I wasn’t going to blog this, but have been persuaded to.
thoughts by way of response to the consolation document on “Prevention”
brief note format
A lot that is good, some amendments in tone and focus could make it even better
For me 5 key messages
- Disproportionate coverage to individual solutions
- List of stuff vs way of doing stuff. Specific policy or services or interventions versus mechanisms for building “prevention” into the wiring – institutional (performance system, financing, expectations re outcome
- How truly cross government. Embedding well being as a priority across Whitehall. Not something that DHSC does. How rooted in “NHS” or “health” narrowly defined is it. Prevention is a concept that applies well beyond “health” (or health care demand). Keeping “prevention” in the realm of health and social care policy is a major mistake as it will limit impact. Arguably I would puth for a HMT or cabinet office lead or failing that a separate unit a la South Australia & HiAP unit within the Leader’s office.
- Funding – we are most at risk in prevention funding, stripped it out most
- Build the organisational machinery, finances, professional practice, targets so this becomes the norm and default. Build the narrative around an asset based model. Set out expectations on the HWBBs to push through a whole of place approach. Build the narrative on inequality. WHOLE lifespan. Of course “whole systems” are important.
- This links to clear understanding of the anchor role of public institutions, at city / county level and at neighbourhood level. This isn’t just about services being provided but overall impact on economy. There is also a need to emphasise a truly place based approach – need to do what works for each place and allow this to be shaped accordingly. This cannot be done through a one size fits all approach or command and control model. The role of the HWBB is central in this
1 Often disproportionate coverage to solutions oriented in individual behaviours, personal responsibility, often at the expense of changing the context in which people live
The evidence is crystal clear in many different spaces and areas that whilst interventions focused on behaviour change is important what really makes biggest impact, and is most equitable, is addressing the upstream context and environment in which that behaviour happens.
There is a general concept issue there, as well as specific policy propositions in certain areas (stop smoking services vs HMT tax policy).
Often those upstream / downstream considerations are about internalising the externalities (loss of profitability from obesogenic environments) and or involve directly addressing ideological points (which is often using ideology to mask commercial interests). However the evidence is clear.
Arguably the GP could strengthen the narrative on this.
2 List of policies and interventions vs way of organising
There is much to support on the specifics, and those single interest groups will doubtless have a lot to say on some of those.
“Prevention”, however, isn’t a “thing to be commissioned” or a specific (or broad set of) intervention. There is something to build on re methods, mechanisms and framing as well as advocacy for specific policies
Prevention isn’t a “thing to commission”, it isn’t a “service”, it’s a way of thinking about things. It can and should be applied to all aspects of an organizations activities. We cant manage demand by becoming more efficient at demand management, we can only manage demand by preventing it. The question for all of us is one of what is the upstream response to this demand, at all levels and what can I (not someone else) do to address this.
Thus the real mission is building a system (whether this be in NHS, or in other areas – criminal justice, transport, housing, welfare or pretty much anything else) where “prevention” is the defult choice and the architecture around the outcome supports and enables this.
The word itself is problematic
The very word “prevention” causes problems, Prevention tends to lead us to a path of being deficit focused, sends us down siloed condition specific approaches. This is easy but problematic for how we think about things (prevention of what etc.). See here from NLGN. It would be worth building some narrative to primary, secondary, tertiary. Or prevention, harm reduction, early intervention to prevent or delay complications or chronicity?
Often prevention is negatively framed in terms of “prevention of a bad outcome”, this isnt wrong. However there is equal merit in framing it as considering how we optimise our policy and services to optimise good outcomes, and work in an asset oriented way (what are our strengths, build on those).
3 How truly cross govt.
“prevention” is something more than NHS. Thus place oriented response is only way of bringing everything together. obvious tensions between national top down / sector specific and place oriented, especially if fully assed based model.
Prevention is not something that should just apply to “health”, it can equally apply to crime, injury, violence, social outcomes. Whether we should be focused on “prevention” of poor outcomes or promotion of good ones is also a frequently occurring conversation. There is merit in formally embedding prevention and well being as a priority across govt, local and national. Not something only that the heath sector does. The details on interventions, the look and feel of how it plays out will vary from area to area, but often with underpinning principles.
While it is accepted this is a green paper rooted in DHSC, there is a valid and unarticulated ask on different govt depts.- HMT, DfE, DfT, DCMS, DHCLG, HO, DWP – what are EACH of the other depts doing. This also plays out locally, and underscores the importance of place based responses. Each govt department needs to take responsibility for the impacts their policies have on human health and wellbeing. This requires leadership from MPs and pressure from the public and civil society
Language matters. If prevention is framed in language of “health”, those stakeholders with “health” or similar in their job titles think its for them.
We should move the concept of “prevention” away from something the director of public health does and or a list of specified interventions / programmes or policies ….. which of course is “in”, to something considerably broader – a way of thinking and organising
4 Funding for prevention. We all want “more prevention”, mostly up to the point of investing. We HAVE stripped a large chunk out of “prevention”
The Impact of austerity induced stripping of preventive interventions isn’t covered in the GP. We know the impact of austerity has had a differential impact on those most vulnerable at individual, family, community and city level.
Thus key will be what follows inc local gov funding settlement, NHS Plan, spending review, across the whole of govt.
5 Build the organisational machinery, finances, targets so this becomes the norm and default
We need to be building “prevention” into the wiring – institutional (performance system, financing, expectations re outcome, professional practice, targets.
We tend to focus on the money, and the short term. This is understandable, but if we only focus on the money we will do the wrong things. There should be no conversation about money until there has been a conversation about outcomes, and no conversation about outcomes till there has been a conversation about inequality.Some should be given to defining currency of success; how to get from a conversation about health outcomes (pick one, HLE is my preferred – but significant caveats) to use of resources, and vice versa.
New funding v bending existing funding.
It is recognised that significant new investment is unlikely to arrive in the short-term. Whilst we may not expect significant new resource, there is a need to be clear how we bend existing resources to the goal. We know significant resource is tied up in meeting acute demand, that arguably would deliver better outcomes if deployed further upstream. Furthermore in any area it is relatively easy to identify where resource is tied up in low value / low return interventions.
If new resource is identified it MUST demonstrably bend the mainstream and accelerate high impact interventions (learning from past failures to do so – HAZ, SRB, NDC where new resource propped up other services but didn’t lead to fundamental change). We should seek to develop a principle of differential gearing for investment focused on a preventive model, and achieve a greater rate of growth in those areas most likely to achieve our stated goals around prevention.
Deficit model vs asset model.
Prevention is something wider than a concept oriented around preventing bad outcomes in order to save the NHS some cash, but something wider to invest in for much wider benefits. We often talks about asset based approaches, but then falls into trap of “designing services around user need”.
The GP underplays any really narrative around an asset vs deficit oriented model. This is a significant weakness, and there is an opportunity to build a place, community & people oriented approach, not (only) service oriented approach.
There is an opportunity to put into practice the asset based approaches being developed in Wigan(Kings Fund here), proposed by the New Local Government Network (NGLN Community Paradigm / NGLN Community Commissioning). This is based on the recognition that the things that enable people to stay healthy and well are often outside the gift of public services – personal resources, networks, assets. The role of a place and the systems within it is developing and supporting the conditions that enable people to develop and maintain these – which means investment in communities, considering how people have the time and access to do the activities that support that sort of stuff
Build on the role of HWBB to push through a whole of place approach
There is limited reference to the role of HWBBs in the GP, it seems only mentioned at the end of the GP and possibly as a subset of ICSs. There are obvious tensions in the differences in working in a placed oriented way (agnostic of individual institutions or sectors) versus a top down approach focused on NHS delivery.
LAs can have more place shaping powers but without decentralisation elsewhere this might not make a huge difference. What does a place-based approach mean for NHSE, esp. below ICS level
Government can provide political cover for controversial schemes that have a positive impact on health and well being (for example Clean Air Zone, ultimately we can say “govt say we have to do this”) which can be helpful for getting over local difficulties
Further develop the narrative on inequality.
Inequalities in health are not improving satisfactorily (see the recent Health Foundation analysis – this has relevance across the whole of government). The Marmot recommendations still are relevant and the basic fundamentals set out by Marmot haven’t lost any coherence. Of course it is accepted that different governments have different views about inequality and its causes, but the evidence is articulately set out by Marmot and hasn’t been bettered.
Often in documents I see on ageing are dominated by a narrative set in old age and very NHS and social care oriented. This is mostly at the expense of a whole life course approach and the lifelong determinants of health and healthy lifespan.
Further often the narrative is rooted in “lifestyles” and behaviours not systems, contexts and environments. This is often compounded by very limited focus on work, sustainability, growth, air quality, lifelong learning, mental reserve, poverty and income, cumulative stress.