If We Want to ‘Level Up’ We Must Change The Funding Formula

“Talk is cheap” – my Dad used to say this to me, if I told him I was going to do my chores but didn’t do them. It was a fair challenge to my teenage self! It’s ok to have good intentions, but if we don’t act to back up what we say, then our words are meaningless. One of my most recent blogs explored what we can do to tackle poverty and health inequalities. One of the things I didn’t focus on, but which deserves a blog all to itself is the inequality caused by and the social injustice which is perpetuated by the funding formula used within the NHS. I will demonstrate, using a few examples why this formula is so antiquated and suggest that the ‘Morecambe Bay Formula’ which we have developed might be a better model for the future if we want to put our money where our mouth is! I’m sure with Boris Johnson’s ‘levelling up’ agenda, that the time has come for us to take this seriously.

 

The current Carr-Hill Formula takes into consideration various factors. Generally it’s what we call a weighted-population formula and distributes money and resources according to various complex factors but puts insufficient weighting on the issue of deprivation. What this means in practice is that wealthier areas (like the South East) have significantly more money, per head of population, spent on them than areas (like the East Midlands or the North West), where poverty rates are much higher and health outcomes are significantly worse.

 

Let me give you two examples from here in Morecambe Bay as to how that makes little or no sense if we are serious about levelling up.

 

Here are a couple of graphics showing how life expectancy changes along two different bus routes around Morecambe Bay (recognising that these are averages within these towns and are significantly worse within some more localised wards):

You can see the stark differences in life expectancy between people who live in Barrow-in-Furness and those who live in Ambleside, or those who are in Heysham compared to those in Levens. People in our areas of 10-20% lowest Index of Multiple Deprivation (IMD) are dying 10-15 years earlier than their counterparts in our wealthiest wards. Surely we care enough about this to want to change things?!

 

So, our team did a little exercise in which we thought together about how we might spend £500k, if we were going to try and ‘level up’. Our Bay, is broadly divided into three districts. The Furness Peninsula, South Lakeland and Lancaster District (which is basically North Lancashire). We divided the area up according to the lowest 10% IMD and distributed the money accordingly, knowing the kind of projects we could invest in to make a difference to people’s life expectancy and wellbeing. The results were stark! We found that out of £500k, we would spend around £232,000 in the Furness area (predominantly wards in Barrow and Millom), £267,000.50 in Lancaster District (predominantly Morecambe/Heysham and some wards of Lancaster) and just under £500 in South Lakeland! £500 out of half a million! But that’s how stark the differences are in our Geography of around 1000 square kilometres. When we then changed this formula to be based on our lowest 20% IMD areas, the South Lakes still only ended up with just over £1000.

 

We’ve also recently done a review of how many people in each area are living with Long Term conditions. What is very interesting is that in two almost identical areas in population size (Lancaster and Morecambe), but one with significantly more areas of increased deprivation (Morecambe), people in that area have a higher number of Long Term Conditions (LTCs). However, when it comes to the allocation of resources into the Primary Care Networks, working in these two areas, this is done on the size of the population, not the complexity of what those populations are dealing with. So, even though there are far more people living with multiple LTCs in Morecambe, compared to Lancaster, they are both allocated the same number of staff through the PCNs to deal with their relative problems.

 

This means that areas like Morecambe and Barrow are missing out twice over. They are not getting the money into their areas in the first place to allow them to level up on the ’causes of the causes’, as Sir Michael Marmot puts it, – i.e. they are not able to get into good preventative public health AND they are not given a fair weighting when it comes to helping those who are already living there with significantly more complex health needs. This means teams working in places like Morecambe can find it harder to recruit and their teams can suffer easier burn out, or are simply unable to provide the help to their communities that is needed. We know that economically poorer areas have higher populations of BAME citizens also, which is vital to understand if we’re serious about ‘Black Lives Matter’.

 

This injustice needs to stop if we are serious about tackling health inequalities. Talk is cheap. It’s time to put our money where our mouth is. We can’t just talk about levelling up, we must do it! We need action and that action needs to take the form of a recalculated funding formula, which ensures that the communities that need the most help are able to get it. When it comes down to it, I’m a pragmatist. There are pockets of poverty, even in our wealthiest areas and issues like frailty can make the provision of care more expensive (though one could argue that in poorer areas, we’re dealing with frailty 10-20 years before it is seen in wealthier populations). So…..we need to do two things:

 

  1. We need to change the way funding is given through the Primary Care Networks to ensure that those who have the greatest task, get the greatest help. This needs prioritising by the national leadership team.
  2. We need to ensure that we create a funding formula from the National  Team into the Integrated Care Systems in each of the regions and then within each ICS that recognises the complexities we’re dealing with when trying to level up. The funding formula based on IMD (either lowest 10 or 20%) is indeed quite extreme – perhaps it needs to be. Perhaps a more realistic formula is to to weight it 50:50, with half of it calculated according to the lowest 20% IMD and half according to the Carr-Hill Weighted formula. This has gained broad support across the board in our part of the world. We call it the Morecambe Bay formula (though it is with huge thanks to Mark Wight and Anji Stokes!). We believe it is far more socially just.

 

 

Share This:

Share

Population Health – The Pentagon Approach

Here in Morecambe Bay, thanks especially to the excellent work of Marie Spencer, David Walker, Jane Mathieson, Hannah Maiden and Jacqui Thompson, we have together developed a way of thinking about population health, which we call the ‘Pentagon Approach’. It draws on learning over a number of years from Public Health England and the World Health Organisation, and synergises nicely with the vision and approach of our excellent Directors of Public Health in Lancashire and Cumbria. It forms part of our overall population health strategy, which I want to give some focus to over a few short blogs. In this blog I will focus on the Pentagon and what we mean by each bit of it!

 

 

 

Population health means different things to different organisations, groups and individuals. However there is agreement that population health is determined by a complex range of interacting factors e.g. social and economic, lifestyle, access to services, including health, as well as our genes, age and sex.

Most of these factors lie outside of the health care system but have significant impact on individual and population health. Lord Darzi recently wrote in the 2016 WISH report (https://www.kingsfund.org.uk/publications/articles/healthy-populations) that we have talked about making a difference to population health for decades, but no-one has really grasped the nettle to make the changes we need to see, particularly around health inequalities. Responsibility for addressing these issues are fragmented. Therefore we need to ensure that we work with a multitude of partners to:

  • Understand the problem and set clear goals for improvement
  • Focus on the determinants of health and not just health care
  • Generate shared accountability
  • Empower people and communities and develop their capabilities
  • Embed health equity as a core element.

Therefore Population Health in Morecambe Bay is defined as:

The health outcomes of our citizens as a group, including the distribution of those outcomes across the geography of Morecambe Bay.”

In Morecambe Bay, we have developed a way of thinking about Population Health through the means of five key strands, namely – Prevent, Detect, Protect, Manage and Recover.

Various definitions currently exist around these words, but in Morecambe Bay, the definitions will be used as follows:

Prevention

Prevention means preventing disease or injury before it ever occurs. This is done through:

  • Working with communities and other partners to tackle the underlying social determinants of health (e.g. living and working conditions, social isolation, health literacy etc.)
  • Encourage the development of health in all policies
  • The promotion of positive behavioural choices which improve a person’s health and wellbeing (e.g. stop smoking, reduce alcohol, take regular exercise, eat healthily)
  • Preventing exposures to hazards that cause disease or injury (e.g. through hand hygiene, health and safety )
  • Increasing resistance to disease or injury, should exposure occur (e.g. immunisation programmes)

Prevention can be primary (before a diagnosis) or secondary (after a diagnosis), but always refers to creating an environment that supports healthy choices, lifestyle changes, rather than medical intervention.

Detection

Detection means early recognition that:

  • a person is developing increased risk factors which may predispose them to a more serious condition (e.g. obesity, rising cholesterol, high BP, low mood)
  • a person has developed a chronic condition, for which they will need further protection (e.g. COPD – chronic obstructive pulmonary diease, Type 1 Diabetes Mellitus)
  • a local population are more at risk of developing a particular condition/set of conditions (e.g. detection of childhood obesity rates, high rates of smoking, high rates of alcohol use, poor housing or air quality )
  • a local population has worse health outcomes than another, requiring appropriate resource allocation (e.g. poor cancer survival rates, high rates premature mortality, low access to preventative interventions)

Protection

Protection means:

  • to protect someone from developing a condition of which they are at risk, through medical intervention (e.g. starting antihypertensive medication) – this would also go hand in hand with some further prevention measures
  • to reduce the impact of a disease or injury that has already occurred (e.g. ensuring protection after a first MI of having a second MI through strict treatment of BP, cholesterol and kidney function, smoking and dietary advice)
  • to soften the impacts of an ongoing illness or injury that has lasting effects (e.g. helping a person to understand a chronic condition they are living with, through structured education and ensure best evidenced treatment, to help them live at optimal health)
  • to protect someone from developing a more serious condition, through surgical intervention (e.g. prophylactic bilateral mastectomy)

Management

Management means:

  • to provide appropriate advice, treatment or referral for a single episode of a health complaint (e.g. minor ailments )
  • to intervene at the time of a medical or surgical emergency with best evidence-based practice (e.g. transfer to a cardiology centre for management of a STEMI – [heart attack])
  • to treat an exacerbation of a chronic condition through a best evidence-based intervention (e.g. an acute exacerbation of COPD)

Recovery

Recovery means:

  • helping people manage long-term, often complex health problems and injuries in order to improve as much as possible their ability to function, their quality of life and their life expectancy (e.g. through cardiac/pulmonary rehabilitation, community integration, support groups, social care provision, vocational rehabilitation programmes, links to financial advice)
  • recognising where people will not recover and enable good palliative care and a good death

This Pentagon describes our ‘population health approach’, but is not the complete picture of how we think about population health. More on this in some follow up blogs and vlogs.

Share This:

Share

Never Let a Good Crisis Go to Waste

Tweet So, the NHS is in another winter crisis. The Oxford English Dictionary defines a crisis  as: 1 A time of intense difficulty or danger. ‘the current economic crisis’ Mass noun ‘the monarchy was in crisis’ 1.1 A time when a difficult or important decision must be made. As modifier ‘the situation has reached crisis point’ [Continue Reading …]

Share

NHS or IHS?

Tweet The commonwealth fund (an influential US think tank) recently declared the NHS to be the best healthcare system in the world, for the second year running! https://www.theguardian.com/society/2017/jul/14/nhs-holds-on-to-top-spot-in-healthcare-survey   Many think of the NHS as the Jewel in the UK Crown, more popular, as it is, then our own Royal Family. Andrew Street (professor of [Continue Reading …]

Share

What Next for General Practice?

Tweet Last week, I had a sixth form student spend the week with me. She is hoping to go to medical school and is gaining the necessary work experience ahead of her applications. It was so great to be able to share with her the variance of my work and the great privilege it is [Continue Reading …]

Share

Social Movements and the Future of Healthcare

Tweet As the crisis in the Western World deepens, and the growing reality sets in that business as usual simply can no longer continue nor solve our problems, our systems must change the way they view, deal with and hold onto power. The NHS is no exception. If we want a health and social care [Continue Reading …]

Share

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 …]

Share