This is a longish blog by Dave Buck and myself. It was done in preparation for the publication of the All Parliamentary Group on Longevity report. An edited version will eventually make it into the report. We try to set out a rationale for a wide ranging approach to longevity and improving healthy life expectancy, why both national and local approaches are important and the core ingredients of success.
As ever, they are OUR views.
The Grand Ageing Challenge will only be met if local areas move to coherent population health systems which maximise the contribution of the four pillars of population health.
National government has a significant role, the activities of each government department are crucial in shaping the environment in which communities can thrive and achieve the best possible health. Central government can (and does) set the rules and background infrastructure by which we make progress. It also sets the context against which norms and culture is set locally.
But we know from long experience and lots of evidence that there is a hugely important role for local systems to both deliver services and set wider policies and ‘place-shaping’ that will improve health, in short local systems must become local population health systems.
Local population health systems
What we mean by a local population health system
Source: Buck et al (2018).
A local population health system is how: local areas arrange and resource activity in the four pillars of population health (the wider determinants, our health behaviours, an integrated health and care system and the contribution of our communities); and how those areas identify, recognise, lead and support activity where these pillars intersect.
Doing this, and therefore achieving the goals of the Grand Ageing Challenge will depend on: strong local system leadership; meaningful involvement of the public; ensuring health inequality reduction is a core system goal; getting the underpinning enablers right; and enabling central government policy.
Local system leadership behaviours
Achieving the Grand Ageing Challenge requires leadership of a complex population health system, this in turn requires five key leadership behaviours (Senge et al. 2015) (Naylor and Buck 2018) from system leaders:
- ‘Seeing the larger system’ that influences population health locally – across to the other pillars of population health and the sectors that contribute to them
- Recognising that not all the solutions are to be found within their organisation, sector or ‘pillar’, actively supporting those who have solutions beyond their own source of power and responsibility
- A shift of focus from reactive problem solving to co-creating the system and designing strategies to get there.
- Strong local political buy-in and support. The soft power of local political leadership (e.g. through city mayors) can cut across this complexity of local governance arrangement and appeal directly to communities
- Dedicated resource that can co-ordinate and help guide system-wide action. Experience suggests this need not be a large function, but it is critical to success.
Where leadership sits or rests is less important than the behaviours above. In some places this may be the Health and Wellbeing Board, in others NHS structure such as Integrated Care Systems, or as in many places a combination, this will depend on local contexts.
The public seen as partners in health by an enabling state
Investing in communities for health needs to be a critical part of any approach to population health and meeting the Grand Ageing Challenge goals.
There has been a welcome and growing recognition of the role and power of communities in health, as well as that of individuals (South 2015; Lent and Studdart 2019; Naylor and Wellings 2019; Buck and Wenzel 2018). The communities we are born, live, work and socialise in have a significant influence on how healthy we are. Strong communities are therefore good for health and local areas – often led by local government – are working in many ways to develop and support this (for example see case studies here https://www.kingsfund.org.uk/events/community-best-medicine-leeds-event#presentations).
The ‘Wigan Deal’ (see box) is one of the best known and documented approaches to working with the public and communities for health, but is not alone. The Deal has given public servants and others in Wigan a set of guiding principles that inform how they work with each other and with people using services and in the community more broadly.
|The Wigan Deal
Since 2011, Wigan Council has embarked on a major process of change involving moving towards asset-based working at scale, empowering communities through a ‘citizen-led’ approach to public health and creating a culture which permits staff to redesign how they work in response to the needs of individuals and communities. At the heart of this is an attempt to strike a new relationship between public services and local people that has become known as the ‘Wigan Deal’ between citizens and the council. In return for keeping council tax low, the council has asked citizen’s to work alongside it. Wigan’s approach has been based on four main components.
Asset-based working: There has been a major drive to work with local people in a different way that seeks to recognise and nurture the strengths of individuals, families and communities and to build independence and self-reliance. While asset-based working has been explored in many parts of England, Wigan is notable for the scale at which this approach has been adopted and for the consistency of implementation.
Permission to innovate: Leaders in Wigan Council have created a culture in which innovation is encouraged and frontline staff are permitted to take decisions for themselves and rethink how they work, based on their conversations with people using services. This has meant taking a different approach to risk – positive risk-taking is encouraged if the potential benefits for clients outweigh potential harms. It has also involved moving away from a ‘blame culture’ towards one which emphasises learning from what has not worked.
Investing in communities: Wigan Council has taken a three-fold approach. First, investing directly in local voluntary sector organisations and community groups through a dedicated community investment fund. Second, the council commissions collaboratively where voluntary and community sector organisations are seen as partners and are actively supported to develop and improve. Finally, it has invested in citizen leadership roles at scale through roles such as community health champions (including young champions and alcohol champions), dementia friends and autism friends.
Place-based neighbourhood working: As elsewhere, organisations are attempting to work together in a more integrated way. A distinctive feature of Wigan’s approach to this is the breadth of organisations involved – in addition to health and social care teams, multi-agency working within the borough’s seven ‘service delivery footprints’ involves the police, housing, employment and welfare services and others. This creates opportunities to tackle the broader determinants of health and wellbeing in a more coordinated and flexible way.
Source: (Naylor and Wellings 2019)
Wigan does not offer a simple, ready-made solution that other areas can adopt overnight. However, it does provide a powerful example of what can be achieved when public services see communities as assets and commit to working in a different way that builds on people’s strengths.
Significantly, Wigan’s headline achievement in relation to healthy life expectancy (HLW) is impressive. The rate of improvement between 2009–11 to 2015–17 was faster in Wigan than in most of its 15 nearest ‘statistical neighbours’ (councils with a similar population and geography), with only three of these seeing similarly positive results
(Public Health England 2019), at a time when HLE across England was largely stagnant over the same period, narrowing the gap between Wigan and the national average.
Inequality reduction as a core goal
The Grand Ageing Strategy will not be achieved without tackling health inequalities as a core goal regionally and locally.
For example, at a regional level, the London Mayor is unique currently in having a statutory responsibility to have a health inequalities strategy for London. The current strategy (Mayor of London 2018) has a twin-track focus on: those things the mayor controls directly (e.g. spatial planning, transport, economic development, housing, environment and culture); and actions of wider partners (e.g. the NHS through London’s Sustainability and Transformation Partnerships). The strategy is supported by a number of key indicators that are monitored over time. More major cities and regional areas need to adopt their own health inequalities strategies.
Good examples at local level include Sheffield and Coventry. In Sheffield the Health and Wellbeing Board has set itself the role of being the coordinator of the city’s approach and work on health inequalities (Sheffield City Council 2019); in Coventry, the new health and wellbeing strategy is the city’s high-level plan for reducing health inequalities and improving health and wellbeing for Coventry residents (Coventry City Council 2019). The local NHS also needs to take inequality reduction more seriously than it does (Buck 2018), the 2012 Health and Social Care Act introduced legislation on health inequalities which needs to be more actively used (Moore 2019).
Six underpinning areas for regional and local reforms
Greater Manchester (GM) is on a journey towards a population health system covering 2.8 million people (Greater Manchester Health and Social Care Partnership n.d.), adapting The King’s Fund framework above to its own context. GM has set itself the task of reform in six core areas to help it achieve this as below; local areas should set themselves the following six goals.
Adopt a future generations and wellbeing policy
Local area need to develop an approach to future generations policy, with wellbeing at the heart, this helps local systems focus on the long-term health of their populations, not simply meeting short-term healthcare demands. GM is exploring how a regional approach could learn from the Welsh experience with The Future Generations Act (see https://futuregenerations.wales/) and New Zealand’s approach to budgeting for ‘wellbeing’ (Charlton 2019).
Have an investment strategy for prevention
All ‘the headwinds’ are to support acute treatment systems in semi-perpetual crisis due to tight budgets, this creates no headroom for non-immediate spending. GM is exploring the case for a prevention investment strategy with a focus on: payment and reward systems (e.g. risk-adjusted capitation); a prevention fund; and the feasibility of setting a prevention target as a proportion of overall spend (as has been suggested by PHE and CIPFA (CIPFA and PHE 2019)).
Use existing local powers optimally
Local areas need to use existing legal powers optimally. These lie in and outside the health care system. Regional and local areas need to be honest and ask themselves whether they are using the full powers available in the following areas: those that apply specifically to the NHS, including in relation to integrated care (NHS England n.d.); powers over procurement through the Social Value Act (Fenton 2016)); the permissive powers under the Localism Act (Department for Communities and Local Government 2011) that provides a general power of competence for local authorities over improving local wellbeing; and finally the wide range of powers in other sectors (including transport, planning and education) in ways that are likely to improve the health the population and narrow inequalities in health.
Integrate governance, assurance and accountability
There are no easy solutions to accountability, given the complex nature of what drives population health – and as a key part of that health inequalities – but it is important to be as clear as possible about where governance and assurance lies locally, and what accountability means.
In Sheffield, the Health and Wellbeing Board fulfils this role around health inequalities challenging local partners to act and holding them to account for commitments made (Sheffield City Council 2019); in Coventry, the Health and Wellbeing Board has been explicit about where the responsibilities for the strategy lie across the four pillars of population health (see Figure) (Coventry City Council 2019).
Broaden population health leadership and use public health expertise optimally
Directors of Public Health play a critical role, but they cannot be the only leaders in place for population health. The role of specialist public health expertise is critical to local systems, as our work on international cities that do well on population health has shown (Naylor and Buck 2018); there are fewer than 150 Directors of Public Health in England, each local system will therefore need to make the best use of this scarce resource in the way to maximise its impact for population health.
But there are many more people with who can contribute, from those with the broadest roles to those with the most specialised. What works it what place and context will be different (for example, see Wigan’s reimagining of the contribution and roles of council employees (Naylor and Wellings 2019) and what firefighters are now doing in many places around England (Taylor 2017)) but every local place should have a local vision for the use of population health skills and roles in their workforce.
Fix perverse incentives
There is a difficult incentive problem in acting on population health and health inequalities. The sectors that by investing resources are likely to have the biggest impact are often not able to capture the financial rewards from doing so. In the United States, some healthcare systems have directly invested in building and improving housing in the poorest areas (Pham and Green 2018) since they know this is important for health and because it will pay off in lower demand for their patients for whom they are only reimbursed a set sum for care.
In England there is less incentive to do the same, since the NHS does not benefit financially from improving health and lowering demand for its services; local government also has less incentive to invest since any gains in terms of reduced demand will pay off to the NHS, and not local government directly. Budgets are jointly held and decisions made more jointly between the NHS and local government in some places which helps mitigate these incentive problems; in some places the NHS is also acting more like an ‘anchor institution’ (Reed et al. 2019) and ‘looking beyond its own pillar’ and supporting other sectors for health. But both are less common than they need to be; and these are workarounds, in the longer term the fundamental incentive and leadership problems needs fixing.
Central government asks
Central government needs to make it much easier for local leaders, organisations and systems to ‘do’ all of the above. Central government needs to commit to a national health inequalities strategy, ensure the right resources are in the right place, and develop clearer accountability between the centre and localities (The King’s Fund 2019).
A national health inequalities strategy
The effort of local leaders, organisations and systems need to be supported by a cross-government health inequalities strategy. The last strategy (active until 2010) was successful in narrowing gaps in inequalities in life expectancy between deprived and less deprived areas (Barr et al. 2017). A new strategy needs to learn from this success, and develop further. The King’s Fund has set out options for possible national ‘binding ambitions’ on both population health and inequality reduction and the reasons why in its Vision for Population Health ((Buck et al. 2018).
The right resources, in the right sectors
We know that public health spending is good value for money, spending on the services supported through the public health grant is three to four times as cost-effective in terms of health gain as putting the same money into the NHS baseline (Martin et al. 2019) but central government has cut the grant. The King’s Fund and Health Foundation have argued that at least £1bn extra p.a. is needed to be put back into the public health grant (The King’s Fund and The Health Foundation 2019) but a more fundamental assessment is required of the optimal budget for local government public health.
Beyond the public health grant, overall local government real spending per head has dropped by 20% between 2009-10 to 2018-19, and more deprived areas have faced larger cuts than least deprived areas, local government has been good at protecting social care services but at the expense of others which contribute to health (Harris and Phillips 2019). Central government needs to put critical resources back into local government, and to reform the way it does so, so that more deprived areas and services that support population health and will contribute to meeting the Grand Ageing Challenge do not lose out.
The relationship between the centre and regional and local systems
There is a constant conundrum about ‘what happens if what we want to happen doesn’t look like it will’ at the heart of national strategies which depend, in huge part, on the actions of local systems. The Grand Ageing Challenge will need to address two challenges. First, that different sectors – especially local government and the NHS – have very difficult accountability (and funding) relationships with the centre; and second (and subsidiary to this) that it is not clear that existing relationships currently is optimal for the Grand Ageing Challenge. We can – and should – learn from the strengths and weaknesses of previous regimes including those governing the previous national health inequalities and other strategies, governed through the Public Service Agreements process across government (Gay 2005).
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