Health in all policies, national level. Volume 1

Health in all policies, national level. Volume 1
Cars, bikes and the transport budget

Health in all policies basically equates to all policies reflecting some aims of getting a healthier population, not using the "health (care) budget to do better things in other policy domains, though that would be nice (see reference at bottom – bike lanes v cancer drugs )

How to effect health in all policies at national level. Here's the first in a series of blogs on the matter. This time transport.

Cycling is good for us and the planet. Etc. I know you know this.
have a look at this from Glasgow – learning over last 10 years around active travel. Not much change delivered by individual behaviour change. More by infrastructure + committed leadership
Seems v. similar?
http://www.gcph.co.uk/publications/702_active_travel_in_glasgow_what_we_ve_learned_so_far

We drive too much and don't cycle or walk enough. This causes all manner of problems.

Why is this.

The money
I was told recently that refurbishing 10 miles of the M62 costs roughly the same as the whole of the active travel budget for DFT for England
is it any surprise we never build many miles of cycle lane etc – there's no money by the time DfT and Highways England have built all those 7 lane smart motorways.

There are rather a lot of 10m stretches of motorway being refurbished.

Then think about ROI (and I know you know this has to be used advisedly)
I'd lay odds that the ROI for building roads doesn't include the health disbenefits of air pollution (on account of extra cars) and disbenetifs of deterred cycling (cars again, nobody likes cycling on busy roads).
The ROI for bike lanes does include health benefits of cycling, it's an obvious link. Obviously.

I'm told the ROI for building roads is tiny compared to the ROI of building bike lanes. Given the above paragraph, if one were to build health consequences into the ROI for road building the difference would be even greater, in favour of bike lanes.

Then think that if I invest £100m in building roads, and the ROI is say 2:1 that buys £100m of net economic gain if I'm sat in HM Treasury. If there's £8m left and the ROI for bike lanes is 4:1 that buys my £16m of net economic gain if I'm in the treasury.

In a world of cold hard cash, despite bike lanes being better value, roads win, they net more cash.

The standard economic model thus seems to incentivise road building. This is bad for our health in many ways.

And locally.
Not many people would want to cycle on trunk roads and motorways, so what does the above matter. Firstly once we've built all those trunk road extensions there's no cash left for local authority run schemes. Secondly I'd lay odds that the dft model operating as described above is also used to distribute resource to local schemes.

Thus roads (and cars) are at the top of the priority list for local transport resource also.

So – the job is influencing DfT (and HMT?) re their standard approach to economic modelling around transport system – that basically drives the investment plan for transport budget, that in turn sets in place what "health" can be achieved through the transport budget.

Healthier folk cycling / walking / getting bus thus not driving is not part of the economic model, but building more roads (that creates jobs etc and – apparently – eases congestion) IS the mission critical function.

this means that when the transport budget divvied up – road is king, thus car is king, thus active travel budget is the scraps that fall of the edge etc

So if we really want to effect a modal shift we may need to invest. The only place investment may come is from the current resource envelope.
Thus difficult choices are needed. Vested interests and policy inertia may need to be upset.

Who argues against
Even if HMT & DFT are neutral or receptive to this theres would be fierce lobbying by powerful vested interests – oil and car industry stand to loose from significant shift from car to non car
have a look at the tactics of other industries that may sell us stuff that's bad for us, and we may get an insight into possible tactics.

Policy inertia from moving one form of investment to another may also be a factor.

I know theres a not insubstantial belief gap also … its not all about the numbers etc… but…

Who's going to push this
Who is going to advocate for Health in All Policies nationally. HMT or DfT probably don't have an interest, DH are interested in the solvency of the hospital, and honestly I'm not sure they've an interest in anything wider.

Hopefully someone, somewhere can be a better advocate for health in all policies with national govt.

Next up – planning framework, welfare reform, licencing – gambling & booze, maybe economic growth / inclusive growth

Refs
Bike lanes and parks v cancer drugs and cath labs. The value of different forms of investment
https://gregfellpublichealth.wordpress.com/2016/10/01/parks-and-bike-lanes-and-healthy-folk-on-the-value-of-different-forms-of-investment/

Ten thoughts on reframing transport policy
See point 7
https://gregfellpublichealth.wordpress.com/2016/11/02/ten-thoughts-on-reframing-transport-policy-as-a-health-investment/

ACO indicator metrics volume 4

 
Ding ding, seconds out….. round 4

I've had a few goes at the question of what should our outcome framework look like for our ACP, ACS, ACxxxx.
See the references.

Here's next instalment. In short note format.

1)
There’s not single pithy answer.
I know you know that
The task = probably impossible…. But there you go
 
 
2)
Indicator sets should be directly related to the programmes, which should be directly related to the scope (ie what budget lines? / services) and mission.
Im not sure we’ve got the mission 100% straight yet, the programmes are mostly there in terms of BAU, maybe not the transformational bit.
 

 
3)
The thorny question of whether the setting of a “new” metric framework will change behaviour – either boardroom or shop floor….
Im not convinced on that. I hope I'm wrong
Unless we genuinely live it and make a focus on (say for example) delivery of smoking very brief advice and intervention as importance as 4hr wait
 
 
4)
There are existing frameworks. Don't reinvent them
NHSOF
ASCOF
PHOF
 
The domains in those have some overlap

 
 
4a)
Other stuff that’s about at the moment
ONS Understanding local needs for wellbeing
https://whatworkswellbeing.org/understanding-local-needs-for-wellbeing-data/
These are pretty handy – widerthan health care, oviously
 
 
CHE – inequalities indicators
NHS equity indicators – Centre for Health Economics
https://www.york.ac.uk/che/research/equity/monitoring/

Excellent stuff
 
 
Marmot indicators
Marmot profile 
https://fingertips.phe.org.uk/profile-group/marmot
Re inequalities – Marmot indicators re H Ineq – cant recommend better
These are mainly outcome indicators and only collected once every 2y or so
So may not do for performance framework

Similarly PHE Wider Determinants tool
https://fingertips.phe.org.uk/profile/wider-determinants

 
 
 
You may have a HWBB Outcome Framework

 
The CCG Assurance framework and maybe your local authority performance framework
The latter will be home to a host of indicators on what some folk call wider determinants

 
 
5)
Perhaps a space to think of use of indicators in terms of setting culture… and the sort of direction we want to fly in??

  • Outcome – making outcome focused (as opposed to service throughput focused….. even for the service throughput indicators… what pop level outcome do they contribute
  • Secondary to primary shift– do the indicators you select help in that regard – for eg indicators be that would be suggestive of transformation ie 4hr wait for GP appointment, % of the NHS budget spent in primary care (demand management). 
  • Moving away from indicators that are “core NHS target and hospital centric”….and thus danger that we then default to continuing to deliver these and not transforming + outcome measures + primary care / community care.
  • The ongoing difficulty o the measurable vs the important.
  • Where does NHSE / I and CQC expectaitons fit.
  • Levels of granularity, clinical input needed to address.
  • Get the clinical indicators right – eg don't overlook the excellent stuff in the national clinical audits and similar?
  • Something in the framework needs to focus us on the “A” bit of ACS rather than just the “C” bit.
  • There's also something about the “P” or "S" bit is that the partnership or system needs to collectively work together for the outcomes at pop level. Nobody wants to be accountable for population outcomes not within the sphere of individual services, or sets of services.

6)
Any other business, as I can't fit it anywhere else.
Some thoughts on financial process measures Indicators
·         %of budget envelope that is subject to outcome based payment
·         % of physician salary at risk for qual outcomes
·         % of contracts that are subject to up and down side risk sharing
·         % of budget that is capitation
·         % of budget that is spent on hospital vs out of hospital.
·         £ / capita on district nursing.
·         What is the trajectory of GP v hospital v mental health expenditure.
 
 
Efficiency measures
·         OP procedure rate (efficiency)
·         Day case rate (efficiency) – aim on cutting down on bed use. We may already fare well in this respect.
·         % of visits (OP and GP) conducted by phone as opposed to face to face
·         % of referrals that are e consultations.
 
Cost measures –
·         cost / patient month – needs more sophisticated data than we currently have, and needs to be done in segmented pops 
 
 

 References
Volume 1- outcome measures for ACO
https://gregfellpublichealth.wordpress.com/2016/11/23/outcome-measures-for-aco/

Volume 2 – What outcome measure for an Accountable Care System – how will we know its working
https://gregfellpublichealth.wordpress.com/2017/03/31/what-outcome-measure-for-an-accountable-care-system-how-will-we-know-its-working/
 
Volume 3- Outcomes at population level in the context of accountable care
https://gregfellpublichealth.wordpress.com/2017/07/03/outcomes-at-population-level-in-the-context-of-accountable-care/

 Other
ACO Metrics 
http://www.yhahsn.org.uk/wp-content/uploads/2016/04/5.-GF-ACO-Performance-Metrics.pdf

The framework used by CMS – Quality indicators in the USA ACO programme http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ sharedsavingsprogram/Quality_Measures_Standards.html

 

What proportion of health outcomes are attributable to health care

how much does health care contribute to health 

Debate rages. 

Continually. 

I don’t know the answer.

Lots of different agendas contribute to health outcomes, we know this. Dalghren and Whitehead highlted it nearly 30 years ago, maybe more. The basics haven’t changed.

The relative contribution of different determinants

Debate continues to rage on the extent to which health care contributes to health outcomes. 
The Health Foundation have been in thus space recently: 

http://www.health.org.uk/blog/infographic-what-makes-us-healthy

 

The Kings Fund are also there

https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/inequalities-in-life-expectancy-kings-fund-aug15.pdf

The best I’ve ever seen is the work done by RWJF, summarised here:
 

Does it matter. Maybe, maybe not
My previous view was as follows:

  • Without doing the analysis it is impossible to give  quantified answer
  • I think trying to nail a quantified number is likely impossible and we’d spend more time arguing the question
  • Depends on timeframe, local context, what outcome measiure, what coverage of interventions that make a difference to outcomes of interest, a host of other factors
  • Im rarely absolutist about it
  • Health care is one of the determinants of health
  • Heath is one of the determinants of well being

 



Why it DOES matter…..

 

 There’s a great pic in circulation on twitter underscoring the notion that BOTH supportive policy environments AND social factors beyond health care are considerably more important than health care interventions delivered one person at a time
 

There’s a key weakness in this (excellent) picture in that it doesn’t represent the unequal distribution of the those determinants of health, or the determinants of the determinants (current economic model, underling ideology). 

That would be a tricky diagram indeed, but may significantly steepen the hill for some and make it shallower for others, and determine how strongly individuals needed to push etc.

This picture and this picture alone underscores the point about the need to focus on communities, populations and toxic environments and give this primacy over services that help individuals

And doesn’t it depend how steep the hill, how big the ball, and how strong the push? That all varies over time/case. ‘Very often’ not always?

 
I’m firmly of the view that the allocative split of resource within the health care system is not in keeping with our stated goal – healthier folk etc. 

The implication is an investment in social care, mental health and primary care, at the expense of other investments.

If we want more health, we may need to shift our profile of investments away from health care towards other social investments that are more closely related to health outcomes.

As Richard Smith points out we may be at (in some cases well over) the flat of the curve (of diminishing marginal return)
Quoting directly……

We know, however, that healthcare has only a small effect on length of life and that its benefit is on quality of life. But attempts at aggregating health benefit show a similar graph to that for life expectancy—at a fairly low point further expenditure produces little benefit. What is sure is that the extra value produced by further expenditure becomes smaller and smaller, meaning that hard-hearted economists (and even rational soft-hearted ones) would spend the money on something else—housing, environment, education, the arts—where extra spending would produce unquestionable and easily measured benefit.

In fact, in many places increased spending on health is “crowding out” expenditure on other areas. Don Berwick, a paediatrician who recently ran for governor in Massachusetts, shared a graph at the World Innovation Summit for Health in Doha that showed that state expenditure on health had increased considerably while expenditure on everything else had gone down.

Worse than flat of the curve healthcare is the point where more spending means worse outcomes. Enthoven thought that he saw this in areas like coronary bypass surgery where people may be given operations that they don’t need with some of them being harmed by the surgery. This is the phenomenon of “supply led demand:” once you have many (indeed, too many) cardiac surgeons they will not be idle, they will operate on people where the benefit of the operation does not outweigh the inherent risk..”

Don Berwick says pretty much the same when he was interviewed by Simon Stevens (pre beard)





If we want to control spiralling health care costs, we must invest for health

The path to healthy life expectancy is a complex one, but health care doesn’t feature that strongly in it, certainly not beyond primary care.


As I have made the case in many previous blogs the problems in health care are accountable to unrealistic expectations, high cost low value technology and disease incidence (and not the ageing population). Turn disease incidence on its head, you have “health”

If we want better healthy life expectancy, we can either choose to invest our resources in health care or things that might lead to health.

Government have stripped local government cupboard bare. We are 7 years into a 4 year austerity programme. Of course it’s the result of a policy choice. The requirement of governments to make those choices must be respected, but there are consequences of those choices we may come to see – note faltering life expectancy worries.
the solution‪ to the conundrum depends whether you want more health or more healthcare. ‬

Of course this is difficult, of course we always need more CT scanners, and diagnostic capacity. These priorities will always be present. If we only ever address the (unending) demands of the present we won’t make the right long term investments.

‪If we want health, we should invest in things that might best lead to health. In the era of boundaryless accountable care, that means using “health” money to invest in non “health” investments.‬
My own solutions

  • I’d invest in primary care and social care (best chance of addressing here and now challenges) & primary schools (short hand for best start in life and best life chances). Particularly, I’d focus my investment according to the principle of proportionate universalism.
  • I’d end austerity – it is doing harm, directly and indirectly through stripping out services that help folk. 
  • And ensure decent & affordable housing standards
  • One last thought – community building. There are two things that really worry me, one is an outbreak that goes wrong – can go wrong quickly and in a big way; the second is our perilous state of community based approaches, often focused on strong community anchor organisations. This is a trickier problem to solve than the outbreak issue. I suspect Roz Davies knows how.

That’d do for week 1, most of the Ottawa Charter picked up. Maybe in week two I’d look at the economic determinants of health and the determinants of the determinants.

Just saying…….

References

Don Berwick https://m.youtube.com/watch?v=mumF_glVi8

Richard Smith: “Flat of the curve” healthcare http://blogs.bmj.com/bmj/2015/03/23/richard-smith-flat-of-the-curve-healthcare/

Richard Smith: How to stop the medical arms race? http://blogs.bmj.com/bmj/2011/01/13/richard-smith-how-to-stop-the-medical-arms-race/

 

The role of Directors of Public Health in STP. 5 thoughts.

This is niche, and mainly for DPH types. 
Been thinking a lot re the q of what is the role of a DPH in the STP land.
here are some thoughts – as always thanks to others who helped develop these thoughts.

It’s not quite finished yet, and I’d welcome views.

I’ll be clear this isn’t about my local STP, it’s just a set of observations more generally.

1  There seem to be 4 main roles for PH types in STP / ACS etc

  • Health improvement across the board. Strategically and operationally. The left shift.
  • input to individual workstreams – planned care, urgent care etc. Remember why however….to enable the leftward shift.
  • Link to LA – operational, corporate (sometimes this is also done by DASS, Ch Ex, other)
  • Balancing the local v regional agenda


2. How this is operationalised will look different in each area

Different levels of intervention are ok, opportunities may look different with different STP.

Reflects history, dominant agendas

Different shapes are needed to address the different approaches across our areas.

A one size fits all is unlikely to work – must be tailored.

 

3. Attention is continually needed to ensure weight to local place based answers is not lost

Most accept that 70-80% of the business end of the mission of STP is rooted in place. Thus 70-80% of the attention should be focused there.

If the role of DPH is to be focused on creation of health opportunities (reflecting on fact that c20-30% of opportunities for health gain are within the NHS) and of that 30% of health gain from NHS most of that is locally driven (mostly primary care, mental health?).

Thus it is important it not neglect the local in the balance of time and resource and be mindful we have multiple masters, most of whom inhabit the town hall and will want us to be doing stuff in our own places and focused on things a long way from the NHS.

I’m also mindful that our capacity has been stripped bare over the last 5 or so years through successive cuts to the PH grant, and our (correct imo) attempt to protect frontline services funded through the grant. I reckon I’ve got half the staff I had 5 years ago.

I’m not necessarily whining about that, it’s a statement of fact.

4. We need to be mindful of danger of constant regression back to the 1) hospital model, 2) structural solutions to problems

Often there’s an additional role around ensuring that transformation beyond the workstreams is also on the agenda – culture, value, payment reform, regulatory, the “left shift”, and a focus on population outcomes not service use metrics. 

This will vary from place to place.

all three of the gaps are equally important – not just the money gap.
There are as yet unanswered questions. For eg – What does “addressing health inequalities” mean at STP level. We are trying to answer it in ours. Happy to share the detail
5.  What ARE the high impact actions for STPs to consider? Get them in the discussion

All to consider. My list is as follows

  • Primary care – significant shift of resource base 
  • Mental health and LD parity. Not just the % of £ ( though that would help) but much greater mental health competency amongst generalist workforce and hospital systems
  • PHE menu of preventive stuff – helpful, but also must move towards policy (away from services). Smoking remains, by a margin, the most important.
  • Principle around £ distribution and need. Disproportionate investment for disproportionate need. Unequal offer for unequal need. This is the difference between equal and equitable.
  • Attending to the prevention belief gap might be by far the most important issue,
  • and moving away from the narrative that ROI is all. If we applied this mantra to the current £114bn investment in the NHS we might not fund half the stuff we do!
  •  workforce development  – supporting staff to work in more holistic, reflective, solution-focused & person centred  ways. Also boundary spanning.

Only my thoughts. What are yours. 

Others later had some other additions to this list

start with real (big) needs of ppl and populations!

Creating community alignment on interventions for prevention and wellness . Eg Haltons links with rugby league clubs around their moonshot 

If the battle has been won on the value of community building the next Q is will the system colonise or genuinely share power & resource?

matching effective scale to interventions (one of the reason I am so keen on the primary care home

working to define and legitimize core purpose in terms of health / inequalities i.e. outcomes that matter to citizens
 

Embedding the notion of social value in leisure contracts. 10 thoughts.

Thanks to those that helped draft and with ideas – Rob Copeland, Alex Shilcoff, Ollie Hart, Piers Simney, Kate Ardern, Emma Edwards

Probably others who helped and I’ve forgotten.

Everyone is doing “social value” now in commissioning. This is great, it’s a bit of a slippery concept however. I got asked for views on this a few weeks ago. 
In the spirit of not reinventing wheels here were my thoughts on what that might look like in measurability & indicator terms. I’ve tried to be practical rather than eretheral.
 

 

1)

Target audiences -4 obvious high priority target groups for me.

Those that don’t sweat at all vs those that are currently quite sweaty (getting them to sweat more, or market provider shifting)

Pre frail – im still not forgetting about potential of PA to delay frailty…. Theres cashable savings for health and social care here

Families – whole family approach.

the need for continued disproportionate focus on the inequalities agenda – most deprived populations, those with disability, those with mental illness or physical underlying conditions.

 
2)

Ethos

‘Leisure centres should be a vehicle for community development’ aswell as facility providers. How this is enacted, in contractual terms, might be difficult. Evidence to support that – to support a contractual discussion – will be difficult…. But easy to see how it could be quite a game changer

Social return scheme – something which rewards people / volunteers / community members for their contributions via social prescribing or something. Could be done through SIV type ife cards or something ?

Duty of linking into range of community activities outside the walls of the LC rather than remorselessly pursuing throughput

Staff that reflect the makeup of their community

Wider wellness offer as PART of the programme IN the centre, not “something that happens elsewhere”

Some way of tie up with social prescribing and way in which we approach neighbourhoods…. So leisure becomes part of social fabric

Creation of similar feel and space to private provision (on the cheap obviously)

sense of community engagement in the look, shape and feel and execution of new / reshaping of existing services…..”we are all Move More”

Work with likes of Timebuilders/ volcom orgs to do volunteer and community development but could take astronger approach further down the line – develop the people, skills and assets.

 
3)

Data and intelligence

Standard measure of physical activity to be included in all contracts. 

Shared data on all aspects of participation and access to facility. Need to get much better at understanding who centres are engaging. This data should be in a format that is sharable with the commissioner. If there’s public funding in it, then the data should be available to improve services, reach and outcomes.

Any provider app to include tracking tech from move more app to enhance coverage. 

 

 
4)

Integration between sectors and wider fit

Principle if refurb to capital or other similar project we consider as a matter of routine the integration of “health” and “leisure” – ie mainstreaming the NCSEM precedent…. So running nhs services from leisure facilities where space allows

Maybe library link up, other council & other services run from same space (in Sheffield this is aka the ZEST type model)

linking into the review of the weight management services and other services the local authority or NHS operates etc

make sure we capitalise on huge opportunity for marketing and social prescribing and linking things up etc. eg front end of ponds forge basically sells various sizes of speedos but it’s a huge space which could be used as a health and fitness library / information zone. 

link in with the social prescribing/ community groups…….we need leisure providers to be part of the network that cares about how the city networks together

incentivise getting new kit for parks in return to doing good stuff? Neighbours or communities cutting park grass and maintaining and then spending money saved on more kit or events or stuff.

 

 

5)

On site stuff such as Food

Vending to be at least 80% healthy choices and for this to be monitored with fines etc

Same standards as per schools re nutritional content of stuff sold

Sugary drinks in vending machines – taxed, or not there at all

LGA healthy food procurement guide here.http://www.local.gov.uk/sites/default/files/documents/healthier-food-procuremen-ade.pdf

 

 

5)

Post within the centre to be embedded in the broader cities approach and programme and integration of health, leisure and social care. Post should be funded for lifetime of contract. Need some sustainability. 

 
6)

Staff and environment

Reception staff/front of house guide people in/MECC potential – full idea about products and able to engage

Staff to be actually be good at behaviour change – demonstrate competencies and training of staff

Disability friendly, dementia friendly, mental health friendly environment/staff – there are accreditation schemes

Family friendly stuff (making it easy for parents to exercise – not just hold the baby in the water….mum/baby classes, crèche)

Something re training and competency of staff to appropriately support those with disabiltu and medical conditions (not just a training thing, but a cultural thing)

Linking in properly with active travel – bike racks galore?? Already have lockers etc

 

 

 

7)

Service offer

If they do exercise on referral – do it proper – systems and evaluation

Other clinical services within a gym setting

Rehab services – stroke/cardiac/pulmonary – on site

Training their staff to take advantage of secondary prevention potential – a fit for purpose workforce, with golden handcuffs so you don’t train them up and they leave ya

Focused programmes and provision for those with pre existing medical conditions …. Place and provision that’s SEEN as for that group

Ditto disability??

 

8)

Outcomes considerations – real pop level outcomes

A leisure provider would happily be accountable for good user experience in members. What about being accountable for population inactivity. 

Obviously this is the key point about service users vs population, and also control of all bits of the causal chain that get to a more active population.

There’s a side discussion – but an important one – here about efficiency, and the cheapest way to achieve a goal. The service provider perspective, the Commissioner perspective and the Population perspective are all different. 
 
9)

Other (I cant quite fit anywhere)

Flexible memberships, and having viable pay and play options rather than totally pursuing DDs monthly members

Use of digital for follow up/customer interaction – simple to more complex

Marketing using people like me images – fatties; oaps; pwd – get beyond the body beautiful brigade

Daily Mile in school holidays…

 
10)

finally who else has done what 

E Riding been doing some excellent work

http://www.local.gov.uk/sites/default/files/documents/public-health-transformat-f75.pdf

 

Ditto Wigan – some fab stuff there
Searchable case studies here

http://www.local.gov.uk/case-studies?keys=Sport&from=&to=&sort_by=created&sort_order=DESC&page=3

 

 

Outcomes at population level in the context of accountable care.

We’re all setting up ACOs, ACPs, ACSs and similar. Outcome frameworks are, again, on the cards. Outcome based commissioning is, again, on the cards. This time it will (I hope) be a ‘different’ kind of “commissioning”.
I’ve written a lot on outcome based commissioning and on outcome frameworks for an ACO, mostly about specific metrics

See the references. I won’t go through those again.

This will be the last, I hope, time I commit thoughts to paper. I’ll cover some thoughts on population level outcomes across multiple organisations.

Here are 4 quick thoughts to (hopefully) finalise my thoughts on this one.
1)

Accountable to who, for what, over what timeframe

An important consideration in developing a framework.

In this ACS thing, there’s the obvious danger this is all about the “C” and “S” in ACS, but nothing about the “A” (apart from assurance to boards, who remain sovereign). 

Key to “A” is that the choice of outcomes / measures need to be meaningful and reflective of / sensitive to the intended transformation / system changes.

And also something about the “S” bit is that the partnership needs to collectively work together for the outcomes at population level.

There’s also a fundamental point about single accountability for the health of a population. Tricky across a range of outcomes (or more likely process measures that serve as proxy outcomes) across many sovereign organisations.

 
2)

Service or population outcomes. What different stakeholders are accountable for. 

Those that provide and often commission services are mostly (not always) happy to be ‘accountable’ for ‘outcomes’ in those that use their services. That leads to consideration of what ARE the outcomes that it is reasonable to expect of the investment of current set of services, individually, vs a whole system.

As we commission services – it is unreasonable to expect service xxxx to be responsible for the system level outcomes. Maybe.

There is a tricky mismatch between the population outcomes a system will be judged by and what ACTUALLY happens in the services in that system.  

But as commissioners (currently) commission services from providers and providers (currently) provide those services, whats the incentive for a provider of xxxx services to take on responsibility for things that its not responsible for – ie broad range of health outcomes.

Few want to be accountable for population outcomes – i.e. being responsible for outcomes in service users and those that don’t use services. Or where “outcomes” cut across many different services and organisations, and are part of a complex causal chain, and tricky proximal and distal issues.

Anyone fancy being accountable for healthy life expectancy, and the 25 year gap between best and worst? ……… no, just me then. It’s a lonely club.
Two examples 

Outcomes considerations for leisure providers vs physical activity 

Consider this, our lack of population and individual sweatiness leads to poor outcomes. Leisure providers have a big role here. Consider a leisure provider would happily be accountable for good user experience in members. 

What about being accountable for population inactivity. 

Obviously this is the key point about service users vs population, and also control of all bits of the causal chain that get to a more active population.

There’s a side discussion – but an important one – here about efficiency, and the cheapest way to achieve a goal. The service provider perspective, the commissioner perspective and the population perspective are all different. This needs to be considered in indicator selection.

Then apply the same mentality in say cancer. 

Is the outcome we want cancer mortality, cancer 5yr survival, or some process measure – say the % of diagnosed cases commencing treatment in 62 days. 

All matter, some matter more. 

No provider is responsible for cancer mortality, it is the metric that matters most.


3)
The tricky business of the gravitational pull of the current must do framework

How many indicators can we cope with. A limited number focuses the mind. 

There’s the obvious danger that in an ACS, accountability is to statutory boards then the ACS would never escape the gravitational pull of statutory targets 4hr waits, 18 week, 2 week, DTOC etc etc since that’s what trust boards (rightly) obsess about. 

Thus the risk here being that the ACP just becomes a vehicle for delivering that.

And if we must be accountable for the existing national must do framework (which is fair enough given parliament expectations of the NHS), then that’s a lot of indicators that will give little or no space to population outcomes and inertia will continue in the current direction.

The crunch is whether our indicators focusing minds on the strategic long term objectives and shifts, or are they focusing minds on status quo system shape wise. (For eg secondary to primary shift, locus of primary care and place, moving away from core targets that are hospital centric).

Of course, pragmatically and innthe relay world we need to ensure  we’ve the right mix of indicators around 

  • Must do indicators, some of which are plain perverse and drive the wrong sort of system, but are linked to parliament expectation of NHS
  • Sustaining the performance of the system
  • Transforming – what would the indicators be that would be suggestive of transformation. Two specific off the cuff examples – 4hr wait for GP appointment, % of the NHS budget spent in primary care (demand management). 
  • Outcomes – individual level or population. 

 

4)

Technical considerations 

Mainon & Davies provide an excellent commentary on some of the considerations re outcome selection (admittedly related to payment). 

My take on those points is below.

What is it that you want your indicator to focus on – Quality / performance (against what standard) / efficiency / equity / volume
Performance standards – Absolute. Thresholds. Relative to peers. rolling programme of performance, retirement of indicators that have maxed out. half life targets. trajectories vs threshold

What are the Units of assessment

Process v outcome indicators. Timelag between process and outcome may be an issue

Complexity. Is it possible to attribute outcome to the input of the individual, a service, or are there other factors at stake.

Financial rewards linked to targets – Too small – not strong enough incentive. Too large – too risky, unpredictable results. Gaming. Tunnel vision on some areas / adverse selection / erosion of professional and ethical basis.

Can the system be gamed – overtreating / cream skimming? How easily? How can this be verified. Does the compensation system reward efficiency at the expense of quality. A constant trade off.

Investment for monitoring and verification – has costs. Other non non quantifiable aspects can also have an impact on behaviour – promotion, prestige, social context.

Methods of risk adjustment – So as not to penalise unfairly clinicians with more complex patients – poor, multiple comorbidities, complex health and social issues, BME.

Adequate sample for performance measure – No of patients included in data sample – random variability will be > in a small pool & risk of year on year variation, random effects

Patients with multiple providers – how does this look in indicator terms.  Must be more nuanced that aggregating up individual level performance data – great performance in some areas might mask unacceptable in others
Literacy and health literacy – impact on outcome indicators can be considerable.
Propensity to seek health care varies between populations. An impact on performance

The effort needed to achieve clin meaningful change in some pt groups is considerably greater than others.
Data availability – Directly addressing the issue of the measurable with routine data vs the important stuff that may not be so readily measurable with easily available data.

Development work on metrics and leading indicators that will be tangible 

Levels of granularity at which indicator data is available.

Get the clinical indicators right – eg from national clinical audits and similar? Always more nuanced than administrative data.
Where does CQC & regulator fit fits into this.

 

 5) lastly some specifics

 The assiduous will note I’ve avoided specifics….

There’s one reason, you’ve got to think about it, or if you aren’t prepared to think about it trust the view of someone else who has. I have. The National Academy of Medicine also have. They by are cleverer than me

Their suggestions for a streamlined set of 15 standardized measures can be found here

https://nam.edu/programs/value-science-driven-health-care/vital-signs-3/


 References

 I’ve had a few go’s at outcome measures for ACO over last 6m or so

Outcome Measures – https://gregfellpublichealth.wordpress.com/2016/11/23/outcome-measures-for-aco/

What outcome measure for an Accountable Care System – how will we know its working https://gregfellpublichealth.wordpress.com/2017/03/31/what-outcome-measure-for-an-accountable-care-system-how-will-we-know-its-working/

Outcomes based commissioning – https://gregfellpublichealth.wordpress.com/2016/09/10/on-being-an-outcome-based/ ……if you’re properly commissioning for outcomes, esp pop level, you’d commission something different. Very different.

Value in pathways versus value in populations – Don’t forget population health in your efforts to improve “efficiency”. Its important but remarkably easy to forget – https://gregfellpublichealth.wordpress.com/2016/02/21/value-in-pathways-versus-value-in-populations-dont-forget-population-health-in-your-efforts-to-improve-efficiency-its-important-but-remarkably-easy-to-forget/……If you want to improve stroke outcomes, prevention and management of population risk factors is the best bet.

Mainon & Davies – Payment for Performance. BMJ. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2234517/

The role of multi agency boards in complex environments 

Like all areas in the universe, we are busy working out what “Accountable Care” actually means. 

The ACP “Board” like other “grand boards” (inc HWBB) will have responsibility of “transforming stuff” in a context where individual organisations are still sovereign. 

In various guises I've been giving a bit of thought to big “partnership boards” and our ask of them. Immediate thoughts below. I don't profess to know “the answer” just have a few thoughts. It's clear there's no neat pithy answer so has to be built

1 What do we want our ACP Board to "do" 

We may want the ACP Board to be many things, but it is definitely not run the organisations within a partnership operationally. 

‘Transform things’, is the general answer to the q of what we want partnership boards to do. 

“Transforming” is not "improving things", it is "fundamentally redefining the job and the mission, then improving things". 

A counter view to this is to not accept that transformation is ever “done”, or a completed project. By itself, transformation is necessary, but as means not end. Probably what we want the ACP Board to do is “oversee delivery of an equitably healthy population” or something like that, with transformation as a critical component.

Another counter view is that we should expect such boards to improve business as usual in a way that can't be achieved by individual organisations working along. In general we do BAU quite well in our various silos. However this isn’t universally agreed on. There are some areas we may NOT to BAU well, and we may do BAU well in the interests of our silo or organisation but not in the best interests of the population or city as a whole. Maybe it depends on how we define silos. there are some tricky business and sticky points within BAU. But as well there ARE some things we want to make a difference in. This should be the space of the ACP board. The ACP may usefully draw out what outcomes each org is trying to deliver in BAU and how this relates to overall outcome AND overall agreed system principles. Someone suggested recently an audit of what the givens, red lines and statutory responsibilities are – agree 100%.

Some thoughts on what we might want such a board to do in a transforming things context:

* Create and hold us to common incentive structure and similar.

* Develop the narrative around a common mission – what is it that we are supposed to be accountable for, to whom, at what level.

* Create common culture…. I accept I need to define better what I mean here, but it’s a dealbreaker. Something around all orgs see the world in same way, see mission in same way, act in a way consistent with the mission.

* Agree common £ strategy. HOW we use the ££ we have, investments and disinvestments. 

* Commission OD – As system, not orgs focused on the mission

* common principles – as per stuff already done. I’d also add something along lines of 

* Each org within the system as a whole needs to be responsible and accountable for their aspect of the system performance.

* Agreed that "it's a system" shouldn't be a reason to mask poor performance of one org within the system.

* Each org needs to be responsible for its own data and performance. And share this transparently.

* And maybe something on lines of  purchasing power, economic anchor institution local $ and local economy
there are some clues from available literature on areas it may be good that the ACP focuses in a transformation context.

for example P51 of this WHO document on multi sector governance is very useful (a bit obvious, but useful starting framework http://www.euro.who.int/__data/assets/pdf_file/0020/235712/e96954.pdf

  

The Kings Fund also publish helpfully in this space (see below)

What teeth do partnership boards have.

There doesn’t seem to be a collected body of wisdom or research on how we give those boards actual teeth to get change done. Of course “grand partnership boards” are often suggested as toothless talking shops and not as “something that controls the agenda” or “shapes it”. 

As a bare minimum we should expect something around positive influence over a complex system in a complex environment.

Many would say that all multi organisation “boards” wont / cant have teeth – unless they REALLY control the cash. Do they need "teeth". If it doesn't have "teeth" most then say it's a talking shop – the classic name for grand partnership boards. 

Are "teeth" actually control of the resources, or control or influence over how the system operates, the rules, the mission. 

So role of such boards is to 1) set common rule structure 2) agree common investment programme 3) agree common narrative and shared principles, and ensure all orgs have same interpretation of the mission and are able to hold each other to account for it.

Some might suggest that realistically – meaningful control of resources by ACP board will only be granted by central government – voluntary arrangements can work but will always be vulnerable to one org taking their ball home. So without this the best teeth we can hope for are a culture of mutual dependency, cooperation and holding to account, centred on a collectively owned vision. In this context the Board IS the teeth.

Soft influence might look like

  •  "how do the discussions at the board influence the strategy, give all partners a better collective and system understanding of an area, and understand the points of influence and inflection from the lens of all of the different constituent parts”
  • There is something around different partners holding each other to account (whatever that means) in public and private. So for example – when was the last time organisation A held B to account for xxxx or vice versa for yyyy. How does this work across multiple organisations
  • Maybe the acid test is the question of when was the last time a conversation at HWBB actually influenced the resource commitment profile, strategy or policy or investment / disinvestment of one or more of the constituent orgs… what was the line of sight.
  • Single unifying mission/goal/vision is critical from my point of view – and not sure how close we are to agreeing this. Suspect the world looks very different from organisation xxx and yyy points of view – and funding/ constitutional arrangements obviously contribute to the mission,

What does an 'effective Board' look like

A few have picked me up on the effectiveness of HWBB of late….along lines of ineffective talking shops etc. Often folk say these things are talking shops…. to which my response is talk is is ok if the alternative is not talk, as long as we're talking about the right stuff.
 
My standard response is to ask the questioner the question back – "what does 'effective' looks like"
There is the ever present challenge of getting into the gritty detail of services vs a role of multi sector boards around a broader shape agenda – exerting influence in complex environment…. it's ever harder to measure 'effective' in that space.
 
I have an ever present fear that if we delve into detailed focus on "stuff" we may 1) never come out of the rabbit hole and 2) inevitably get sucked into the gravitational pull of health care services, and the detail of one sector not a multitude of sectors – health vs health care etc.
 
On effectiveness of multi sector boards, and making them effective
Maybe something to be said about Ideas sponsorship, what are the high level, and details level ideas that we develop.

Right mix of
programme oversight
Specific detail on services and projects
Strategy development
Strategy implement
Performance review

 
 
 

2 People and behaviour vs contract and organisational governance

The Kings Fund recently published a synthesis of learning on leading across organisations. It's excellent

Leading across the health and care system | The King's Fund

https://www.kingsfund.org.uk/publications/leading-across-health-and-care-system

Key messages

The paper details five factors that facilitate system leadership:

* develop a shared vision and purpose: this requires a shift from a reactive problem-solving mindset to creating a positive vision of the future built around the needs of local populations

* have frequent personal contact: face-to-face meetings enable leaders to build rapport and understanding and to appreciate and acknowledge each other’s problems and challenges

* surface and resolve conflicts: this depends on leaders’ ability to recognise conflicts, work them through and create the conditions in which it is safe to challenge

* behave altruistically towards each other: to work together in a collaborative way, leaders need to move away from a traditionally competitive style and to focus on the bigger picture

* commit to working together for the longer term: leaders need to invest time and energy in forming effective long-term relationships and to resist the pressure to focus on the immediate, transactional issues.

In a relatively short number of sides, in simple clear language, this sets out the key elements of "partnership" that a thousand pages of governance guff and legalese contracts will never get close to.'

There is nothing new in this, however, we all know that it always boils down to people and not structures; a common sense of mission; shared principles and wider than individual organisational self interest. This document reinforces and plays well into the people not structures, language and narrative type of discourse rather than complex discussions about contracts and organisations. 

Of course, shifting the culture, powerbase (and resource base) from one part to another may require more than fancy language, but it does need to be written down and agreed – but if its not written down it wont happen etc

As ever, being clear about the mission and problem we are trying to solve is something I come back to time and time again. We obviously need to continually reflect on WHAT we are accountable for, and to WHO, and at what level.

I feel we often under-invest in these kind of discussions. Too often people develop visions outside boards for presentation and agreement – we need the ACP Board to own the vision, which will come if they develop it themselves. This is not a quick job by any stretch. And involves hard conversations if it is to be meaningful.  

We must think about how to bring workforce and public/service users into such a conversation too – the former definitely need to buy into any vision too, and the latter maybe do as well (see: Wigan Deal. It's a pre requitiste. Something needs developing about getting mandate and ownership of our owners, customers, users, patients

More practically, proposed purpose early on could be:

1. What is our job, role (below may help)

2. What’s the expectation of other stakeholders (national and local)

3. What IS our mission – collective mission (again refining the below might help, as might getting our clear and unequivocal principles straight). Is the mission better health or better health care. Of course it's both, but what's the balance.

4. What big things are in flight (the usual list of  suspect programmes, can be described through BCF or similar)

5. What’s missing – the big transformative pieces – Im working on my list, but will include 

    * payment reform, 

    * overdiagnosis –wasted resource on grand scale. 

    * population systems of care for segments of pop – agnostic of service provider. 

    * primary care at scale – …. This is a dealbreaker for me.

    * focusing on disease (or event) incidence not prevalence – if we only ever manage  prevalent disease…we miss the real value opportunity – ie prevent stuff!

6. What are the things we REALLY want to change…. For me – 

    * big shift of resource away from hospital / episode centric to non hospital / population centric – measurable in ££££, 

    * redressing inquality in GP and primary care resourcing, 

    * local ownership of delivery system and democratic accountability. 

 

All of these things are easy to say.  Who does what at what level

* HWBB, ACP Board, Ch Exec, level down, etc etc 

* likely director level group of all our orgs to push it on…..

* programme office stuff….. 

Principles – some suggestions

We all agree we need a common set of shared principles. Mine are as follows

1)

I’d start with outcomes – the goal is healthy (healthier?) population, equitably distributed – everything flows from this. Single unifying mission/goal/vision is critical from my point of view – and not sure how close we are to agreeing this. 

The world looks very different from different stakeholders (not just organisations) points of view – and funding/ constitutional arrangements obviously contribute to this.

2)

Resource in the NHS should be distributed according to population need, and disproportionately distributed to reflect disproportionate need.

Resourcing should be focused on outcomes, not service activity or flow

Addresses problem of providers do not need to address need, but demand, and heath service, particularly where most of the resource is, is funded according to demand, not need.

Also addresses problem of inequity of resource allocation

3)

Neighbourhoods and primary care – defined widely and broadly – is the building block from which we should start

Investment is needed in primary care and social care. A 2% shift of resource from hospital to primary care buys 9% increase in GP resource. Or about 8-10% increase in GP consultation capacity. That can readily be linked to outcomes. 
Focus on community building and strengths based community approach.

4)

Services should be provided to meet the needs of segmented chunks of population, defined by population need and agnostic of service provider.

Shape of segments to be considered

Personally I would shape around population focused issues rather than service oriented segments
 

5)

Person centred

Person centred, goes without saying (or should) but need some careful definition and unpacking as it's not universally agreed on. Wigan Deal / Strengths based approach sort of stuff….

6)

Agreement of the principal causes of cost growth – disease incidence (under investment in prevention), over diagnosis (cultural and system driven), low value technology, multimorbid population and fail of demand management side.  It is NOT the ageing population. 

7) 

Conflict. no org will unilaterally take a decision that disadvantages another? Does this need unpacking a little more? 

How we handle scenario where the legal and financial responsibility of an individual organisation is in conflict with the system as a whole or other orgs within the partnership. 

 Addressing this in principle before the rubber hits the road will help. A lot.

8)How do we share risk and benefit

how does this risk and benefit share reflect the mission.

9) 

Something about purchasing power, economic anchor institution local $ and local economy

I'll come back to this one,



Only my random views 

You may have better ideas 

Be keen to see them



Population health, public health – what’s in a name

Joint blog by me and @andy54321

Everyone is talking “population health” these days. 

 

It’s great that the world is moving to think of populations not just individuals within a population. 

 

In the 00s when “health improvement” was in vogue, many couldn’t see the distinction between that term and “health promotion”. So “population health” could be seen as a phrase, so is “public health”, so is “population medicine”, history shows these being bandied around until one national body or another  makes a call. 

 

The inimitable Dave Buck recently asked one of us to distinguish. He suggested to us a two min view

Is the term, however, simply emperors new clothes for public health (in drag), is there a distinction between the terms. His two minute answer is here

We don’t profess to know the answer, there might not be an answer, we suggest a few reflections. 

 

 

 

Definitions 

Here’s the wikipaedia definition of population health……….’defined as”the health outcomes of a group of individuals, including the distribution of such outcomes within the group”. It is an approach to health that aims to improve the health of an entire human population.’

 

And for public health……..’the science and art of preventing disease, prolonging life and promoting human health through organized efforts and informed choices of society, organizations, public and private, communities and individuals. It is concerned with threats to health based on population health analysis’. There’s umpteen curriculum statements, training programmes and the like.

 

Similarities?

In our original off the cuff view, in a world of overlapping circles in a Venn diagram, there isn’t much overlap here. We just cant see much of a distinction between the two terms 

It’s worth saying this was from our perspective as trained and experienced public health specialists. This gives us a certain lens and the biases that go with it. Others, with different experience and training may see it differently.

Both are about “health” – which obviously isn’t just “health services”, but something broader.

Both are broadly about populations and the individuals within it.

Broadly starting point is population rather than individual.

This should affect the strategy and the mission, often we talk populations but act in an individual focused way. Tricky.

Both are inherently about allocative value – getting better outcomes out of the £ put in… but almost universally is “going upstream sort of stuff”.

Both have many domains and lenses – from intelligence, data and evidence, social / political / environmental sort of things, treatment care and support sort of things etc

If anything population health often seems to be the term increasingly preferred by clinicians and health care management types as they can distinguish this from rats and drains and “town hall public health”. 

 

 …..”there is also resistance on the part of clinicians to the brand of public health, which they still see as being associated with a 19th century agenda; the term ‘drains’ is still used by some clinical colleagues”. Gray and Ricardi 

 

In this vein. there was a move to a term of population MEDICINE a few years ago. Obviously there the locus there mnay be on health care delivery (rather than health per se?). It’s worth noting the Faculty of Public Health dropped the M word years ago and is still standing. 

 

Perhaps what population health is NOT

Furthermore, we often spot that population health is shorthand for analytics, actuarial level population segmentation and (maybe worse) the notion that high tec gizmos and gadgets will be the saviour of our problems.

We don’t agree. Population health is not (only at least) gizmos and actuarial analysis, its determinants / real pop needs / doing right things with right set of services and interventions. Actuarial type analysis, segmentation and sophisticated population level risk management is a part of that, but part of a larger whole.

An over focus on actuarial and analytics also overtly draws minds eye to the top of triangle, the most poorly, the most visible, tangible, kickable, identifiable……and notion that “we can do something here”….(Which is NOT borne out by evidence). IF we always always start here, we will never get beyond the “high risk”, the frequent flyers etc, garunteed.

This will inadvertently lead to under focus in human and system aspects, basics of population approach.

And gizmos…….Gizmos may be a part of that if someone can demonstrate they make a difference on a population scale (hint we’re talking population health thus population outcomes matter) and are worth it (cost effective) and affordable.
 

The distinction.

If there IS a distinction in the terms, is that borne of your worldview and starting point. 

 

If we have to separate them them  it may be helpful to think firstly re what is the vision? Is the vision the same? If so, then choosing a badge is less important. 

 

Secondly, it may be helpful to consider what is the approach/methodology? Now it gets interesting, there might be a case for delineating the “soft” and “hard” – the “heads up” vs. the “heads down”, the “engagement and strategic influencing” vs. “systematic methodology”, the geek vs. the leader. All are needed.

 

Are the competencies required to execute ‘population health’ and ‘public health’ are probably the same. And the curriculum to train folk – probably pretty similar. All clinicians can benefit from an understanding of the nature and extent of variation in equity of access and equality of outcome on their patch. The lessons of Geoffrey Rose are important, enduring, often forgotten and ignored at our peril. Martin Roland repeats these from time to time! You have been warned.

 

Inseparable?

So, having thought about it, we can’t really separate them.

 

There’s a need to be clear about whether we are discussing one and the same thing, or whether there truly are a number of evolving strands of classical Public Health which need to be defined further

 

Yes of course there is an element of semantics (well, lexical semantics – the analysis of word meanings and relations between them) but we’re all savvy enough to know what we’re talking about here so we can move on. 

 

But basically our Venn diagram is a rectangular box with ONE circle in it an few overlaps…..

Should there be? We don’t know 

 

 

References 

 Geoffrey Rose’s 1985 paper Sick Individuals and Sick Populations in the International Journal of Epidemiology: http://ije.oxfordjournals.org/content/14/1/32.full.pdf+html

 

Roland. Reducing emergency admissions: are we on the right track https://www.ncbi.nlm.nih.gov/pubmed/22990102 
From public health to population medicine: the contribution of public health to health care services. Muir Gray, Walter Ricciardi . doi:10.1093/eurpub/ckq091 

 

Designing healthcare for a different future. Muir Gray. Journal of the Royal Society of Medicine; 2016, Vol. 109(12) 453–458. DOI: 10.1177/0141076816679781

 

https://en.m.wikipedia.org/wiki/Population_health

https://en.m.wikipedia.org/wiki/Public_health

The anatomy of a healthy city.

 

I did a seminar last week. I was very nervous going into it, was a packed house.

slides are here online:

http://iwun.uk/seminar-anatomy-of-a-healthy-city/
This is the “full set”. I actually presented a very cut down version. 

Use and abuse these as you wish. You can have the ppt file so you can use the slides, email me.

 

The video is also here. It’s a good job I’d done my hair.

 

The questioning was gentle at times, but a bit tough at others

 

It was largely focused on environmental sort of stuff. Unsurprising given the provenance of the seminar series and audience.

 

I hope I didn’t upset the GP community by my comments about over medicalisation doing harm and waste. It’s true I was ovefcharacterising a little, but it is a serious deal this one, and very real. I do see both sides of it – in a resource constrained environment what’s a time pressed GP to do other than adopt the path of least resistance, I would. The TV programme – the doctor who doesn’t use drugs – aptly demonstrates the dilemmas.

 

I hope I didn’t upset the mental health community by picking on antidepressant prescribing to illustrate some of the above. Again, unintended upset if I did cause it. 

I agreed with (almost) all the comments and points made in questioning afterwards.

  

I left with 7 reflections. 

 

1)

I don’t have “the answer”

There probably isn’t “an answer”, it needs to be built from little bits and from big strategic bits

I certainly don’t have a button on my desk that is the ‘sort out x’ button. If I did, I’d have pressed it long ago. Neither does the chief exec, nor the leader.

The problems are devilishly difficult, often intractable, multi faceted and as history has shown us difficult to solve. 

 

1a)

There isn’t a single thing that will achieve the goal of a “healthy city”

The right kind of environment matters as much as the right services as much as the right policy context.

Some things are not in the control of the city per se.

The environment people will care most about “environment sort of stuff”, mental health advocates will care about that, community advocates, ditto. And so on. 

Given that 1) we don’t know “the answer” & 2) all of the above matter, it becomes a giant spread bet informed by intuition, experience and evidence.

 

 

2)

Many say if only we had the resources they would be readily solvable. 

There was a time in the past where there was a great deal of resource sloshing around, we didn’t solve the problems then – to be fair we did make a few tangible inroads but the problems remain.

Maybe it’s NOT ONLY about resources, it’s certainly not only about resources at the margin, it’s about what we do with the whole that matters.

 In times of plenty, we didn’t make the mainstream better, we funded stuff at the margins to correct the deficiencies of the mainstream. And thus we never corrected the problems in our view of allocative value in the mainstream (in everyday language we failed to shift upstream).

3)

If only you invested in xxxx then things would be better, the value of small investments in communities is incalculable.

I agree.

I doubt doubt the value. I also don’t doubt it’s incalculable.

 

4)

The return on investment for xxxx or yyyy is excellent, why don’t we use the resource we free up to make that investment.

I agree.

I’ve blogged a lot on this in the past. See references.

The evidence around ROI is indeed excellent.

There is a need for “I”. This requires cash now. We’re all busy having a tough time here.

And the “R” bit implies free cash. The cash is locked into other things – buildings, staff, equipment etc….it’s not readily freeable in cash terms.

 

5)

Belief vs evidence

Linked to the above, but also standing in its own right a point about evidence base.

Often progress is not really about the “evidence” per se, it’s about belief, different views on the same problem, power base, vested interests, freeing up resource from within (see above point) and other things.

To address those issues one has got to be a trusted ally and part of the system or able to shape the rules and the system in some way. Shouting from the outside isn’t a way to build trust.

 

6)

Evidence, data and rational argument vs narrative and angriness

The converse point, we explored, also holds. The world isn’t full of neat rational logic. Political will to act doesn’t exist by magic, it is grown. Creating alternative narratives for change requires multiple means.

This is Mark Gamsu’s point. He’s right.

 

 7)

Stuff that didn’t crop up is also important

We barely touched on the political, ideological or commercial factors that have a bearing on the health of individuals and populations. In the light of subsequent events in Grenfell tower, we ought to have.

 

 

 

 

Refs

The limits of Return on Investment analysis – https://gregfellpublichealth.wordpress.com/2016/12/31/beyond-return-on-investment/

 Beyond ROI – https://gregfellpublichealth.wordpress.com/2016/12/11/beyond-return-on-investment/ 

The asymmetric approach we have to expecting cashable returns on investment -https://gregfellpublichealth.wordpress.com/2016/09/05/the-asymmetric-approach-we-have-to-expecting-cashable-returns-on-investment/ 

 

This excellent blog is also well worth a read, from Rethink Health – The Sense–and Nonsense–of Using ROI in Population Health – https://www.rethinkhealth.org/the-rethinkers-blog/the-sense-and-nonsense-of-using-roi-in-population-health/

 

Children, healthy ageing and the opportunity in the transformation of health and social care.

I read this amazing blog last week, partly focused on on the marginalisation of the children’s agenda in the STP landscape. 
Building communities with resilient children at their hearts | The Nuffield Trust

https://www.nuffieldtrust.org.uk/news-item/building-communities-with-resilient-children-at-their-hearts

…….Powerful words by Professor Sir Al Aynsley-Green argues that the UK now needs a long-term, coherent, cross-party ideology and overarching policies that see children and young people as a vital priority and as citizens in their own right.
 


This is a resolvable problem. 

I was asked for my take on that by a few people of late who have expressed a concern that the children’s agenda is seen as important as the elderly one.
I had a think. Is a tricky conundrum. And I don’t have a definitive answer.
My response to the question is coming from a “health” lens, quite broadly, but a health lens nonetheless

 

 

For me 5 key points

 

1)        

Why is it as it is…….

· the key drivers of cost growth are: disease incidence (prevention),

· high cost technology (manufacturer pressure & patient expectation) and

· over diagnosis (clinical culture and system pressure)

· And NOT demographic pressure or the “ageing population”

 

the Glasgow work (Deep End and other) found that the current problems in NHS in Scotland are as a result of

· falling % of NHS £ to “community and primary care” led to hike in non elective (and a range of other issues)

· problems not due to too little funding overall

· worried well – especially in most affluent population

· systemic and cultural incentives leading to over diagnosis and over treatment. Diagnosis that leads to treatment that may do harm, may not help and has opportunity cost.

· degradation of primary and community care over 10 years, including social care.

 

 

2)

The basic ask of STP is to

· fix the provider model

· systematise integration and collaboration – micro to macro scale

· put into place structural (transformative – actually and transactional) changes that lead to greater sustainability of the health and care system in the long run.

 

 

And thus the central challenge for SPTs =

· shift from where we spend the ££ (frail poorly folk) to where we get the most gain (earlier in life, the earlier the better)

· address the specialist / generalist mix – not right for current challenges, never mind the future

· address the power and resource imbalance between hospital and GP + other non hospital – ditto

 

 

3)

Onto children’s agenda- where the above intersects the children’s agenda 

· Because children and young people aren’t sick (or at least they’re not sick in big enough numbers) – the NHS isn’t that much fussed because it’s there to treat sick people. Wrong mission syndrome?

· of course the energy and emphasis for ACS and other will be on the here and now, the current pressing demands. Understandable 

· We will never satisfy that, if we try we will neglect our responsibility for future generations.

· This would be a failure of stewardship and a wasted opportunity.

· Todays (mostly) healthy children will end in frail patients in 50 years or more time. This represents a window of opportunity to establish “healthy ageing” from birth. “healthy ageing” if done well will result in delayed or prevented morbidity and (more importantly) more economically active population.

 

 

4)

Areas of focus for the system to ACT as a SYSTEM

This is principally coming at the issue from a health and social care lens. Those with background in education may come at the issue from an entirely different perspective – validly.

In rough order of importance (to health outcomes)

Obviously some overlap in these areas

· poverty

· Adverse childhood experience

· Parenting

· Mental health – challenging behaviour v’ poor emotional wellbeing and mental health…. (schools are constantly challenged with this issue). CAMHS/Mental Health (getting ALL tiers right, not just T3 &4),

· Children in care, inc care leavers

· School readiness, education outcomes

· Cigs (5 kids a day start), obesity (20% of 10/11 yr olds obese)

· services and models working with the most complex children & young people – often described as fragmented and unable to cope. Classic eg = would be a young person they had on one of their wards for over a week…. Medically fit for discharge for 7 days but so complex no one knew what to do next….

 

And within each of these inequalities between best / worst etc.

 

Just my own starting point

 

 

 

 

5)

The implication and the ask of the ACS

In your rush to provide better care for those with complex illness and manage multimorbidity ….. both of which consume vast resources for not a lot of gain……DON’T forget that we also have responsibility to be stewards of the future health and wellbeing of people who are currently (mostly healthy) children……

It will require a different way of thinking about things, and maybe agreement about a different mission.

 

There….. children’s JSNA written in less than a side!

Anecdote

Archie Cochrane – yes, he of Cochrane reviews – was once talking to an undertaker at a Crem. The undertaker said – “Ive never seen a place where so much goes INTO the machine and so little comes out”…

Archie was reputed to have said – “you should try working in the NHS”….

 

Others have also written in this space

The conundrum of children’s and young people’s health: time to address it-https://www.kingsfund.org.uk/blog/2017/01/conundrum-children-young-people-health

Agree with all there also 
 

Core Quality and Outcome Measures for Pediatric Health – http://jamanetwork.com/journals/jamapediatrics/article-abstract/2634363?amp%3butm_source=JAMA+PediatrPublishAheadofPrint&utm_campaign=10-07-2017