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The welfare benefit system is a public health system

June 25, 2017


This blog is based on a talk I gave at the recent Faculty of Public Health Conference  – reacting to the Ken Loach film I Daniel Blake.

In a recent blog I set out how public health has struggled to recognise the important contribution that the benefits system makes to wellbeing and tackling health inequalities. We need to think of the benefit system as a public health service.

Nonetheless, we are in a position where this crucially important Public Health Service is increasingly difficult to access and where it is even hard to have a discussion at a local level about how we can ensure that vulnerable populations make best use of it.

A reminder – the NHS budget is just over £100 billion a year and the social welfare spend is £126 billion – not including pensions.

In fact as the figure below from Simon Duffy (Centre for Welfare Reform) shows the actual cost of social welfare to the state is considerably less than this.

Portable Network Graphics image-1AD8168FC5D4-1 2

When it comes to public health strategies and practice at a national level we look to two agencies to scope the landscape – Public Heath England and NICE. Between them they would argue that they describe the strategic public health challenges and actions needed to improve population health and tackle health inequalities.

At the conference we heard that this is not the case. Both agencies work within the constraints of Government Policy – Public Heath England strategic focus has to be consistent with the government agenda – not only does it not publicly challenge DWP actions – the only time it mentions welfare payments in its strategies is with regard to actions that will reduce their take up! It also does not offer strategies and actions to ensure that the benefit system is used to its best effect.

PHE Welfare Payments

NICE works to a shopping list of priorities signed off by Government – again this list does not include welfare benefits.

This means that we must not accept that the Public Health England Strategy includes all the issues we need to address and the actions we can take or that it even includes the most important ones! In fact the Public Health England strategy is based on a mixture of evidence and a government ideology.

Local Action

Luckily, local Public Health teams have a degree of autonomy from central government. However there are challenges here too. It is quite difficult to have a system level conversation about access to the welfare benefit system – I think that this is for three reasons:

  • Poisoned Minds – Local leaders find it difficult to engage with an issue that has been represented by large elements of the press and respective governments as being about scroungers and layabouts.
  • Pot of gold – Partly for the reason above local decision makers would rather focus on creating employment and getting people off benefits which is of course commendable. However, there are many unable to work, low paid jobs rely on benefit top up and there is some evidence that people with good financial security through appropriate welfare support are likely to find employment more quickly than those ‘incentivised’ through punitive benefit regimes.
  • Welfare Economy – I suspect that some local leaders worry that a focus on improving access to the benefit system will lead to accusations that they lack ambition and are building an economy that is dependent on ‘handouts’.


Five actions for local Public Health.

  • Narrative and Conversation – have a strategic conversation at an appropriate level which considers what is known about need, levels of financial insecurity and demand on benefits services (this is difficult because DWP release little local data). Data sources could include StepChange, Citizens Advice, Insolvency Judgement trends, Public Health funeral (Paupers Funeral) trends, local Food Bank data etc. Organisations like the Centre for Welfare Reform and the Money and Mental Health Policy Unit can offer analysis.
  • Investment – consider the current level of investment in welfare rights services – what stories do providers tell of the strategic picture? Too often their data is kept at contract manager level in local systems rather than being used to develop strategies.
  • Focus – Often local Citizens Advice Services are left to get on with it – there is plenty of demand out there. Local commissioners need to understand the whole population effect – in particular are services targeted on the most vulnerable? For example:
    • People with mental health problems such as those receiving IAPT or on the Care Programme Approach
    • People with progressive long term conditions such as Cancer – Macmillan has done tremendous work here
    • Families in poverty especially those who are expecting new children
  • Collaboration – Local Public Heath teams can help by pulling together welfare rights providers and NHS provider and commissioners to consider how to strengthen the contribution of welfare benefits to people with long term conditions.
  • Evidence – local Citizens Advice services have a long track record of translating issues faced by their clients into evidence to challenge policy (I gave a Sheffield example here) local Public Health Teams need to consider how they can strengthen this.

What do you think?

Does Return on Investment help improve Public Involvement in the NHS?

June 14, 2017


I recently gave a talk at the annual NICE (National Institute for Health and Care Excellence) conference on a review Leeds Beckett University did of the Bradford District Care NHS Foundation Trust public engagement strategy ‘Involving You’.

NICE has published an account of our work here. Our full report is here.

As I went in to the workshop with my co-presenter Cathy Woffendin (Deputy Director of Nursing at the Trust) I noticed that the sub title to the workshop was “Demonstrating the Return on Investment of patient and public involvement” I should probably have clocked this earlier! When the workshop kicked off I made it clear that we were not going to be looking at this, instead we were going to talk about how we reviewed the actions the Trust was taking to strengthen their relationship with the public and what actions they had taken after our report.

After our presentations one of of the audience asked whether a Return on Investment approach would help decision makers in health take public engagement more seriously.

At the time I was unconvinced by this argument – on the basis that I think we should expect that leaders of NHS organisations have a value base that emphasises the importance of individual and collective relationships with members of the public.

Nonetheless it is perfectly possible to argue that there are financial benefits to having a strong relationship with the public – these include:

  • reducing cost of delays to proposed changes or innovations due to public challenge
  • added value arising from patient/public ideas about how services could be improvement
  • increase in reputation due to being seen as a good responsive health organisation
  • Accountability to local people – strengthening quality of governance

After the conference and prompted by the question I did do a bit of searching and came across a good paper titled Patient and public involvement: how much do we spend and what are the benefits? published in 2015. This is a thoughtful review of current state of play and I recommend that people read it.

The paper recognises the position that I and others have taken:

“Many PPI practitioners are sceptical about any attempt at ‘valuing’ participation practice and see economic and monetary analysis of the costs and benefits as reductions or simplistic”

Nonetheless, the paper’s premise is that it important to measure the cost of Patient and Public Involvement (PPI) with a view to determining its added value.

I remain unconvinced for three reasons – which are all to do with context.

If its small we must measure it!

It seems to me that innovative and low cost activities are too often subject to the greatest demand for evidence on impact and cost. They have to prove their value in a way that mainstream parts of the health infrastructure do not. For example I suspect that more is invested in Quality Assurance teams in Clinical Commissioning Groups than in Patient and Public Engagement – yet there is no call to demonstrate their Return on Investment.

The system is not listening

Sometimes it is too easy for health systems to say that PPI produces little added value – when the reason for this is actually because the health system has not framed its engagement in a way that allows the public to contribute in an effective or powerful way, or even worse when the system lacks the ability or will to respond to challenge from the public.

Deliberative Democracy

Finally, PPI is about deliberative democracy. The UK is a democracy – talking with the public is part of our culture –  we do not need to prove that this brings a ‘Return on Investment’ in order to do it.

Where next

The paper concludes with some ideas about how to measure the cost of PPI. Its a useful list – because it gets us thinking – although I am not sure how practical it is.


I think that local health organisation should consider:

  1. What is our vision for building our relationship with the public?
  2. What are the actions we are taking to move towards our vision and what resources (number of staff, their grade) we put into this?
  3. How are we changing our organisational culture in order to make it easier for the the public to work with us?

What do you think?


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?