Are we ready to support the governments health mission?

Diagnosis and treatment.

The new governments Independent Review of the National Health Service by Lord Darzi confirmed what we have all known for some time, it is in crisis but recoverable. The political response as many expected includes reforming the NHS, the devolution of more services into communities and a further commitment to prevention. Although detailed proposals will not emerge until next year the indication was any funding to expand community services and prevention may have to wait until the reforms yield greater efficiency in hospital services. At least we do know that reform will not mean further structural reorganisation with an acknowledgement that Integrated Care Systems are here to stay.

?Lord Darzi a week later released a second report and it is here that we may find numerous clues about what may emerge next year. In a recent Guardian article he said “I have released a second piece of work – the final report of the IPPR Commission on Health and Prosperity – which I have co-chaired with Dame Sally Davies, former chief medical officer, for the past three years. Last week I focused on the diagnosis, but this final report turns to treatment. Given this, it may seem ironic that the focal point for this piece of work is not the health service at all, but almost everyone and everything else. This should not come as a surprise. While we might spend a few weeks or, if we are unlucky, months of our lives in hospital, we’’ll spend years of our life in work, school and in our communities. If we want to stem the rising tide of demand on our NHS, we need to look at what is happening beyond its hospitals and clinics. This is the “pivot to prevention” that successive governments have talked about but failed to deliver on.” This second report is a fascinating insight into the scale of shift envisaged and enables us as a sector to now prepare to contribute to both the policy development and future delivery.

?Although the sector welcomed the direction of travel towards community and prevention in the first Darzi report I am not sure those behind the report were defining prevention as we would. Strategically, prevention is very much viewed in the terms of Marmots social determinants and health inequality with lots of references to poverty, good employment, homelessness and poor housing and early years all seen as responsible for putting the pressure on health services, alongside the recognition that social care must be fixed to help older people both stay out of hospital and leave hospital quicker. But operationally, prevention is still viewed through the traditional lens of public health with references to health promotion, vaccination, sexually transmitted diseases, smoking and vaping, alcohol and drug abuse, diet, and obesity, all factors driving demand alongside the growth from declining mental health. We have seen already that legislation is on the way to reduce junk food advertising and the return of the smoking and vaping bill with even more restrictions. But I do not recall reading in the report or in media reports, any direct reference to physical activity and being more active. Just because prevention and community-based services are back on the political agenda does not necessarily mean that the door is now opening to sport and physical activity being better recognised, and new funding starting to flow. Clearly the case still needs to be made but in a very different political context.

?Health creation and pivoting to prevention.

I am more optimistic having read the second Darzi report where the focus is on a much more holistic and less medical solution. There are many interesting and innovative ideas in their plan. A focus on ensuring that people work in healthy environments and can maintain their working lives after illness or with a disability through fair pay, flexible working, better work life balance, improved work standards and easier access to health care. Also, the idea of health levies to incentivise businesses to move away from products and services that damage our health with the revenues from these levies funding prevention. A new focus on early years and providing the right start for children including the restoration of Sure Start, and nutritionally improved free school meals. The concept of healthy places with a focus on the poorest ones through designated Health and Prosperity Improvement Zones with a better sharing of what works, and a need to restore healthy infrastructure lost over recent years including leisure centres, swimming pools, parks, libraries, community centres and youth centres, all seen as vital to sustaining healthy communities. Finally building and supporting greater community powers to protect and develop these assets. The report ends with proposals on greater devolved governance and proposals to fund these changes which reads very much as an agenda for cross-government action.

Whilst all these specific ideas will not emerge in policy next year, I do believe the underlying concepts in this report will. The link between health and prosperity, the switch from managing illness to health creation, the pivot to prevention, greater devolution and community empowerment and the focus on priority places and health inequality. Our challenge now is to shape our response in these same terms and stop looking at it as just a ‘dash for cash.’

?A supportive narrative.

This years’ spending review and budget will deal with some of the current financial pressures, and it will be difficult for councils and the sector over the next year. But after the budget is out of the way there will be the switch to shaping longer term policy with the creation of cross government policy forums based on the five missions including health. What is becoming clear is that there are political intentions to focus not just on new policy and funding but on better deliverability. This was confirmed by the appointment of Sir Michael Barber as an adviser to the Prime Minister on effective delivery which will include setting ambitious, measurable, long-term objectives that deliver change. Part three of the second Darzi report sets out the commissions ideas for delivering the health mission including hardwiring health creation across government. It sees a shift in the government’s role from a top-down command and control function to a role of enabler whilst still holding to account those responsible for delivery through mission boards. We must prepare now to support this mission driven policy making process by not only making the case for sport and activity and presenting the growing evidence but also showing how we would actually deliver the change required and what we need to help us do that.

?In the summer we formed the Place Based Physical Activity Leadership Network to do just this. By bringing together organisations and individuals who are already making a difference we are creating a network of people who can help support the policy process with innovative solutions that we have already seen make an impact. We do not see this group as just lobbying for the sector but see it as helping the government design and deliver their mission.

?In our first thought piece on An Active Wellbeing Service we have already started to shape a future for the sector that is in tune with much of the emerging thinking. Our four cornerstones are consistent with the thinking, place-based working, system change and system thinking, proportionate universalism and the pivot to wellbeing. We have shown how the change is already happening through several case studies from around the country but pointing out that they are representative of pockets of great practice that needed scaling up. Listen to the Andy King Conveners podcasts and you will hear even more innovative ideas from passionate practitioner’s working in this field and recently further evidence emerged from the evaluation report into MSK hubs.

?Given the new political context it feels as if we are, as a sector, at our own pivotable moment when we must switch from just lobbying and advocating our case to demonstrating how we would make it work. We need to shift these pockets of innovation and good practice into defining what an active wellbeing service looks like and how it will function. We need to explain that we have a workable, sustainable and cost-effective solution? Reading the two Darzi reports it strikes me that we need to be less generic in our pitch that simply claims activity improves health and be much more granular in demonstrating the different roles we can play in terms improving the performance of the NHS, supporting the transfer of more services into community settings and supporting prevention.

?Healthy places.

Our sport and leisure, arts, libraries, heritage, play, and park services are all valuable partners in creating healthy places to live. We are the providers of the declining infrastructure referred to in the second report, keeping people healthy, happy and engaged, teaching every child to swim, helping give children and young people the best start in life and help divert them from less healthy lifestyles and into employment. Helping build more cohesive communities and build active citizenship. Helping keep people healthier for longer particularly older people, helping tackle loneliness and isolation, supporting homelessness and helping tackle drug and alcohol abuse and declining mental health. An Active Wellbeing Service has the potential of taking the concept of prevention way beyond just health prevention and into a much wider concept of prevention that reflect Marmots wider social and economic determinants of health inequality.

?But we need to agree with councils, the owners of these assets, a new business case and a business model that ensures we serve all communities and particularly serve those priority places where those most deprived live. We must start by acknowledging that we have not done this well in the past and a client enforced commercial model that has driven financial sustainability above all else has also helped us make health inequality worse not better by serving mostly those who can pay. We need to demonstrate to councillors that these assets are not drains on their budgets or ‘cash-cows’ to solve their budget problems but central to creating healthy places. We need to negotiate not new commercial contracts but partnership agreements that work better for everyone; we do not need subsidies to keep prices low, we need targeted and incentivised investment that delivers better outcomes for those that need help the most. But we also need to accept that commercial operators and trusts may not be the best providers in our most deprived communities and transferring public assets to the community itself to run or locally trusted community organisations may be a better option. But they need viable long-term funding that may mean transferring the profits from the more commercial operations to support these community organisations. This model need not only be about leisure centres and pools but also about voluntary sports clubs and private gyms and health clubs so encouraging greater collaboration across the whole system.

?Community health services.

If we can protect and enhance these assets we can then take the opportunity to utilise them to support a range of community-based medical interventions aimed at supporting various health pathways both for physical and mental health, including cardiovascular diseases, cancer, diabetes, musculoskeletal, pre-hab and re-hab including back to work, alcohol and drug abuse, dementia, and strengthening and mobility support to lower the risks from trips and falls for older people. Such services would also support in particular those with long term conditions to be more active and move more in community accessible settings as recommended by the Richmond Group of Charities in the report Millions More Move.

?However, with these opportunities comes the need to address quality, safety, and clinical governance, otherwise the NHS will not signpost or refer. We must be able to operate in their frameworks (NHS Digital, ORCHA, CQC) and adopt those kitemarks/certifications to validate our programmes to be aligned to the NHS. We need to move to meet them, they are not going to meet us, and using their frameworks and language consistently will be the most efficient route to achieve this.

The challenge then is who pays, the patient or the public purse. Of course being part of the NHS we would expect services to remain free at the point of delivery however we need to remember that many of us already have to pay ￡9.90 for every prescription item with exemptions for those on some benefits, under 16’s, those in full time education, pregnancy, over 60 and some with certain medical conditions. The NHS will need to acknowledge that some services cannot be free and will involve some element of personal payment but with similar exemptions funded though ICB commissioning in accordance with local health needs.

?Next, we need to build conference and greater visibility with both primary care and secondary care to resolve how patients would be referred to these services and how demand and supply is managed within the financial constraints of any commissions and the capacity of providers. If we, for example, look at current GP referral schemes we would not find any consistent model. Few GPs currently recommend/signpost to physical activity and exercise. Some lack the training, some lack the awareness or the confidence to do so.? Any GP referral route will need some form of incentivisation given GPs are themselves businesses and already under pressure to meet current patient demand. Also to work effectively and efficiently for GPs the activity based interventions will need to be included in Medical Expert Systems so they recommend activity-based treatments where there is medical evidence to support this, alongside automated referrals to the appropriate local service centres. Some examples of this already exist and if referrals are also to come from hospitals similar automated arrangements will be required across the whole NHS. And schemes that had established specific criteria for the availability of the service could also then accommodate people who may self-refer.

?In addition to these developments, we know investment would also be required in the many independent suppliers that include national operators, local trusts and council in-house operations. They will need access to IT systems to manage patient records and reporting and automated triage to help signpost patients to the right sort of activity, also investment in staff to ensure they have the right skills to provide the range of services being prescribed, common standards and accreditation agreed with the NHS, and consistent methodologies to collect and measure impact acceptable to ICBs and national government. There are already many examples of these being developed across the sector, but they exist in the same pockets and need scaling up in a consistent way across the sector.

But could we go even further? Why could we not co-locate our leisure-based health and wellbeing services alongside the suggested new primary care hubs so when patients visit a health practitioner, they are already amid welcoming activity environments and seeing other people being active and enjoying themselves. Is this not the new vision of a health service envisaged by the government?

?Our healthy places business model could then be supplemented by the income from self-referrals, ongoing memberships and other self-funded activity-based interventions. But it would still be some time before a fully sustainable service emerges notwithstanding any capital costs required to cover the initial set up costs. In our paper ‘An Active Wellbeing Service’ we suggested that the government introduce a prevention threshold for ICB budgets, requiring ICBs to allocate initially 1% to prevention, through commissioning strategies overseen by Integrated Care Partnerships and councils create a ‘prevention precept’ enabling all local authorities to generate up to an additional 2% of council tax revenues for service transformation linked to prevention. This would provide some of the resources to meet these initial set up costs and get an active wellbeing service functioning.

?Conclusions.

The two recent reports from Lord Darzi have set the scene for the governments’ health mission. One describes the diagnosis the other starts to define some of the treatments. They now give us a chance to start and prepare our response which will require us to present not just our evidence but our approach to delivery. To be more successful in integrating more effectively within the context of an ICS then the sector needs to develop a more effective and consistent narrative with an equally consistent language that accords with, is aligned with, and is understood by the Health and Care System. It needs to be supported by evidential examples of exemplar practice such as those provided in our document, An Active Wellbeing Service. Our narrative will need to be much more granular, responding to the concepts emerging in the reports. We need to demonstrate our role in health creation, how we aid the pivot to prevention, our role in creating healthy places and our role in taking some of the pressure off the NHS by providing services at the very heart of communities. But An Active Wellbeing Service has the potential to reach beyond just health prevention into other policy areas where a greater investment in prevention would yield other long-term benefits and financial savings. We should not at this stage limit our ambitions just to health.

?But a narrative alone is not enough, we need to answer many of the questions identified above and put in the hard work to develop the infrastructure to make it work. Simple incentivised referral systems for GPs, online Medical Intervention Systems recommending the use of activity and automated links to local activity providers also available inside the NHS, IT systems for patient management, standardised staff retraining, a national accreditation system that health practitioners will have confidence in when commissioning and prescribing and a national evidence measurement framework that enables commissioners and government to consistently measure and evaluate their investment and measure impact and value for money will all need to be developed not in isolated pockets as now but consistently across the country. There are already many examples of these developments happening for example in Sheffield with a consistent approach to Exercise Referral and in Stockport with the development of an Active Pathway, a comprehensive and connected approach to triage but they now need scaling up.

?If the work on the cross government missions begins soon after the spending review and policy development feeds into the next spending review starting in the spring which will set budgets for the next few years, we have limited time to get our act together and be ready to contribute to the health mission the government want to deliver.?

?

Martyn Allison

With thanks to members of the Place Based Physical Activity Network for their contributions.

3rd Oct 2024.