Let The Children Play!

In The Guardian today, there is an article in which the Children’s Commissioner, Anne Longfield, is calling for more adventure playgrounds across the country, especially in our ‘poorer’ neighbourhoods. She believes we need more play schemes across the country for the long summer holidays which she argues are having a profoundly negative effect on children’s physical and mental health. Most starkly, she cites a study in which “primary school children lost 80% of the fitness levels gained during term time. The poorest 25% experienced a drop in fitness levels 18 times greater than the richest 25%”. Sadly, this undoes some of the great work of schemes like ‘the daily mile’ in schools and has hugely negative consequences in terms of future health risks.

 

I would personally therefore welcome such a move – it is absolutely the case that increased active play and exercise improves a child’s physical, mental and social health. There is no doubt that more facilities, especially located closer to home would be better than having none at all….but I don’t really think it’s quite that simple (and for the record, I don’t think Anne Longfield thinks it is that simple either, she is a great champion for children across the UK). There is a danger, that by saying children need to play more, that it gets oversimplified by policy makers and could perhaps sound a little too Marie Antoinette! Yes our long summer breaks are becoming like ‘battery hen’ experiences for many children across the UK, but simply building them more parks is not going to change this, and I can give you few reasons why.  To understand why kids are spending more time indoors and on screens, we need to dig a little deeper into some pretty uncomfortable truths and wrestle with the complexity of them.

 

I have a friend, who is one of the kindest and best people I know. On top of his very heavy work schedule, he invests an enormous amount of time into young people, who are often living with really challenging circumstances. Every summer, he runs activities for them, right through the summer break and does extraordinary things. Ten years ago, when he applied for funding through a variety of grants (and let me tell you he is a seasoned wizard at winning bids for such things) he was getting £20k for a packed out summer programme. These days, he struggles to raise £4k. That leaves the situation in which he is having to ask families to contribute more for the care of their kids over the summer. What this leads to is a drop in numbers and more kids stuck in at home.

 

I have another friend, who runs a school in one of our most deprived communities. Throughout the summer break, her school opens up to ensure the kids from the locality do not go hungry and so that families can afford to eat. There have been emergency appeals from many food banks this year. Many working families are seriously struggling to provide both childcare, through the long summer breaks and food….there are some really tough choices to be made. Out of 50 young people on a local holiday scheme, that I know of, 19 of them were relying on daily food parcels, meaning they have no idea from one day to the next what they will be eating and actually no choice about it. When you are working two jobs and struggling to make ends meet, what else can you do with you kids? Just let them roam the streets?

 

I know a police officer who works on some of the toughest estates in the UK. He tells me that the war on drugs has utterly failed and the gangs are absolutely running the show. Cuts to the policing budget and massive stress levels in the force, as a result, are seeing whole neighbourhoods overrun with crime. The play parks in these places are totally unsafe. No parent in their right mind would let their child out to play in such an environment. It’s a bit different in leafy Surrey or middle class suburbiaville. Without police to build relationships with young people and keep the streets safe, simply building new parks or putting on play schemes will not be enough. Without children’s centres, youth centres and health facilities readily available (many of which have been closed or privatised and so less affordable to communities who need them most), there are less places to go.

 

If I’ve learnt anything over the last few years, it is that we have to stop coming up with schemes that we think are good for communities and simply delivering them. We have to really learn to listen to people’s stories and the complexities of their situations and from that place hear what it is that they want and need and then create real partnerships to bring about that change together. Hilary Cottam is all over this in her brilliant book ‘Radical Help’, which is a must read.

 

I love that Anne Longfield, Tanni Grey-Thompson and Sarah Woolaston see this whole issue as being so massively important. Play schemes and parks and cutting sugar (though all excellent) will simply not be enough in and of themselves to get kids out doors and playing in them. We need a a very holistic approach which starts with communities, hearing what their dreams are for their kids and hearing the hopes and desires of the kids themselves. Next we need to understanding what the steps will be to get there. Then we have to build that together. I would suggest a great place to steward this kind of resource would be through health and wellbeing partnerships, like the ones we have in Morecambe Bay. Cross public and voluntary sector partnerships, rooted and working well in their local communities. But I can also guarantee, that this idea will require the right kind of resource – appropriate funding of the required schemes, affordable access to facilities, work that pays a decent wage so families can afford to eat and taking the safety of our streets seriously. That is going to take both a reimagining of youth work/social provision and appropriate help and resource to a diminished and struggling police force. Bring on the parks, but first listen and make sure they can be used!

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Four Circles of Population Health

In my previous blog in this series, I wrote about the ‘Pentagon Model’ which we have developed in Morecambe Bay to help us think about how we manage Population Health. The Pentagon approach actually forms one of four parts of some over-lapping circles, based on 4-Ps (Population Health Approach, Partnerships, Places, People Movement), which give a more holistic view of what is involved.

 

At the heart of the model we are working with, sits the people and communities who live in Morecambe Bay. Communities can be geographical, communities of interest (e.g. faith-based/workplaces etc), or transient (e.g. students). We are absolutely passionate that we do not do things TO people and communities, but rather, guided by the brilliant principle that ‘nothing about me, without me, is for me’, we do things with the people and communities we are trying to serve. We look to co-design, co-create and co-produce our services, because the services belong to the people. This takes culture change and some new thinking on our part and we are learning to work differently.

 

Our Venn-diagram gives us a framework with which to think about Population Health more clearly. The Population Health Approach Pentagon of prevent, detect, protect, manage, recover really forms one of the circles. Included within this, also, are a few other important factors. Firstly culture. If we don’t get culture right, then we don’t get care right. I’ve done three separate vlogs on the kind of culture we are trying to embed across the health and care system in Morecambe Bay – Joy, Kindness and Excellence. Secondly, we are redesigning work around various different health problems, for example, diabetes or respiratory problems WITH people who actually live with those conditions and use our services on a regular basis, building pathways for people that actually make sense and work for everybody. Thirdly, we are taking time to really understand the data available to us through many sources and using it to enable both the leadership team and our local teams to make informed decisions about where we need to focus our efforts to improve care.

 

More than ever before it means that we need to share resources with other organisations in order for us to be able to cope with current budget constraints. It also means that we have to think very carefully about where we align our resources. One of the issues for us in population health is that we have never really tackled the growing health inequalities in society. It is simply NOT OK that some people in this Bay die 15-20 years earlier than people who live 6 miles down the road. It is also NOT OK, that it is in these areas of higher deprivation, where we also see more complex medical and social problems, but do not allocate the money or the staffing to cope with the increased demand. And yes – it is true, that the problems are complex, and so money and resource is not the only answer, but it is definitely a part of the answer! If we’re ever going to make an inroad into changing the health of our population and tackling health inequality, we need to apply the triple value approach of Professor Sir Muir Grey – of how we prioritise our resources. (http://www.nhsconfed.org/blog/2015/05/the-triple-value-agenda-should-be-our-focus-for-this-century). Here is a short clip about it, if you’re interested! (https://vimeo.com/155569869).

 

Partnerships are absolutely key in improving the health of the population. There is so much cross over between county and city/district councils, the police, the fire service, the NHS in it’s various guises (including mental health, GPs, acute hospital trusts and community services), the CVFS and indeed the business sector. The relationships at strategic-leadership level and within each locality are the oil that allow us to work effectively together. It is only through honest, transparent vulnerability that we learn to trust each other and to share the resources we have to serve the needs of the population. As social care continues to sit under the remit of the County Councils and Health remains under the NHS, increasingly devolved into the regional Integrated Care Systems, without a deeper and more shared accountability and effective working together we will not have the necessary leadership to enable local team to transform the future of care.

 

This is where Place becomes really important. It is harder to get culture right, and build relationships that really work well if we’re always talking about “working at pace and scale”. As services are reconfigured, it is important that team structure allows for small enough teams to enable good working relationships to happen and that the necessary work is done to get culture right! I was in conversation with Professor Sir Chris Ham, CEO of the King’s Fund, and he is adamant that it is at this local neighbourhood level where the real change takes place, because this is where we are able to work with people and our communities in a very real way. That’s why we are so passionate about our Integrated Care Communities (ICCs). This is where, in a very relational way, traditional barriers between organisations are broken down and new bonds are formed in working together for local communities across the public and community-voluntary-faith sector (CVFS). There is a real danger that we focus so much on the ‘super structures’ and put huge time and energy into reorganising the system and lose sight, in the process, of the very thing we are trying to do, which is to make care better! Our ICC teams must feel the full permission and receive the resource needed to do this transformational work.

 

The reality is, however, that unless we have a people movement for improved health and wellbeing, nothing will change. The issues we are facing health and care-wise are incredibly complex and multi-faceted. In Morecambe Bay, we currently spend £1.20 for every £1 we receive. We are doing our very best to try and reimagine how we deliver health and social care, working more efficiently in partnership and redistributing resource where we can – but when we are all in financial deficit (and in our local NHS we need to cut our cloth by £120 million over the next 3 years – 1/5th of our total budget) when we have already had some eye watering cuts to the county councils budgets, especially in the area of public health, there is only so much we can achieve! We understand the frustrations that people feel when it comes to health and care, but we cannot fix it from within the system alone. There is a need for us all to recognise that things we could provide a few years ago may no longer be available or not within the same time frame as previously. It would be wrong of us as health leaders to simply make changes without the communities having a say. But for example, if we are to improve our Children and Adolescents Mental Health Service in South Cumbria (which is desperately needed), we might, as an example, need to do less knee and hip replacements……we simply can’t afford it all, with our current allocations of resource and staff, and therefore we need local people to work with us on this, and help us work out where our priorities should be. We know, if we don’t involve our communities in these decisions, complaints will go through the roof, which drives down morale and is utterly exhausting for teams to deal with. However, we are going to have to be brave in some of our decision making.

 

As a society, we also need to all be more healthy and well, taking care of ourselves and each other.Some might argue this is all down to personal choice. Of course, there is some choice involved – however, when you read the National Audit Office report (https://www.bbc.co.uk/news/education-44468437) into the huge difficulties Universal Credit is causing, and the Joseph Rowntree Foundation Report into Destitution in the UK 2018  (https://www.jrf.org.uk/report/destitution-uk-2018) then you begin to realise that it is easier to make healthy choices in some communities far more than in others. These are inconvenient truths, and need to be reflected upon with due diligence. There is a danger that we choose to work with highly motivated communities to improve health and wellbeing and actually make health inequalities worse. However, if we really listen to what is going on with local communities and work together, we can do some great stuff . Work from the University of Birmingham shows that if we can see a change in just 3% of our population, then this will have an effect on 90%. As the work in Canterbury, New Zealand shows though, this takes time and relationship – the process is actually more important than the end product. And for an under-resourced, already exhausted community, supporting any social movement requires investment at many layers. The NHS 5-year forward view and the learning from the Institute for Health Innovation both recognise that social movements/people movements are key to transformational change. We must press on with this work, and base it on a foundation of love and collaboration if we are really to change things together. So, this is why we are so passionate about really working with our communities, here in Morecambe Bay and will continue to host  and hold space for community conversations. We are talking about many things, from economic development,  to childhood, education, loneliness and mental health. These spaces are vital for us to connect together, hear one another, meet people who are different from us because it is only together that can reimagine a future that is good for the planet and socially just for humanity.

 

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Inconsistent and Incongruent Messages

Tweet The King’s Fund have just released an excellent video to help explain how the NHS works and some of the complex things going on in it at the moment. It doesn’t shy away from making it crystal clear who is in charge of the money, nor the difficulties we’re facing in staffing and resource [Continue Reading …]

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What Every Northerner Should Know About the North/South Health Gap

Tweet Everybody knows about the Gender Pay Gap – it’s well publicised and very much in the public domain for discussion – and too right! – How is this even still an issue? It it is quite simply wrong that women should earn less than men, any time, any place, end of discussion.   Well the [Continue Reading …]

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