You’d think it was a stupid question to even ask. It’s obvious isn’t it.
But in austere times we are slashing preventive services and loosing focus on upstream determinants and their link to healthier folk. We still aren’t landing the rationale for why PH folk hassle others to build bike lanes, parks, not advertise junk, do progressive licencing, why poverty matters to health and things of a similar nature.
We are rewriting our health and well being strategy, this got me thinking about the basics & some thoughts on linking “how healthy we are” and the structural determinants of health back to demand for our always overspending demand led services.
• “Health” and “well being” are flip sides of the same coin. There is a whole philosophical debate about the definition of “health” and of “well being”, read about salotogenesis theory and have a look at Harry Burns on YouTube. One for another time
• Not addressing well being or health simply sets up demand for services. Demand for NHS and social care is a response to failure to optimise this further upstream and is buying back health that we’ve already lost via policy choices in other spaces.
• Social care demand will be the bit that bankrupts any local authority. Thus considering the upstream causes of that demand is a highly legitimate goal. Upstream includes the built environment, green space, transport policy.
“We should have a health in all policies approach”, or “we should be more preventive”. Both are easy to say and the right aspiration to have.
How we build our environment and city – built places, social neighbourhoods, the services we provide, what the economy looks like and how it develops and includes all. All of this, and much more, matters and matters a lot for how healthy we are.
We underweight the importance and relevance to “health” of changes we make in landing service and policy discussions, we underweight health (by which I don’t mean health care) and inequalities in outcomes in the trade offs we make.
Defining “health” and why is matters to service demand
Healthy Life Expectancy (HLE) is the standard proxy used for describing years in wellness or illness, or lack of it.
Other metrics are available (activities of daily living, functional ability), there are some distinguishing features but they are all sides of the same coin. All have tricky methodological issues with calculation.
We have broadly accepted that HLE is the measure.
HLE can be readily linked to NHS demand.
More people with more years of less than good health. That demand is inequitably spread – affluent / poor, mental illness / not etc.
Social care demand is related directly to how poorly people are (that’s a medical model construct) or loss of independence (often related to consequence of decline related to illness or broader social factors)
It is easy to track that demand back to interventions to reduce or manage risk, and thus delay complications (and thus loss of functional ability, illness etc). This is easy to do re NHS services, and its easy to track back (or forward) to social care.
These risks are due to well known risk factors. Downstream and upstream risk factors matter. Upstream always matters a lot more.
Not addressing risks sets up demand for our own services.
Thus it IS important to set up an environment where people can be healthy, it is an investment in preventing future demand.
To use an over simplistic example, if we build a city like Amsterdam more people will walk and cycle, there will be less obesity, less downstream complications of obesity – diabetes, cancer, heart disease, joint pain. And all the NHS demand, and loss of function thus social care demand that ensues. The city will be more connected, likely mental health will improve. Some if this is near impossible to prove in modelling terms, though plenty have done a good job – see here (Pop benefits of Dutch levels of cycling) for an example directly linking active travel, health status and economic productivity via GDP.
Im not only picking on bike lanes here, though there are a neat simple example. The same can be said in almost any area of policy. Poverty – in and out of work poverty, low wages, financial insecurity and insecure zero hours contracts as a driver of mental well being for instance. Poor quality housing leading to both mental and physical health problems.
Having a healthier set of folk than you would otherwise is probably the biggest, and seemingly as yet untapped by those that “do” the economy, economic lever you can pull at a city level. I’ve written a little on that before – the link between “health” and economy is two way. There are occasionally single sector articulation of this, but it’s (very) rare to see cross sector and or whole economy articulations of this. People talk about trade offs, say between health vs economy. My standard view on that is health is economy. There is a symbiotic relationship, especially when externalities are factored in.
Thus it IS in the cities interests that we DO use the various levers available to a city to get a healthier set of folk than would otherwise be the case.
Why don’t we do better, and what to do about it.
Many obvious reasons.
Austerity has led to us stripping out lots of service to maintain statutory.
Even before austerity, however, this was an issue. “health (or “prevention”) isn’t my job, its done by someone else, somewhere else, leave me alone I’ve got other stuff to do”.
There is something in here about business planning/budget/accountancy
• We didn’t want to make severe cuts to any of our preventive services. Circumstance dictated that result – we need to balance this budget NOW, we have these stat services we must deliver, something has to go somewhere, etc. We can’t fix the problem of the amount of money available – so will need to affect that decision process in other ways.
• This is the classic Public Service Reform problem of where returns on investment go – and how long they take to accrue.
• Given that we cant make the challenge go away, there IS a case to add more information to the frame so it is not just a financial calculation – or can we design a budgeting/business planning approach that exposes the dependencies across the system (so we can model “make this cut now and you will add 5x the pressure to future budgets”).
• We probably don’t have the data for this sort of approach, or peraps the capacity (and maybe the capability) for the modelling
A “business case for cuts” process might be an interesting exercise.
Makes it more complex, admittedly. The mechanism/what would need to be in place for someone (cabinet? EMT?) to be able to say “the long-term implications of change x in service y for service z is not something we can ignore – go away and think again” and possibly then look to move some money around the system in response? This might make budget setting even more terrifyingly complex than it is already.
More broadly and away from narrow budget view: application of COM-B to this might be useful
what is the behaviour we want from colleagues on this – need to define this clearly, something like “decision making with full view of the long term outcomes and implications”? Then from this, do they have capability, opportunity, motivation? Suspect capability and motivation might be a problem, haven’t really thought through opportunity.
Knowledge is important but values too.
Who are we delivering for? Eg think the evidence on active travel etc is well understood but we are continually under ambitious.
Ultimately it needs to be a performance issue for senior staff?
Thanks to Dan Spicer for, as ever, incredibly useful thoughts.