/22 – 8-12 SPR/1,000 WP
22/23 – 12-16 SPR/1000 WP
23/24 – 16-22 SPR/1000 WP
This simple quantitative target is purely about activity it tells us nothing about where people went, what their needs were, what difference this “prescription” made to their lives and what costs the referral placed on others such as the community or the voluntary sector.
These metrics only feed Whitehall – they give an illusion of impact but only count activity.
Quantitative performance management like this is completely at odds with an initiative that aspires to change relationships and bring quality to life.
What we need
I suggest that Instead every primary care network is required to hold a yearly workshop with people who have received “social prescriptions” local community organisations and local voluntary sector. This meeting should discuss the difference that social prescribing made, the challenges that it faced and the actions that need to be taken to improve it.
The report from this meeting should go to the practices in the PCN, the CCG and to NHS England. The National Academy for Social Prescribing should be required to analyse these and produce recommendations back to DHSC and NHS England.
What do you think?
Acknowledgement – thanks to Charlotte Augst CE of National Voices for the ‘heads up’ and the inspiring conversation
How independent is the new National Academy for Social Prescribing?
At its best Social Prescribing is about trying to take a holistic strength based approach to health and wellbeing. It recognises that some of the solutions to improving health and wellbeing cannot be found in clinical interventions but instead already exist in communities, and by connecting people to these it is possible for people to build on their own strengths thereby improving their confidence and wellbeing.
NHS England has an ambitious programme of rolling out Social Prescribing Community Link Workers to all Primary Care Networks in England. Complementing this the Department for Health and Social Care has just established a National Academy for Social Prescribing (NAfSP) to foster the development of Social Prescribing in England.
The Strategic Challenge for Social Prescribing
Shifting a predominantly clinical NHS model to coproduce solutions with local communities is a significant cultural change. Some of the challenges include:
- If social prescribing is to have a real impact on General Practice there will need to be a radical change to the primary care delivery model. Not all GPs are convinced of the model and it barely reaches the acute sector.
- Local Government is not systematically involved in this NHSE programme (there are local examples where this has happened) developing holistic models will require multi-disciplinary engagement in neighbourhoods.
- The relationship between social prescribing and specialist services like community development, youth work, welfare rights, advocacy, health trainers and local area coordination, needs thrashing out – otherwise people will just be referred from one service to the next – or even worse specialist services (often supporting the most needy) will continue to struggle with lack of funding because some will believe that social prescribing renders all other services unnecessary.
- The voluntary and community sector has borne the brunt of the cuts under the Coalition and Conservative governments – it is already struggling to respond to demand – social prescribing risks overwhelming already hard pressed local communities.
- Inequalities – to date NHS England has seen social prescribing as something that can be rolled out equally across all practices – little thought has been given to whether this is a model that should place a greater emphasis on addressing structural inequalities – both with regard to resource allocation and service design.
These challenges mean that the NAfSP will need to:
- Gather and Share good practice
- Influence NHS services and General Practice
- Work as a critical friend with NHS England in the further development of personalisation
- If necessary challenge Government with particular regard to the impact of its policies and funding on communities and local government
- Ensure that it has strong links and some accountability to communities
Problems
Given the above challenges and actions needed to address these it is concerning that the NAfSP appears to be very reliant on the patronage of Matt Hancock the Secretary of State for Health and Social Care, who according to this FOI request has authorised:
- the establishment of NAfSP as a private company limited by guarantee – there has been no tender or approach to any existing organisation
- a direct initial donation of £5m of DHSC funds with the promise of more to come.
- the appointment of a board of directors for the company – with no external recruitment of whom at least 2 are active in the Conservative Party.
It is interesting that NHS England (who have a who have a Director on the Board and appear to have provided over £.6m) accept no responsibility for the funding of or appointments to this new organisation – despite Social Prescribing being a clear part of the NHS England action plan on personalisation.
Matt Hancock has close links with the Institute of Economic Affairs a free market think tank who have a clear position on charities that are funded solely by Governments, they call them “Sock Puppets”. In other words not really independent – just mouthing the interests of Government.
Given the NAfSP fits all the IEA ‘sock puppet’ criteria – a company with all directors appointed directly by the minister with 100% funding from government it is hard to see how it is well placed to drive forward an effective change agenda that will need to achieve two things. First, make sure that attention is paid to the needs of hard pressed communities and second bring effective independent challenge to the health system, key stakeholders and of course government to help local health systems become more more person and community centred.
Between now and the new financial year the new charity will be established – it will be important to be sighted on who is on the board, will key players be involved like:
- the local voluntary sector for example Locality?
- local government – the New Local Government Network?
- Universities with a track record such as the University of Westminster or Sheffield Hallam?
What do you think?