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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How do You Solve a Problem Like………..£50,000,000?!!

On Friday night, watching comic relief, I got quite excited as the total neared £50 million – I turned to my lovely wife and said – ha – there now, we can plug the gap in our local health economy for next year! (Obviously the money is desperately needed in many situations across the UK and Africa, so I wasn’t being flippant), but – that’s the target we’ve been set by the government in Morecambe Bay – save £50 million pounds – one tenth of our budget in 1 year!! Sure thing! The public just love to hear about cuts! Comic relief – you have to laugh, or you’d cry……..but the situation isn’t really very funny and yet, if we don’t head into the fray with some joy and hope in our hearts, we will become wearied very quickly.

 

Let me frame this problem by stating something we must then put to one side. Professor Don Berwick, health advisor to Barack Obama, and president of the IHI (Institute for Health Innovation at Harvard – a clever man by all accounts) recently stated very clearly to the Department of Health that it is quite simply not possibly to continue having a National Health Service run on only 8% of GDP (the lowest spend on healthcare of almost any OECD nation). We must also put to one side the recent publication by the King’s Fund, the independent think tank, that states quite clearly that the government are not investing anywhere near what they promised they would  in the NHS. It also demonstrates that the NHS is not a bottomless pit, as some of the media would have us believe. Read it in more depth here:

(https://www.kingsfund.org.uk/topics/productivity-and-finance/nhs-myth-busters)

 

We know we need more funding. We know there is much negativity in the press about the crisis we are facing, we know about the recruitment issues and we know about the low morale of staff and high strain on the service.

 

Having put all of that to one side and accepting that the NHS remains a political football, currently being given a good kicking, we do need to have a sensible conversation. Whether we like it or not, as we look into the future, it is unsustainable for the health and social care system to have to allocate 1/5th of its budget as a direct result of our lifestyles, 1/10th of its budget on diabetes (the vast majority relating to type II, which is hugely preventable and reversible) or to double pay for beds in nursing homes and hospitals because of unnecessary admissions. So…..what are we to do? Simon Stevens, the head of the NHS will, this week give a major speech on the direction the health service and the progress of the Sustainability and Transformation Plans (STPs), of which there are 44 across England – they have little chance of success if we do not believe that we are all in this together.

 

It truly involves all of us! We, the people, together must face this problem head on. We do not have to turn on each other in a time of crisis, we can turn to each other and use our collective wisdom and gifts to find a way through. This does not have to mean doom and gloom. It could mean better community cohesion, a more positive way of working together across the system, organisations working collaboratively in a way that makes more sense for those who need help and all of us taking a bit more responsibility for our own health and wellbeing. We must learn to rebuild the very fabric of society, based on love and trust, de-professionalise the public and civic space (as per Cormac Russell) and reconnect as human beings who care for each other and want to have systems that serve our needs. This will be made possible through multiple, small and large conversations in which we take time to ask some really deep and important questions, holding the space through the process of frustration as we wrestle together for solutions that we can all work with.We don’t leave our brains and expertise at the door, but nor do we behave in archaic hierarchical ways or hide behind our name badges and lanyards.  Here in Morecambe Bay we have started this very process, using a set of values from ‘the art of hosting and harvesting conversations that matter’ – here is a link to one of our conversations in Morecambe:

http://aohhealthandwellbeingmorecombe.weebly.com

 

Over the next two years, our team will be working with communities right around this Bay to ask and explore some important questions, such as these:

 

  1. How do we begin well? Put another way – How do we enable our children to have the very best start in life? (This may include areas like breast feeding, bonding, parenting, healthy food, exercise and the massive public health issue that is child abuse – or adverse childhood experiences, or maybe issues like indoor vs outdoor learning, music, arts, sports, targets, sex, screen time, social media etc) – what are we going to do about this as a society?
  2. How do we live well? How do we face some of the issues we are now having to tackle? How do we square up to some of the nonsensical adverts, learn to laugh at them, rather than be sucked in by them and change the message?! How do we reconnect, heal our divides and learn to live well alongside each other? How do we heal our past traumas that have such a huge impact on our health and wellbeing now? How might we build the kind of economy that cares about people and the planet? How might we live in an altogether more healthy way? How do we become less dependent on a medical model to fix our problems and take a more holistic view of what it means to be well?
  3. How do we work well? How do we create work that cares for the future and sustainability of the planet? How do we work in ways that are beneficial to our health and by doing so actually help us to be more effective and efficient? How do we create a culture of kindness and compassion in our workplaces?
  4. How do we age well? How do face retirement, without it becoming  only a selection of cruises and alcohol (biggest problem drinking now in women over 60)? How do we connect three generations back to each other and enjoy life more fully together? How do we live well with increasing frailty and health issues? How do we understand the conditions we live with and learn how to manage them ourselves (self-care) as effectively as possible? How do we create the kind of social care that is compassionate, caring and serves to create community?
  5. How do we die with dignity? We must ask ourselves some difficult questions here. Why do we admit so many people to hospital from nursing and residential homes, when there is little evidence that they get better any faster and then end up blocking the beds? Why are we not more radically reallocating resources out into the community to care for people in these settings and in their own homes? Why are we so afraid of our own mortality and allowing people to die well in environments that are familiar to them, surrounded, where possible, by people who know them and love them? How can we face our own deaths well and plan for them in a way that makes the end of our lives better for us and those around us?

 

If we take each of those questions in turn (as we plan to do) and really talk together about how we make society and therefore our health and wellbeing better for everyone, rather than leaving it to others to make those decisions from on high for us, then I think we will achieve more than we could ever imagine possible. It is in discovering one another, in encountering the other that we can be transformed and find new ways forward together.

 

A people movement or social movement such as this will invigorate and create space for those within the systems not only to reconnect with our own humanity but enable us also to have braver conversations about how we can share our resources more effectively, work together more creatively and reimagine how we can provide the kind of health and social care that makes sense for the needs of the people we serve. We might not save £50 million, but we can’t continue with things as they are and if we talk and work together, we could make a really difference.

 

 

 

 

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We Need to Be Ambidextrous in Solving our Health and Social Care Conundrum

Tweet All this week on the BBC, there has been a focus on the NHS and the crisis we are in – don’t panic Mr Mainwaring…..There is a heady mix of opinions being thrown around – Question Time became quite a furore of ideas and thoughts last night – not enough beds, not enough staff, not [Continue Reading …]

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