Health inequalities and the NHS

Many speeches have been given to mark 70 years of the NHS. They have rightly celebrated the considerable achievements of this much-loved institution. Few though have mentioned the origins of the NHS in the Welsh valleys. It was the experiences of those here, unable to afford access to doctors and medicine, which shaped the vision for today’s NHS.

In 1915, the Tredegar Workmen’s Medical Aid Society was set up by, and for, the people of Tredegar, a mining community in South Wales. The people of Tredegar were pioneers. What they did went beyond anything that had gone before. They provided the inspiration for Aneurin Bevan, a local MP, who as Secretary of State for Health went on to design the new national health service in the same fashion.

It’s often repeated that the NHS is a ‘religion’ for the British people. The fundamental belief underpinning it, common to young and old, is in free health care for all. I believe this is because we have a visceral memory of the suffering and cruelty people experienced before the health service was founded. And a memory that, of all the public services we enjoy today, the NHS is ours because we designed it.

National Helth Service

The impact of the NHS on the nation’s health has been transformational. Decade after decade, life expectancy and health outcomes across the board have improved. Something created by a community with relatively little has benefited everyone, including the middle classes and the wealthy.

And yet today this situation is in danger of being reversed, with the primary benefit for the better off and the poor being left behind. In the 10 years since the publication of The Marmot Review, health inequalities appear to be widening. Shifting trends in life expectancy, and a widening gap between rich and poor, are of deep concern. Recent data published by the ONS indicates that, for those living in Herefordshire, the average disability-free life expectancy is 71 years. However, if you live in Tower Hamlets in East London, your disability-free life expectancy is 55 years. Unless the NHS makes a significant investment in preventive services, the gap between rich and poor will likely continue to grow.

In his speech to NHS Expo 2018, Simon Stevens referenced the twin needs to work towards narrowing the life-expectancy gap and to measure the impact of NHS services on reducing this divide. Not only is there a huge injustice happening here but it’s also costing us all a lot of money. The cost to the NHS of failing to provide comprehensive preventive services to people living in poor communities is huge – £4.8 billion a year according to York University’s Centre for Health Economics.

One response is the idea that people should ‘take responsibility for their own health’. This is part of what preventive services are about. But without explicit reference to the relationship between poverty and poor health, there’s a risk that this will become a political slogan that undermines and marginalises people living in poverty. Dr Andy Knox wrote an insightful blog recently about involving communities in the design and delivery of services to tackle health inequalities in Morecambe Bay. He rightly reflected that improving health and wellbeing is far easier for some individuals and communities than for others.

On a recent visit to Turning Point’s integrated healthy lifestyles and Improving Access to Psychological Therapies (IAPT) service in Luton, Total Wellbeing, I was impressed by the team’s work. This service is supporting people to learn new skills and motivating them to make changes to their lifestyle, keeping people out of hospital. Services like these – treating people holistically and recognising the impact of the wider determinants of health and the relationship between mental and physical wellbeing – can genuinely empower people to take responsibility for their own health.

It’s my belief that we are failing to shift resources towards prevention because the NHS is no longer run by, and for, the people. Our national health service is highly complex and in so many ways so much more sophisticated than it was in 1945. But, communities are no longer involved in the design and oversight of bespoke local health services as they were with the Tredegar Workmen’s Medical Aid Society. There are some pockets of good practice in terms of community involvement but mostly this is tokenistic, under-resourced and unable to make much impact on how services are delivered. When it’s done well, community involvement takes time, effort and resources – but will pay dividends by enabling services to work more effectively in the longer term.

One good example is Turning Point’s Connected Care model, which provides skills for local people to work alongside commissioners to redesign health and social care services and test new ways of working. Across the country we trained 250,000 local people, including by sharing information about health inequalities facing the local community. Our experience of applying this approach in diverse communities across the country is that people want to get involved in the design and delivery of preventive services. Sadly, this and other similar approaches such as those documented in Public Health England’s A guide to community-centred approaches for health and wellbeing are simply not incentivised in a system that continues to reward hospitals for treating people rather than keeping them healthy.

We need to learn or re-learn the lesson that the creation of the NHS teaches us: the NHS cannot be imposed on people but must be developed with them – and it has to change with them too. In my mind, devolved health and social care budgets, overseen by democratically elected representatives as in Greater Manchester, provide the greatest potential to make this a reality. There’s a long way to go but this is how we will ensure that local people are involved in the design and delivery of local services that genuinely meet their needs. We need services like the Tredegar Workmen’s Medical Aid Society – services run by, and for, the people.

Source: Lord Victor Adebowale writing at The King’s Fund

‘Moving at the speed of trust’ – the journey to integrated care systems

Anna Charles writing at the King’s Fund: In May of this year, NHS England announced four new integrated care systems (ICSs) to join the ten existing systems. But ‘announced’ is not really the right word; as we have found in our work with the systems, creating an ICS is most definitely a journey and not an event. 

We’ve been tracking these journeys over the past year, conducting interviews with more than 70 NHS and local government leaders and other stakeholders in eight of the first ICSs. Our new report, published today, sets out the findings from this work and identifies emerging lessons for local systems and national policy-makers.

Integrated Care

ICSs (and the new care models that came before them) have been introduced in a very different way to the NHS reforms of the past. Instead of central bodies passing legislation that enforces a uniform organisational model across the country, ICSs are being designed and implemented by local areas, within a broadly permissive national programme that emphasises peer learning and support. In the words of one local leader:
The honest discussions about the wicked issues and how they can best be navigated has felt, to me, like a breath of fresh air…You can’t just impose a blueprint from Skipton House or Whitehall. This has to be more iterative and co-produced.

There are some drawbacks to this approach in terms of the clarity and consistency of the changes taking place, but our work suggests that an ICS can only be developed in each place, by each place; they must evolve and be owned locally if they are to succeed.

Why is this? After all, we found strong similarities in the governance arrangements that the different systems are developing and in the service changes that they are putting in place. ICSs have much in common, and there is much they can learn from each other. But the strongest message that came through loud and clear from our interviews was that this had to be founded on collaborative relationships and trust between partner organisations and their leaders:

It’s relationships, relationships, relationships…all the governance structures and technical things in the world are great, but if people don’t have an aspirational intent to work together, it doesn’t really matter what you write down.

The systems have used a variety of strategies to address this, including bringing leaders and staff from different organisations together to spend time face to face, working through collective challenges, and creating a shared purpose. Building relationships cannot be rushed or centrally imposed; it takes time and commitment and can only be done locally.

We can’t do any of this quickly. This is very big change for a lot of people across the system. I think that to do it any quicker we would have just fallen over.

Individuals spoke candidly about how developing an understanding of other organisations’ priorities and challenges had altered their own perspectives and behaviours. They described greater openness and transparency across different organisations and new ways of collectively managing finances and performance as a result:

I’ve learnt more about how local authorities work in the past 18 months than I’ve done in the past 42 years…it’s been spending time with one another and understanding one another’s problems and issues.

It is still early days for ICSs. Local leaders need to continue the work they have begun by giving priority to strengthening relationships and trust, redoubling their efforts to involve key partners, and focusing on delivering further changes in service models to improve heath and care for their populations. They also need to take active steps to listen to and work with members of their local communities on an ongoing basis, ensuring they design services that meet their needs and reflect their priorities.

National leaders must hold their nerve in allowing ICSs to be built from the bottom up, while also offering guidance and support and doing their upmost to remove the barriers that ICSs encounter.

To end on the words of one ICS leader:

The ICSs will move at the speed of trust…this is really about relationships and trust between the partners.