Positive health and education paper draft
By Paul Goldsmith
2017.Three North East children's lives.
James is 13, comes from a loving family. His path in life reflects a combination of his intrinsic personality and school and parents not quite picking up and nurturing his vulnerabilities. He hides these well and ticks the boxes, doing fine, no concerns. He has learnt to live in a safe zone. Perhaps that is why he chooses the easy jobs after college and allow he probably drinks too much when work feels stressful. Life trundles on. At age 34 when he's made redundant. The prospect of acquiring new skills is scary, a little bit too much alcoholand lack of exercise is taking a toll on both body and mind and the hole is looking too big to climb out of. There follows an inexorable slide into chronic ill-health and dissatisfaction.
Ellie, age 14, hates her appearance; both her body and her face. She was always going to struggle with weight. The whole family is obese, although they think they are not. It is not Ellie’s fault she has been brought up on big portions, multiple courses and treats. Some boys like her, but only if she “sexts” them. These relationships are all shallow and her private moments of a sense of control with the knife on the wrists eventually lead to an overdose attempt. The psychiatrist says she is low risk and puts her on the waiting list for counselling. Education has taken a major hit, although she limps through, eventually getting a job in a call centre. Adult life is a series of failed relationships and frequent trips to the GP with psychosomatic symptoms.
Lilly, is age minus 8 months. But Lilly's mum does not yet know she is pregnant and Lilly’s brain is already being impaired by alcohol and drugs as it goes through its most critical phase of development. And its most vulnerable. Her nerve cells are not wiring together optimally as their highly complex growth and reorganisation occurs to form a recognisable brain. When she is born she will be met by at times love, but at times shouting, as the mother fails to pick up her cues and deliver consistency and safety. Lilly in later years displays similar inconsistencies and irritability in her communications with teachers and classmates, fails to focus on education, which her mother says is pointless anyway and leave school with intermittent drowning out of a sense of worthlessness with alcohol and drugs. Hassle from the DWP makes her stop her pill and she falls pregnant, father unknown.
Why has this become the norm for the North East ? Our cases represent different backgrounds, different life histories, but are unified in reflecting a mismatch between potential levels of well-being over the course of their lives and the actual. It has been this way for so long that some fail to appreciate it, or just accept it as the norm, knowing no better. Indeed too many seem to think that everything is OK. Perhaps it is because the hard facts are hard to bear facts?
The “healthy life expectancy” of children in the most impoverished communities is 52, worse than children born in war-torn Ethiopia who can expect to stay healthy for 55 years.
In areas of the North East people live on average with 29 years of disabling illness, compared to the best areas where it is 9 years. The key determinants of this are no longer industrial disease from working down mines, but the readily addressable ones of obesity, alcohol, smoking and lack of exercise.
The North East has the highest rates of mental illness in the UK. And at a more everyday level, low levels of happiness and contentment.
- The seeds of this are sewn in the earliest years of life and gradually become more overtwith age. 75% of severe mental illness has become apparent before age 18, with more minor vulnerabilities being extremely common.
- Physical health is terrible in our children, mirroring that of adults, with 25% of children obese by age 11 and levels of alcohol and smoking remaining stubbornly high.
- Teenage pregnancies remain a career alternative to education for too many
- Serious and failing children’s services in Sunderland leading to take over by a voluntary trust.
- On average, the worst schools outcomes in the UK. Repeated criticism of poor skills, educational achievement, low levels of ‘doing’, whether this be personal hobbies, volunteering, sporting activities, acquiring new skills or setting up and driving forward the businesses of tomorrow.
We are in a trap. We have the highest health spend per head of population in the whole of the UK and more GPs per head of population, yet the need is still not met. Our health system is very good at patching people up, but we are very poor at addressing the long-term determinants. With a generally accepted figure of 30% of health spend due to lifestyle factors, the money involved is huge. Complex, interrelated problems impact on the life chances of the next generation. Excellent and well-meaning parents, but children influenced by non-ideal environments; to disinterested parents who think, what's the point; to frank neglect. It is a tough ask on teachers to generate the grades with this backdrop.
What do we know ?
Time and again research has concluded that the biggest return on investment is in the earliest years of life. Much has been written about the influential Marmot review highlighting this, and the need for sustained positive support through to adulthood. Everybody agrees and indeed various of our local councils have supported similar conclusions in their own reports over the years, but these just gather dust. Most recently a major review was undertaken by national and local experts covering how we could improve the life chances of people in the North East and escape from the downward spiral, summarised in the Health and Social Care Commission devolution report. The authors were careful to point out that although the original backdrop to the commission was preparations for a North East Combined Authority (NECA) devolution, the report and its implementation was not dependent on this (NECA devolution fell apart shortly before its publication). It would be a travesty for the people of the North East if the recommendations in the report were lost. This is a major risk as a key factor the Commission identified for North East problems was a lack of leadership and lack of organisational and institutional maturity to provide the coordination, cohesion and communication of transformational long-term effort.
Without such cohesive leadership and strategic coming together, we have good people restricted by silos and incentives that are not aligned and not in keeping with the greater good for the North East. For example, our health providers get paid for processing sick people, not for making healthy people. Indeed some have said that maintaining ill-health is in their interest ! This is unfair, but does reflect a problem with current incentives. Efforts around healthiness rather than illness are siloed with buck passing the norm. ‘It is the responsibility of public health and the councils.’ ‘The NHS should do it, they have the money.’ ‘We have more pressing priorities’… which might mean the need to get re-elected, or to meet a 4 hour A&E wait or outpatient target. Of course if we had less alcoholism and smoking we’d make a much greater impact, but ‘that is the council’s job’. Health and wellbeing boards were supposed to provide these links, but have largely been a failure.
Similar buck passing occurs with education. ‘Mental health is the NHS’s job.’ ‘Prevention is the school’s job.’ ‘Our funding has been cut and PHSE is not compulsory’. Local authorities say they have no influence over many schools. Schools say they get limited support from the NHS. Teachers get hammered for poor grade results. As for the early years ‘it's the government’s fault for closing Sure Start and it is all due to austerity’. Whatever the more recent politics of funding, the North East problems have been here for decades and we are where we are and for our collective good need to transform ourselves.
Fortunately, we are not starting from scratch as we have lots of good people and areas where progress is being made.
Pockets of excellence
Some head teachers realise that to be able to address the 3 Rs, they need engaged parents, which in the most deprived of our areas has even gone as far as teachers visiting the child's home to wake them up in the morning, such was the parents baseline disinterest. Showing parents a different way, gradually bringing them into the educational and nurturing process, then building the child's confidence and showing then the reward of achieving things is transformational but hard work and resource intensive.
Some schools have fantastic PSHE with dedicated and enthusiastic teachers equipping children with the maturity to thrive as adults. The best private schools in the south do this for all their children, so it is great that at least some of our children are similarly benefitting.
Some local authorities have run positive mental health pilots in their schools, for example the peer reviewed Penn Resilience Programmeexperiment inSouth Tyneside, then council chief executive Irene Lucas saying it was as though "pixie dust and magic" had been sprinkled on South Tyneside.
The North East Clinical Networks Maternity group, recognizing the importance of the Marmot principles and beginning early, are trying to shift the focus to optimal early parenting with their First 1001 Days initiative.
Child and Adolescent Mental Health Service (CAMHS) transformation plans are moving in the right direction and state the importance of prevention.
Sunderland schools are developing a kite mark scheme for health.
Programs and techniques to provide early intervention to children running into trouble and forming better links between schools and health services were showing positive results in the Target Access to Mental Health Services (TAMHS) pilots when 2010 budget cuts halted this.
A commission led by schools North East is about to explore best practice for “TAMHS revisited”.
But the same old problems remain
Despite these efforts, as it stands things are unlikely to improve the way the Health and Social Care Commission outlined, or we should demand. CAMHS is focused on the more severe end of the spectrum. Even with a relaunch of TAMHS, this just targets the 10% deemed to be in trouble. Adult problems affect vastly more than 10%. And most don’t live as good lives as they could. Positive mental health programs remain bitty, e.g. the South Shields Penn program was for a single year. We need this to be a sustained life course from birth. Thus starting in the first 1000 days is critical, but the majority of pregnancies are unplanned and to make the biggest impact we need to be preparing the ground pre-pregnancy.
At a broader organisational level we now have the Strategic Transformation Plans (STPs) for health services as key vehicles for transforming our fortunes and making healthcare sustainable. The Cumbria STP embraces education and a life course approach, but currently the Northumberland and Tyne and Wear (NTW) STP is lacking in such visibility, lacks reference to the Health and Social Care Commission, and risks being focused on acute health services, thus leaving us stuck with the same old story of us becoming ever more efficient at patching people up, of picking people out of the river, but unable to teach them, or encourage them, to learn how to swim.
1. A steering group is established with leaders from education and health with the authority and influence to effect change, including representation from maternity, early years, primary and secondary education, CAMHS, public health, community and ‘acute’ health services. Academic Health Science Network (AHSN), University and Police and Crime Commissioner representation should also be considered.
2. This is provided with leadership and drive by the relevant local authority leader, whether this be a Mayor or an equivalent.
3. The Terms of Reference are to are embed and established a systems architecture and core principles, taking a systematic and sustained life course approach to well-being from antenatal through to adulthood, with everybody benefiting from a core curriculum, then with additional support for those with extra needs.
4. Subgroups are established to advise on curriculum content, with on going review, shaping and improvement.
5. Health professionals are expected to ‘move upstream’, get out of the clinic and into the classroom, to develop closer relationships with those delivering primary prevention and facilitate easier transition for those needing extra support.
6. Health professionals to provide a greater up skilling and supportive role to teachers, teaching assistants, nursery staff and other professionals who come into contact with children and parents
7. Information silos are broken down, as well as people silos, with the key question always being what is in the child's best interest. Support from the AHSN is explored to see if repurposing or expansion of their nascent Great North Care Record work could facilitate these aims.
8. Greater use is made of the latent resource of parents, the wider community, retirees, as well as the 3rd sector, with an ‘all hands to the pump’ approach.
9. The Sunderland kite mark scheme in development is expanded in scope and implemented regionally, with different kite mark levels reflecting the degree of progress.
10. Regular assessment and audit should be embedded to ensure quality implementation and reach, as well as facilitate improvement. Ofsted could support this.
A 2020 vision of our three North East lives.
James was vaguely aware that he had anxious tendencies, but his techniques for managing it had been embedded from such a young age that he wasn't aware when seeing his cousins from the south in a meltdown about exams, that it was in fact himself who had the greater genetic vulnerability. Challenges still made him nervous, but he could rationalise them and rose to them, which made him a great employee. It wasn't his fault that the firm went bust, but the endorphin release from his daily run kept him focused. Learning new skills was a bit scary, but exciting and paid off soon with new employment.
Ellie’s parents decided as a family to take action on their health, prompted by a new ‘shared responsibility’ initiative running across primary and secondary care. A new ‘healthy fast food’ licensing approach from the council and the mile a day run scheme at school helped her keep a healthy weight. Her mental wellbeing is also much better. She finds those lessons the most interesting and eventually trains to become a social worker. Her first marriage doesn’t work out, but her life is so full of activities and friends that she takes it in her stride and lives a fulfilling life which touches the lives of many.
Lilly’s mum gained enough insight into the situation that she requested a long term contraception implant. Just being told not to drink or drugs was always going to be a very hard temptation to resist, so changing her environment and being encouraged by her support worker into new hobbies was key. As she felt more of a sense of achievement and capability she took a job in a local factory. It was low skilled, but she appreciated the structure to her day and the people around her. One of the unions was running a development and wellbeing course which she found she could enrol on, which gave her extra confidence and skills. She did eventually fall pregnant and found the parenting skills education fascinating. She wished her mother had had that. Well, at least Lilly’s life will be different.
Whether the 4th R isResilience, Responsibility or Roundedness, getting this right is key not just for delivering success in the educational 3Rs, but also in our region’s social and economic Recovery, Regeneration and Renaissance.
*The author writes in a personal capacity and the views and opinions expressed do not necessarily reflect those of any other connected parties*
HEALTH INEQUALITY IN THE NORTH EAST
By Michael Whitaker, Emeritus Professor of Physiology
Newcastle professors Chris Drinkwater and Louise Robinson have written here about the challenges of integrating health and social care as the population ages rapidly. They point to an increased number of old people with high levels of chronic illness accompanied by social isolation as families become increasingly dispersed. They cite the finding by Michael Marmot and his team that two in three Britons will fail to reach the planned retirement age of 68 free from disability. The disturbing fact behind this statistic is that the two Britons with disability will almost certainly be from more disadvantaged communities while the healthy Brit will be relatively well off.
Carol Jagger, another Newcastle professor, has used information from the Office of National Statistics to calculate the predicted age of first onset of disability of 55 year olds in Newcastle wards along the Metro:
A 55 year old living in leafy Ponteland can currently expect another 20 years of life free of disability, while in Byker a 55 year old must be content with nine, a gap of eleven years in healthy life expectancy. This scandalous gap is repeated in every city in the UK. Illnesses in the ageing population are a growing drain on NHS resources and remedies are usually proposed at a system level. But these statistics also represent lives that are compromised by ill-health at an age when others, harking back to Chris’ and Louise’s paper, remain active rather than vulnerable and dependent.
Ask a public health professional and they will tell you that there are many reasons for these striking differences in healthy life expectancy between rich and poor: housing, diet, smoking and so on. They also know that public health campaigns to encourage better diet, exercise, quitting smoking, have a disproportionate impact on the better off: ironically, such campaigns are, if anything, increasing the gap in healthy life expectancy between the better and less well off. We are taking a different approach.
It started in the War Studies department at King’s College London. The essence of a war game is to provide facts on the ground, a succinct scenario that players use to inform their decisions within a framework that then evaluates the outcome of these decisions, good or bad. We have collaborated with these war gaming experts to develop a game that sets out the causes and known remedies of the health inequality gap and invites participants to choose the health interventions that they believe, based in the facts, will have most impact. The challenge is to halve the gap with no new money.
With help from Healthworks Newcastle and local Councillors, we have offered the game to residents in Elswick, Fenham and Wingrove wards in Newcastle. They chose which of the diseases that contribute to the health gap to prioritise. Over the six teams in the three wards, the near-unanimous choices were mental illness (the biggest contributor to the health inequality at age 55), type 2 diabetes and heart disease. With the notional but realistic budget that they were given, they were able to reduce the projected gap by 4-5 years. There was a strong focus on local solutions developed in consultation with residents. Fast food takeaways were identified as a concern and calls were made to license them more carefully in discussion with locals, with scores on the doors to identify healthy and unhealthy options. In Fenham, the £2,000 set aside by the ward to fund an outcome project will be spent by the residents on a walking map that will identify and develop activities for 50+ to encourage both exercise and social participation.
Each ward has published a charter for health and well-being, available here. The charters are a call to action by residents who now understand many of the causes of heath inequality and the costs and effectiveness of its potential remedies and, as important, the fact that for 55 year olds it is by no means too late to alter health outcomes for the better in their communities.
For more information, please email: firstname.lastname@example.org
INTEGRATION OF HEALTH AND SOCIAL CARE:
By Professors Chris Drinkwater and Louise Robinson
A rapidly ageing population is leading to an increased number of older people with high levels of chronic illness; as families become more geographically dispersed, our communities will have a growing number of socially isolated, frail older people with complex and considerable health and social care needs. Research has shown that older people are the group most likely to suffer problems with co-ordination of care and service transitions In 2011, the National Voices Patient/Public Organisation stated that ‘achieving integrated (health and social) care would be the biggest contribution the health and care services could make to improving quality and safety’. Findings from other countries such as Canada have shown that integration of medical and social care, usually with a single point of entry and a case manager to assesses need, share information and coordinate care, can reduce hospital use, achieve high levels of patient satisfaction, and improve quality of life and physical functioning; although whether such models are cost effective remains to be proven. Under the Devolution Agreement, a Commission for the NE will now be set up to establish the scope and basis for greater integration across acute care, primary care, community and voluntary services, mental health services, social care and public health, to improve outcomes and reduce inequalities, and report by summer 2016. What can it hope to achieve and what difference will it make? What should it aim to achieve? What is the best way forward?
Much of the current focus in social care is on the assessment, provision and cost of services to those who meet the increasingly stringent criteria for social care funding. The reduction in this funding is an important driver for the integration health and social care. This mirrors concerns in health care about identifying those most at risk of high cost hospital admissions and intervening to reduce this risk. Less attention is paid to the need for a longer term approach to prevent the need for expensive health and social care. It has been argued that in the developed world we now have two life cycles; a developmental life cycle from conception to mid-life and a mature life cycle from mid-life to end of life. If we are going to make better use of the assets that result from the developmental life cycle, we need a more pro-active, strategic approach to the mature life cycle. One option is to think about this as four stages[i]:
- Preparation for active old age
- Active old age
- Vulnerable old age
- Dependent old age
At present the Marmot team estimate that two in three Britons will fail to reach the planned retirement age of 68 free from disability unless action is taken to tackle inequalities. This means that if we want to stabilise or reduce the number of vulnerable and dependent older people we need to tackle the growing epidemic of long term conditions such as obesity, musculo-skeletal diseases, Type 2 Diabetes and the co-morbidity that often leads to general frailty, with much more of a focus on preparation for active old age and keeping people active.
Although this should clearly be a joint agenda the divide is exacerbatedby complex organisational and cultural issues. The most obvious of these is the fact that medical care is free at the point of use, compared with social care, which is restricted on the basis of need identified by assessment of disability and by financial means testing. This is then exacerbated by the political imperative that the cost of the increasing demand for treatment services must always be met. The result of this has seen a reduction in social care and public health budgets, and within the NHS community services have lost out at the expense of hospital services: general practice has lost 25% of its share of the NHS funding in the last seven years, and more recently an under-spend in this budget was used to cover financialdeficits in hospitals.
Political top down attempts to narrow the gap include the Better Care Fund, the Integrated Care and Support Pioneer Programme and the NHS Vanguards Programme. All of these have involved local areas bidding for a share of central money to develop and test new models of care. Although they have produced some interesting new approaches, there is little evidence that they generate cost savings rather than additional cost pressures. They are also more focused on making the current system more efficient rather than fundamentally changing the way things are done. The evidence increasingly suggests that health outcomes are socially and behaviourally determined. A North American study suggested that 55% of all premature deaths are due to social and behavioural circumstances, and in the UK Marmot and colleagues demonstrated, that long term conditions fall more heavily on the poorest in society: compared to social class I; people in social class V have 60 percent higher prevalence of long term conditions and 60 percent higher severity of conditions.
The North East has the highest number of Lower Super Output Areas, which are within the 30% most deprived, and have a higher than average proportion of people with multiple unhealthy behaviours. These areas can also be mapped to high numbers of people with limiting long term illnesses, high numbers claiming out of work benefits, high levels of anti-depressant prescribing and high levels of use of unscheduled hospital care. These areas also have assets: resilient people, voluntary sector providers, and a variety of community groups. However rather than build on these assets, the usual response is that existing services need to be more effective. This can then be compounded by the fact that services tend to be operated and delivered in silos which inevitably results in a fragmented approach, so that someone who is out of work, in debt, depressed, smoking and drinking too much ends up with a variety of service options, none of which take an integrated approach to link all of these together.
The challenge is about how to integrate care and services around the individual in the community in which they live. In addition to adopting a person-centred approach, it is also about creating a supportive network of activities that can promote healthier lifestyles, provide volunteering and employment opportunities and support to vulnerable people. The concept of the primary care home (PCH) is one possible model. The PCH comprises care delivered by an integrated workforce between health, social care and the voluntary sector to a defined, population of between 30,000-50,000 people with a focus on personalisation of care. The model is funded through a unified, capitated budget with appropriate shared risks and rewards. The PCH was developed in North America and has subsequently been taken up in the UK by the National Association of Primary Care and the NHS Confederation. It has a number of advantages: the ability to set a capitated budget according to need; frontline integration of general practice, community and mental health services and social care into a coherent team; better engagement of local voluntary and community sector providers; the option to incorporate input from specialists for care of the elderly, mental health, children and other community based specialities and the potential to develop a local neighbourhood public health approach to unhealthy behaviours.
Another possible advantage of the PCH model is that it could lend itself to a social impact bond (SIB) outcomes based funding model. At its simplest level a SIB is a financial mechanism in which investors pay for a set of interventions to improve a social outcome that is of social and/or financial interest to a commissioner. The added value to public sector commissioners is that it substantially de-risks innovation and the re-design of services with an explicit focus on social and financial outcomes that, in themselves provide a rigorous proof of concept. Newcastle Gateshead CCG has the first SIB in health in the UK, Ways to Wellness, which is delivering social prescribing at scale for up to 5,500 people with long term conditions in West Newcastle with the aim of improving quality of life and reducing demand for expensive hospital services. The North East has its own social investment fund which hopesto invest in viable social enterprises who want to improve their social impact in any of the following areas: homelessness; poverty and debt; health and social care needs; mental health;, offender rehabilitation; unemployment or the regeneration of deprived communities. It is relatively easy to see how a PCH model in a disadvantaged community could develop a SIB model with appropriate outcome measures for addressing one or more of these topics. The challenge for the North East Combined Authority is to establish a support team to identify and work with developing models in disadvantaged areas in each of the local authorities in the area in order to make a reality of the terms of reference of the proposed Commission on Health and Social care.
Christopher Drinkwater is Emeritus Professor of Primary Care Development, Northumbria University and Professor Louise Robinson is Director of Newcastle University Institute for Ageing.
HEALTH AND SOCIAL CARE COMMISSION
By Alastair Balls
In February 2015 the Government and Greater Manchester Council announced a deal (Health Innovation Manchester) under which the £6bn health and social care budget would be devolved to the local authorities to run. It would cover the needs of 2.8m people and was designed to encourage people to have more local control over their physical and mental health.
Initially it drew a storm of protest especially from local Labour MPs who felt they had not been involved in what is a major change in the arrangements of a most important service. Andy Burnham, then shadow health secretary, claimed it held the dangers of a two tier health service developing in England. But since then matters have settled down and the council chiefs have set about implementing their new powers. They were amongst the first to announce the introduction of 7 day GP access from December 2015 though it is yet to see how far this innovation has been implemented or indeed works.
In the North East the government has adopted a different approach to the devolution of health and social care. Includedin the devolution settlement to the7 authority Combined authority – indeed regarded by some as the centre piece in the devolution deal - is the setting up of a Health and Social Care Commission to be composed of all the existing health bureaucracies of Foundation Trusts, Local authorities and Local Commissioning groups plus representatives of local voluntary groups; the Commission is to be chaired by Duncan Selbie the Chief Executive of Public Health England and is to report by summer 2016. The Commission is to look for ways of achieving greater integration of all services, to improve outcomes and reduce health inequalities (which are most marked in this region). It is to look for the most appropriate mechanism for devolution, to seek ways of greater collaboration, and where possible joint management regime and joint accountability.
But it raises other major issues. According to the Combined Authority, Health and Social Care in the region is both financially and clinically unsustainable. Regular reports suggest that, due to local government underfunding, the care home sector is in financial crisis and the quality of care offered to older people well below standard. This raises the questions of the totality of health funding in the region and share out between the NHS and local government. On questions of management the issue arises of how to match and co-ordinate the differing cultures ofthe NHS and local government particularly in the challenges of integration which occur generally a the local community level.
Recent opinion polls in the region indicate that the public puts NHS/health at the top of the list of issues they are concerned about in the devolution context. It is critical therefore that in the next 6 monthsthere is open accountability on the workings of this Commission and we understand how they are tackling these issues, what obstacles they encounter, and the how ambitious they set their targets to achieve a better delivery system for our region. We would prefer for this not to be done behind closed doors.