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


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 this.

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

‘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)

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


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.


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

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. 

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

Person centred

Person centred, goes without saying (or should) but need some careful definition and unpacking as it’s not universally agreed on.

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. 

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. 


How do we share risk and benefit


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

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. 





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’



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. 



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.



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 




 Geoffrey Rose’s 1985 paper Sick Individuals and Sick Populations in the International Journal of Epidemiology:


Roland. Reducing emergency admissions: are we on the right track 
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

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:
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. 



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. 



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.




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.



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.



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.



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.



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.



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.






The limits of Return on Investment analysis –

 Beyond ROI – 

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 –


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

…….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



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.




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




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.




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






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!


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

Agree with all there also 


Ageing population lazy thinking for when you cant be bothered to understand the real issues

By me and Steve Laitner

I’ve (GF)  blogged a lot on the myth that is the “demographic timebomb”, and set out a set of data and arguments to make up case argument wise. See references at the bottom.


 Here are our collected summary thoughts on why getting the narrative wrong on this is harmful


Lessons in demography

Despite popular conceptions, the age distribution of the population shifts very slowly from one year to the next. The population does grow, but the distribution of age shifts slowly. This slow growth in the age distribution of the population limits the magnitude of the impact on utilisation.

Many perceive that the impact of ageing during the next ten years will be higher than it was for the previous ten years; this perception is incorrect.

 Strunk et al estimate that ageing increased inpatient utilisation by 0.35% per year from 1995 to 2005. One can also assess the changing impact of ageing by comparing annual increases in inpatient utilisation for selected one-year periods. For 1994–95, 2004–05, and 2014–15, the ageing factors are 0.33%, 0.63%, and 0.80%, respectively

Ageing therefore accounts for a relatively small portion of the growth in hospital spending projected for the next decade. One USA estimate suggested only 11.8 percent of the total increase in inpatient spending from 2005 to 2015. (Ref 10 from Strunk)

In this country demand is going up year on year – c4%. The population age profile is shifting considerably more slowly than this.


To prove “the ageing population timebomb myth”, you need to:

look at the data and who is actually using healthcare, and other factors

A&E – generally NOT older people

Hospital admissions

 it’s important to consider the a) absolute number b) length of stay (perhaps older people for LOS but for admissions) and c) where the increases are in utilisation d) absolute numbers in a population, especially in e) a fixed capacity system 

 – you then need to demonstrate that it’s AGEING per se that’s driving this, not morbidity or demand side failures. 

In general, the effect of ageing effect on use of inpatient services will be small, but it will have a larger impact on use by patients with certain types of medical conditions that are more concentrated among the elderly.
Finally, and arguably critically, although the AGE of the population is increasing is the burden of disease increasing (NO, what limited data there is would suggest not) or is it just that 72 or the new 70 etc and its just numbers on the clock and mean nothing (probably)

Given all that, are you sure you can demonstrate the ageing timebomb? No, we thought not.

In a nutshell …..Cost, and cost growth, is driven by 

  • morbidity – incident and prevalent disease. Incident disease is CONSIDERABLY more important here.
  • Low value expensive technology, 
  • over diagnosis and over treatment, 
  • unrealistic expectations, 
  • degradation of the demand management functions, 
  • over use of supply sensitive care. 
  • Preference sensitive care choices – an assumption is often made that people want the same care at 90 as they do at 40 – they don’t.
  • End of life intensive tx. 
  • Proximity to death – whether that’s at 69 or 99, it doesn’t really matter doesn’t matter.


These drive health cost inflation and NOT “the ageing population”.

 A number of blogs on this are referenced at the bottom. They are fully referenced.

 And also even IF the ageing population is a reason for increasing demand on healthcare surely the improving health of the population which allows people to live longer should be REDUCING the demand on healthcare for slightly younger population
…and if technology means that people are living longer shouldn’t technological advances enable us to LOWER the cost of healthcare such as through non face to face means
How much is “living with disease” life increasing (if at all)?


This IS, however, proving a very difficult zombie to kill especially as far as popular media and NHS policy are concerned.
Its a fantastic cop-out – “its not our fault its those bloody citizens having the audacity to live longer”!



Here are 5 reasons why it matters that we get this narrative right, and matters a lot.

  1. If we focus on “the ageing population” the wrong response becomes more likely. If we are fatalistic, and accept it’s an inevitable consequence of an ageing population, we will prepare wrongly by building bigger hospitals to cope with demand, not preventing demand. Hospitals are certainly not what the older population want and in most cases need, consider them as expensive hotels that sometimes add value, but often they don’t and can do harm. – as a subset of this, if we get the narrative wrong we will loose focus on healthy ageing (in old money that’s called health promotion) 
  2. We focus on what we CANT do much about, and we don’t focus on what the problems driving demand actually are, ones that we CAN do something about – this becomes a sort of Moral Hazard and we just plead for more money as always
  3. Stigmatising old people. It’s ageist.
  4. It weakens the intergenerational, whole  society compact that underpins the establishment of the NHS. Why should I pay for all those old folk who are expensive to care for.
  5. A reliance on “the ageing population” hypothesis entrenches (as if it needed further entrenchment!) inequity in resource allocation as it (unfairly) further weights age per se over real drivers of need. Given that 1) the distribution of resource in healthcare between hospital and out of hospital is in itself a determinant of health and 2) the distribution of resource within primary care is inequitable – this ‘ageing timebomb hypothesis’ makes inequality worse.

Dear everyone, 

Change your narrative please.


 Postscript 1)

 Critique of these ideas

Of course this is all an unproven hypothesis. 
It’s worth saying that despite this, feedback from our GP friends on twitter – and in real life – has been consistently along the lines of ….. “yep, that about reflects my reality”
One person summarised the ideas as a bit fast and loose

One of us (GF) wasn’t very happy with that. We referred the person to the assiduously referenced blogs at then bottom of this one, and pointed out we were indeed writing s blog not a PhD thesis!

Another suggested that the focus on multi morbidity was a bit medical model. 

Fair critique. We could call it multi morbidity, we could call it loss of functional ability or ability to adapt, we could even call it health and well being. 

We maybe should characterise it as all of the above.

However our point is that those things are not driven by “the ageing process” (which is obviously not modifiable but by extraneous events that often are, but we choose to ignore them at both an individual and a societal level.

Muir Gray has been writing about this for years now – #sod70

This takes us back to place we give to the concept of “healthy ageing” in policy terms versus “preparing for the demographic timebomb”. Guess which one gets more airplay in public consciousness?

Lastly on demonstrating the hypothesis with data.

Tricky, may not be a doable thing. We don’t think we’re clever enough to do it.

  • We think the analytic question is on of whether a robust AGE SPECIFIC measure of morbidity is changing over a long period. 
  • That measure would need to be adjusted for perverse screening programmes that lead to overdiagnosis, over treatment trends, insulated from the impact of changes in supply or demand side factors in the health and care system – i.e. Pure morbidity or functional ability / impairment.
  • This would test whether 72 is indeed the new 70 or whether 68 is the new 70. Ideally this would also need to be data that can be cut along socio economic deprivation and other lines 

Until such time as such analysis is available, our contention is that “the ageing pop” remains lazy shorthand for not addressing much more difficult issues 


Postscript 2) 

Further reflection and feedback from others


Is the focus on multi morbidity the right focus.

Our original blog said that it was multiple morbidity that is driving cost, and that morbidity a proxy for disability and also proximity to death

Alf Collins consistently points out that morbidity is a proxy for disability, which is a proxy for functional impact (see Commonwealth Fund)

See here – Lancet editorial What is health? The ability to adapt:
This has obvious implications for how we take forward the next steps.


Individual vs population approach to frailty and resilience

Of course individuals live in a social context. Many told me that it’s actually about the social context in which individuals live. This leads to the question of whether we can build the resilience of communities to help individuals in those communities. Of course, is the obvious answer.
Wider still, is the need to take into account other changes in social structure are making life rather more difficult – no longer can rely on nuclear families to look after our old rellies, changing job market, melting of welfare state as we know it – and many other things all have profound effect


There are many who take a different line

Eg see here

Can this be summed up as:

Some older people stay for and well and active

Some don’t

We need to think of the latter as well as the former


The paper in the lancet was interesting.

Forecasted trends in disability and life expectancy in England and Wales up to 2025: a modelling study
The study is excellent and warrants a careful read. The cncousyiom line in the abstract – sadly only bit most people ever read – says “The number of older people with care needs will expand by 25% by 2025, mainly reflecting population
ageing rather than an increase in prevalence of disability. Lifespans will increase further in the next decade, but a quarter of life expectancy at age 65 years will involve disability.”
There, said it – population ageing. 

Actually the study is one that puts together disease indecence, prevalence, life expectancy, healthy life expectancy and the number of people of a certain age. All projected into the future.

The sheer increase in numbers of people over 65 (25% in 10 years) must be an issue but this is more demographic than increases life expectancy is it not, and an economic and political issue and offset to some extent by less younger people.

The increase in years with disability (the major cost driver) is small -about 0.7 years increase in 10 years?

I still insist that neither account for 4% per year on year increase in NHS demand and we must get out of that Moral Hazard cul-de-sac quickly.
“Population ageing” doesn’t even get close. You’ve got to distinguish net population growth, changing in disease profile and ageing per se.

There were a bunch of other limitations and caveats. Picked out in both the main paper and the editorial. Obviously nobody likes long lists of caveats – folk have short attention spans and get bored. Suffice to say caveats are important!
That starts with really understanding the causes of increased demand and what we need to do about it!

It is interesting to note the recommendations of the authors

 increased capacity in formal social care (making good cuts of last 7years?)

 improved support for informal social care arrangements

enhanced interventions against predictable risk factors 
Simple, but rather unpalatable stuff as we continue with our narrative around broken hospitals, must fix hospitals etc etc etc

So, all up……we (STILL) can’t robustly, or with any credibility, pin the current problems in health and social care on the ageing pop etc



It’s NOT about the ageing population –

It’s NOT about the ageing population – volume 1

the ageing population” conundrum volume 2 -

prevention – ultimately futile in broad economic terms as folk will likely live longer and get dementia….discuss –

The epidemiology of multi morbidity

The transformation issues we don’t talk about –

The GP 5YFV and the deep end. The importance of inequality. 

Using routinely collected data to demonstrate where the NHS is going wrong
Strunk B, Ginsburg P, Banker M. The Effect Of Population Aging On Future Hospital Demand. Health Affairs 25, no.3 (2006):w141-w149.

Collected blogs to date

People keep asking me to post link to all by category
Here’s the set

Health improvement

1. Prevention generally

a. Transport, active travel, air quality

Ten thoughts on reframing transport policy as a health investment


b. Health Improvement approaches in policy terms

Pills v policies the impact of individual level interventions

Preventing diabetes. Indivudal vs population based approaches – on emptying an ocean with a teaspoon


Are thinking and doing on “prevention” going the same way. A Thought experiment

Health in all policies –

The individualization of PH policy

Improving the determinants of health and well being

c. Nanny state
some (academic) rebuttal arguments to the nanny state line
d. Cigs, fat and booze

Smoking – changing the frame

McKinsey and obesity – the economics of different interventions –

Childhood obesity strategy – worth the wait or not

Scaling up prevention – an STP thought experiment

2. NHS

a. ACO etc

ACOs and the like – will or won’t they save us from certain doom?

ACO – how to guide and considered thoughts

Outcome Measures

What outcome measure for an Accountable Care System – how will we know its working-

Using routinely collected data to demonstrate where the NHS is going wrong


where next for STPs

What IS the “Public Health” contribution to the NHS Sustainability and Transformation Plan –

Up scaling prevention and the STP, some questions for CCGs to ponder –
STPs, prevention and the the ever changing ask of “public health” –

c. NHS Policy zombies

GP Referral Management – one view of what the evidence tells us

High risk case management will save mega dollars?

Case management / key workers – 10 reasons to be cautious

The savings from key workers or case managing “high risk” people

A&E divergence schemes, what does the evidence tell us

Stop before your op – great plan if done well for the right reasons. Terrible idea if done to save money –

You can’t have your op till you’ve lost weight -HTTPS://GREGFELLPUBLICHEALTH.WORDPRESS.COM/2016/10/08/YOU-CANT-HAVE-YOUR-OP-TILL-YOUVE-LOST-WEIGHT/  

how to implement procedures of limited clinical value

d. Other health care stuff

Green Oncology.

A prostate cancer bumper edition -  

Public Health, the “core offer” and supporting CCG commissioning – some thougths –

Transforming the outpatient model – 15 ideas with some evidence –

Quality Improvement Flipped on its head – HTTPS://GREGFELLPUBLICHEALTH.WORDPRESS.COM/2016/02/20/FIRST-BLOG-POST/

Transforming Planned Care – some ideas and some evidence – HTTPS://GREGFELLPUBLICHEALTH.WORDPRESS.COM/2016/02/20/TRANSFORMING-PLANNED-CARE-2/


Do you want the money for another 1500 GPs?

Ten Commandments of diagnostics

Does drug company bribing hospitals improve outcomes and at what cost


Reconfiguring services is back on the agenda what does the evidence tell us

The transformation issues we don’t talk about

AF stroke prevention – turning science into change

DVT. Saving $ and improving care –

Outcomes based commissioning. It’s back. It never really went away, or actually never really got started.

Avastin in ophthalmology Briefing for CCGs

GPs and Generalist / specialist

Abandoning “primary care” and “secondary care”

Dear Generalist…changing cultures and attitudes in accountable care


The GP Five Year View. 4 strategic issues

Public health specific

What does “excellent” look like for a “public health strategy”.
A public health approach to…….five quick thoughts


what does the future of public health services look like?Old world meets new –

Transforming public health. What does public health 3.0 look like. –

The individualisation of public health and health policy. –

Public health in 15 years time. –

On being “an outcome based …….”

to RCT or to not RCT. On the issue of “evidence” and public health -

The glacial pace of change in the practice of public health.

“Determinants of health – if only local government took it seriously” –

Ten grand challenges


Is screening different to case finding in high risk groups

What would it take to get guideline bodies eg NSC to change their view on screening for AF –

Why I argued against diabetes screening –

The case against early diagnosis of cancer


Person Centred Care
Meshing together personal and population approaches – reaching the impossible dream

Can anyone suggest resources to help authors incorporate values/shared decision-making in guidelines? Or examples of it done well? #sdm


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

So then Fell – how WOULD you go about solving the cost crisis

Is the ageing population is accounting for escalating health costs
This is cost saving”A note on ‘invest to save’ proposals
But its an effective treatment, you MUST pay for it”. Five considerations

The parlous state of NHS finances and getting change done

the low value care problem


Lessons in health economics 101 from non economist world


The asymmetric approach we have to expecting cashable returns on investment –

Prevention as cost control

Prevention as long term health care cost control 1/3

Prevention as long term health care cost control 2/3 –

Prevention as long term health care cost control 3/3 –

Prevention – how much money will you save in out STP by next week Fell. Volume 2 –

Five reasons why we will never scale up prevention

It’s NOT about the ageing population

the ageing population” conundrum….where next……

prevention – ultimately futile in broad economic terms as folk will likely live longer and get dementia….discuss…. HTTPS://GREGFELLPUBLICHEALTH.WORDPRESS.COM/2016/08/24/PREVENTION-LETS-NOT-BOTHER-AS-ITLL-NEVER-SA

EPI of multi morbidity

Nudge a few thoughts on what we’ve learned

Drug “recovery” versus “maintenance” and the smart use of indicators

The limitations of administrative data for to describe quality and or outcomes

PeEP – reasons for caution

Public Health, the “core offer”

Conflicts of interest and Royal College Guidelines

Over diagnosis – a new frontier in green and carbon

A note on social impact bond & social finance –

Public health in 15 years time.

A few weeks ago I went to an excellent, small but perfectly formed session on “the future”.
It was Chatham house rules, so I won’t spill too many beans.

The upshot was fascinating and worth sharing

We spend a lot of time thinking about “the future” of the profession of public health.

Opening thoughts
In 10y time there will be fewer off us than there are now
LG really pleased to own PH again. This will likely continue, despite financial carnage, as long as we continue to adapt to an ever changing world.
The value of PH is about allocative efficiency of spending and gravity of spending to get better allocative value
Our core job wont change = how we continue to get to allocative efficiency. Get more outomes out of £ envelope.
LG values these skill sets.

Our job will be highly specialist or technical or creating relationships and trust. It might be both
Business partnering skills will be important.
Technical competency is key, but…..this competency is no use without ability to persuade and get trust.

Get into analytics
Skillset of health intelligence likely to be critical skill in the future. What can and can’t be concluded from different streams of data.
Predictive analytics is a big feature of the future. New professions will develop to do this work. Can we keep up? We ought to try.
Also local contextual intervention as to how to contextualise data from big data predictive analysis is key.

Tear up how you describe & communicate “public health”
People believe who and what they trust rather than experts

Soft skills are as important as “anorak” skills.
Spend time understanding what drives those you are trying to influence, understand their arguments better than they can
Skillset of being bilingual across multiple worlds and ability to carry influence = critical skill
PH Professional of the future = complex systems, linking and joining agendas, sense making,

The world will be more automated. The system in which we operate will be different
Critical job = TRUST in the assurance process that goes around automated systems
TRUST must be built on professional underpinning, and we need to keep our professional training and integrity.
So we still need to understand the basics of the profession….and how the system is put together.
As an accountant = TRUSTED as an advisor to assure automated accounting processes.
This is definitely an OPPORTUNITY.

Think about this now. Be prepared for the future.
What are the new skills I need, what are the skills that already exist that we harness onto a job with a common outcome
Analytics, OD theory, complex systems

Read – Suskind and Suskind – the future of academics in the AI world

STPs, prevention and the the ever changing ask of “public health”

Been thinking a lot on this.
I’m thinking there’s a standard assumption that PH = “prevention” and thus prevention aspects of our STPs will be “done” by PH.

Two fab studies have focused my attention on this issue of prevention how it fits in STP world, one on obesity, one on hip fracture. I could have picked countless others.

Key points of both studies are noted at the bottom of the blog, to keep the main points of the blog short.

Both studies highlighted the lack of a population approach to managing risk and reducing disease incidence, as we spend our time “managing illness in the prevalent population”. We can choose to ignore this, but ever increasing cost of care is in no small part attributed to disease incidence (see many of my other blogs).

I’ve said it before, I’ll say it again in the future – the only surefire way to reduce cost in health care is to not provide health care.
You can either choose to stop providing some interventions and deal with the political and clinical consequences, or you can prevent the need for health care.
Again, again, and again in any system of care primary prevention is the most efficient way to reduce cost and improve outcomes.

“Public health” will not have the reach and depth to address these risk factors at the scale needed.

Thus “the system” needs to decide whether it wants to remain in the business of “providing excellent care” (which by and large it does) or managing and reducing population risk (i.e. Primary, secondary, tertiary prevention mindset) and thus reducing burden of disease and improving outcomes

“Public Health” is:

  • A Function – a responsibility of local government as a whole
  • A set of Services – things traditionally thought of as “public health services” – smoking, obesity, health visiting, sexual health etc. The line between those services as “public health” and any other service is pretty murky, esp if you have a broad definition of the concepts
  • Some source of Expertise – clinical, epidemiological, economic, other. To apply to any issue, problem or opportunity.
  • There’s also some Strategic leadership sort of stuff.

Public health is NOT

  • prevention
  • The public health grant
  • Health inequalities. How many meetings about health inequalities have you been to that are loaded with PH types (often as it’s seen that PH will sort this)
  • It is also not the medical model or the social model. It is both.

Doing public health (or anything) when there’s tons of cash is easy – do the right thing with the £ available
When there’s no £ – you have to do the right thing with what you’ve got but change the overall mission of the system.

My core job wont change over the years = how we continue to get to allocative efficiency i.e. to get more outomes out of £ envelope.

I should be clear here, I’m not really shirking out of my responsibilities- I accept them. I’m reflecting on what is doable, not doable and trying to get a common understanding. We should think about this when we are thinking who “does” prevention in your STP.


Hip Fracture
Hip fracture, falls, fear of falling is a big deal for both the NHS and social services.
Here is an awesome (mainly Scandinavian) epi study Papadimitriou et al considering the burden of hip fracture.

My key points are below.

  • Prospective cohort study aiming to quantify the Burden of hip fracture and risk factors.
  • 223 880 men and women aged 50+ were followed up
  • 3.5% risk of hip fracture (7,724 fractures) and 413 (5·3%) died as a result.
  • Significant disability (and consequent impact on health AND social care system – quantified in the paper)

Once again – same old risk factors….Cigs, lack of sweat etc
Current smoking was the risk factor responsible for 7.5% of the hip fracture burden, physical inactivity – 5·5%, history of diabetes – 2·8%, and low to average BMI 2·0%, 1·4–2·7), low alcohol consumption and high BMI had a protective effect.


  • hip fractures are an important cause primarily of disability & mortality
  • Many opportunities exist to ameliorate the burden of hip fractures via a focus on treatments that will facilitate a rapid and complete recovery.
  • Primary prevention measures should be strengthened to prevent falls, and individuals should be encouraged to avoid smoking and a sedentary lifestyle.
  • Secondary prevention should also focus on treatment of osteoporosis and coverage of effective interventions at population scale (there’s pretty low coverage of osteoporosis meds and falls is, well, pretty messy….overly focused on “specialist services” not generalist population approach)

Hip fracture
Papadimitriou et al – Burden of hip fracture using disability-adjusted life-years: a pooled analysis of prospective cohorts in the CHANCES consortium

Cauley – Burden of hip fracture on disability

Obesity & overweight
Closer to home Kent et al looked at hospital costs associated with overweight and obesity in a 1.1m women cohort. That’s quite a big study and a lot of person years!

Key points

  • Follow up of 1.1m women in England aged 50–64, recruited between 1996–2001
  • Followed up for c5 years starting in 2006.
  • 1·84 million hospital admissions were recorded in this cohort in that time
  • Every 2 kg/m2 increase in BMI above 20 kg/m2was associated with a 7·4% (7·1–7·6) increase in annual hospital costs.
  • Excess weight was associated with increased costs for all diagnostic categories, except respiratory conditions and fractures.
  • £662 million (14·6%) of the estimated £4·5 billion of total annual hospital costs among all women aged 55–79 years in England was attributed to excess weight
  • of this £517 million (78%) arose from hospital admissions with procedures.
  • £258 million (39%) of the costs attributed to excess weight were due to musculoskeletal admissions, mainly for knee replacement surgeries.
  • This cost looks likely to increase substantially especially with regard to diabetes complications.
  • Many health economists are now focusing on the broad societal costs of being overweight, including early retirement, efficiency at work, and prospects of promotion. These societal costs are now estimated to account for 60% of the total costs of being overweight or obese
  • i.e. The NHS costs quoted above (nb in a small slice of the whole population) is c40% of the total societal cost.
  • In 2014, the McKinsey Institute estimated the economic burden of being overweight or obese at US$2 trillion, matching that of smoking and all armed conflict.

Kent et al – Hospital costs in relation to body-mass index in 1·1 million women in England: a prospective cohort study – The Lancet Public Health

James – The costs of overweight

Improving the determinants of health and well being

I was once asked “why local government didn’t take the determinants of health seriously”. After I’d picked my jaw from the floor, I had think of an erudite answer. It was blogged (see references at the bottom) and I won’t revise or review that further.

Health policy is mostly focused (in the minds of the public) on the NHS. The Health Foundation published an excellent report from the Health Foundation that focused on three questions:

  • Why do governments focus on health care rather than health? 
  • Where has a shift to health started and what have been the contexts, drivers and benefits? Where that shift is held back, what have been the obstacles – funding mechanisms? 
  • What is the relationship of the state and the individual? What is the nature of evidence in complex systems


And to their credit, the HF have published an excellent strategy for health that is very refreshing. It is worth you reading it.


Sheffield City Council has now agreed a strategy for public health. It is referenced.

Health in all policies is a key focus of this. We are trying (again) to move “health policy” away from health care and more toward the things that determine our health – funnily enough often called “the determinants”.


Here I will focus a little energy on “the determinants”.


As we all know the determinants of health are complex. 

Each of the things known as “determinants of health” are 

  • complex, there are many moving pieces, many intersecting service delivery, capital investment and policy areas. 
  • Some of these are in direct control of local govt or other local actors, many are not.
  • This is true for all things considered “determinants” for example air quality, education, spatial planning, economic development, poverty, or housing policy.

To make progress you need to to be able to understand the drivers of those systems… they operate, the incentives, the power bases…..and what outcomes they are measured by…

So “addressing the determinants of health” is just as (arguably much more) complex than many who are outside this world might think.

Take “Education” for example . Education is an obvious determinant of health and well being (and lost of other socially useful outcomes!)

(I won’t dwell on the evidence for this statement. There’s rather a lot of it. Google will set you right if you look. See the ref from RAND as a starter.)
Two obvious indicators of “the problem” and markers of improvement – school readiness age 5, educational attainment age 16 – and the inequalities in both. Again, there’s plenty of evidence of inequality in school readiness and attainment.
Im told both are fundamental determinants of adult outcomes and life chances, and that improving school readiness changes life trajectory age 26 and is a good predictor of income tax paid (a proxy for income among other things). It’s an area I don’t have great expertise in, but have no reason to disbelieve it.


However, it’s complex. Schools are increasingly outside the control of local government. Early years services are not.

 There are no silver bullets, no single investment or intervention that will solve the problem. 

Many aspects of policy of service delivery overtly not within LA control. There are many crazy and perverse incentives and issues.
It is a complex system, difficult to “control”. Obviously this then takes us into complex system type of discussions and the extent to which they are “controllable”
So – some thoughts on improving health via addressing the determinants – here using school improvement as an  example, and a repute to improving educational attainment 

I should caveat that I’m no expert in “education”, nor should I be. If we’ve signed up to a health in all policies type of framework we need to ensure we have organisational competence and a plan.

There’s pretty much universal agreement that in the absence of a mega innovation, an Incremental change with right model of delivery and an intelligent / intelligence led approach is the way to go

Detailed understanding of the data matters
Some investment may be needed in key priorities, but not much.

There may be scope for social investment type models to try and test innovations, this shouldn’t replace state funding.
We have broadly a locality based approach to school improvement and partnership of schools in context of local community. This seems to matter, and I’d argue it’s the right approach.

Academy status doesn’t really matter (it may do if academy isn’t bought into the local vision – this is the bit that seems to matter.)

Leadership matters. A lot.

Accountability for improvement matters. Capacity to improve is inherent in all. We have a model of competitive collectivism, again this seems to matter.
Lastly, it cuts both ways – good health and healthy behaviours is important fundamental for learning (and thus downstream attainment). No shortage of evidence there either.

  • Making improvements to “the determinants of health” is complex, tricky and there are no easy answers. Just like health care?!
  • The logic of improving school readiness and educational attainment leading to improved life chances and downstream health gain is pretty sound.
  • Like most other policy areas we won’t get population gain till we have addressed inequalities
  • If you want to improve “a determinant” you need to be able to understand the system and provide the right sort of help and support, but not necessarily be an “expert” (remember we all hate experts now etc)
  • The same basic principles apply to anything that is a determinant.



If only local government took the determinants seriously –


Why are We Hooked on Health Care? Designing strategies for better health.


The HF strategy for health


SCC Public Health Strategy


Implementing a  health in all policies approach in the context of a public health strategy
RAND- Investing in the Early Years: The Costs and Benefits of Investing in Early Childhood.