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

NHS chief demands political consensus on funding elderly and social care

Britain urgently needs a new political consensus on paying for elderly and social care, and the funding debate should consider the value of pensions and homes, the boss of the NHS has said.

Denis Campbell and Paul Johnson for The Guardian Simon Stevens argued that one of the main questions in tackling the challenge of how to pay for and look after an ageing population was whether some of the money spent on increasing state pensions should instead be allocated for social care.

In an interview with the Guardian, the NHS chief executive said that David Cameron’s administration should look at all the options for finding the billions of pounds needed, including revisiting the “triple lock”, which guarantees Britain’s pensioners generous annual increases in their state pension until 2020.

“What are the pros and cons of dedicating some of the proceeds of the triple lock to older people’s social care?” he asked. The triple lock promises to raises the state pension every year by the higher of inflation, the increase in average earnings or 2.5%.

Stevens also suggested ministers should also be prepared to risk upsetting Britain’s growing army of senior citizens by looking at whether the benefits they receive are fair to working-age and younger people.

“Would intergenerational fairness support a further increase in the share of public funding on retirees, at the expense of children and working-age people? Does there need to be more flexibility between current disconnected funding streams for older people, so that at times of need everyone is guaranteed high quality social care?” Stevens said.

He floated the idea that it could become “easier for families to flexibly fund social care by drawing down resources tied up in housing, pension pots, and other benefits and entitlements”.

Simon StevensThe comments raise questions about whether he thinks it is time to stop giving all pensioners regardless of income benefits – such as free TV licences, prescriptions and bus passes and the winter fuel allowance – to free up money for social care.

Social care is funded by cash-strapped local councils, who have had their budgets cut by 40% over the past five years. It includes services such as help for people at home with basic tasks such as washing and eating as well as adjustments to homes to reduce the risk of a frail, elderly person falling, such as grab-rails.

NHS England’s chief executive fears the service will be unable to cope if the recent decline in help received by older people from social care services, especially in their own homes, continues to increase demand for medical care and problems of hospitals becoming overcrowded.

He wants the government to rescue social care services from their downward spiral of funding cuts and increasing unmet need by reaching an agreement on how such care will be paid for by 2018, to coincide with the NHS turning 70.

“2018 will be the 70th birthday of the NHS. That will be a fitting moment to seek, as the NHS turns 70, a new national consensus on properly resourced and functioning social care services,” he said.

Without urgent attention being given to the “pressing” issue of social care, the inadequacy of local provision would keep having a big impact on hospitals, GP surgeries and other health services, he said.

Even more older people would become trapped in hospital despite being fit to leave – a key reason hospitals run out of beds – and more operations would be cancelled unless ministers started seeing social care as a top priority, he said.

Stevens said he wanted the Westminster parties to start talking to each other now, well ahead of the 2020 general election, and find “a settled and durable new political consensus” on social care funding.

However, the parties’ responses suggested that Stevens’s appeal for a constructive debate between them had, initially at least, fallen on deaf ears.

A government spokesman declined to commit it to seeking cross-party agreement and simply reiterated its existing plans for social care in England, which many – including Stevens – believe do not address the scale of the problem.

“Simon Stevens is right to highlight social care funding in the context of our ageing population. That is why in the spending review we gave local authorities access to up to £3.5bn extra a year by the end of the parliament with the social care precept and additional investment,” the spokesman said.

Organisations including the Local Government Association, King’s Fund health thinktank and Age UK have criticised the 2% levy on council tax as unlikely to raise anywhere near the sums ministers claim and no substitute for proper funding from central government for such key care.

Labour claimed that “Simon Stevens’s comments are further evidence that the government’s plans for funding social care are completely inadequate.”

Heidi Alexander, the shadow health secretary, said cuts to social care over the past five years had left “hundreds of thousands of elderly people without the care and support they need to live independently and with dignity”.

She added: “There is an important debate to be had about how we reform and fund health and care services for the future. However, this debate cannot be left to politicians alone. We need to have a national conversation, with the public, about how we can guarantee the future of health and care services for generations to come.”

She declined to speculate on where the money might come from and said that Labour would soon launch its own review of the subject.

Norman Lamb, the Liberal Democrats’ health spokesman, said a consensus was vital “The NHS and social care face an existential crisis,” he said. “Demand for services continues to rise year on year but funding is failing to keep up”.

Lamb, a health minister until last May, said the approach by Stevens endorsed the call he had been making for more than a year for a cross-party commission to investigate how much money health and social care would together need in the future and agree where the money should come from. Alan Milburn, the ex-Labour health secretary, and Stephen Dorrell, health secretary in John Major’s Tory government, are backing Lamb’s initiative.

“The government cannot avoid this issue any longer. These issues transcend narrow party politics and that we should be prepared to work together,” Lamb said.

The NHS boss told MPs on Monday that English hospitals’ fast-ballooning deficits were largely down to the exorbitant fees for temporary staff charged by employment agencies who are “ripping off” the taxpayer.

Hospitals could spend as much as £4bn on temporary and agency staff this year, Stevens said while giving evidence to the Commons public accounts committee. That is much more than the £2.6bn spent in 2013-14 and last year’s £3.4bn and reflects hospitals’ increasing reliance on temporary staff, including locums, because of serious personnel shortages.

Stevens said the soaring bill for temporary workers lay behind “the vast majority if not all” of the record £2bn-plus deficit that trusts are forecast to run up.

Some MPs said that rising costs were inevitable, given the extra staffing needed to maintain quality of care. But Stevens voiced frustration that indebted hospitals swallowing up £1.8bn of the extra £3.8bn the NHS will receive in 2016-17 meant that less money was available to spend on primary care, including GP services.

“Up to £4bn on temporary and agency staff this year – scandalous – ‘talk about a broken NHS !!’  Not to mention the catologue of other health and care issues”