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The financial crisis in health – making prevention and the public part of the solution

Ours is one of the better performing CCGs, but there is still considerable worry about whether we will be able to balance the budget this year.  A lot is being done to tackle the problem and, as a lay member on its governing body, I don’t think I have anything to add to the professional expertise with which it is being managed within the CCG.  However, there seems to be a whole world of options outside the CCG that aren’t being seriously addressed; particularly doing more to involve the public and improve prevention.

You can see this at national level too.  NHS England’s recent ‘reset’ announcement seemed to be reverting to blaming individuals and organisations rather than looking for systemic solutions.  It’s not that the importance of public involvement and prevention aren’t recognised, nationally or locally.  Indeed they are key parts of the main strategies.  It’s just that too little seems to be actually done about them, and what is done is fragmented.  While there are lots of individual services and projects, generally provided by public health or the voluntary sector, little of it is ‘system-wide’ – where the system includes the whole public, private and voluntary sectors and the public themselves.  I think that’s possibly because it’s all fine in principle but too hard in practice.  Or that it would be too time consuming and there’s a risk it would bear no fruit.  Or that positive results would take too long to emerge.

However, I think there could be in-year savings and the changes wouldn’t have to be difficult or expensive in themselves.  Just fiendishly difficult to make happen.  People deciding to walk rather than take the car, or going out and meeting up with other people is simple and low cost.  The problem is how to get a lot of people to change their behaviour.  Of course I don’t have any simple answer to that, but I believe that pulling together, we could, if not find it, at least get closer to it.

Two local examples might shed some light on what is possible: mental health and frail elderly.

A lot of the people going to see their MP or attending A&E have mental health problems.  Some of those could be helped at an earlier stage.  That doesn’t necessarily require expensive service interventions.  A lot of it is about peer support.  And there are resources – people prepared to donate their time – that could help make it happen.  People in my local area have been pushing to get initiatives off the ground, like a drop-in café where people can just come and have a chat, and a ‘recovery college’, giving people the skills to help tackle their difficulties.  However, local services like the CCG or council don’t seem to be equipped to step in and provide, what might be fairly minimal support, to enable such projects to take off, even when much of the input would be voluntary.  In the case of the recovery college, an energetic and enthusiastic individual is starting to make it happen and is applying for and starting to get funding from grant making bodies.  It’s happening despite, rather than because of the CCG

‘Falls’ has been identified as a priority within our local health and wellbeing strategy, but there appears to be precious little joining up in tackling the problem (that is my impression, but I may be doing them a disservice because I haven’t been closely involved).  It seems to be compartmentalised into a problem of individuals falling over, rather than looking at the whole population of those who are, or may soon be, ‘frail elderly’ or to consider it in the context of physical activity in the population as a whole.  Rather than just providing suggestions to people who have already fallen to do specific exercises, why not join this up with the promotion of physical activity and social relationships in the community as a whole?  As part of a wider campaign, having a neighbour help an older person to go and post a letter could aid both physical and mental health possibly for both parties.  That should not be just a series of public health projects but should involve all parts of the public, private and voluntary sectors.  Yes, there might be some costs – improved footpaths and cycle ways, showers at work, support to community groups – but they could be built into ongoing refurbishment and development.  Just as significant would be the peer pressure as everyone started to do just a little bit more.

So what could be done to make this happen?  A start would be to include a wider range of people in trying to find solutions.  At its simplest, just within health, that would include front-line staff, CCG members and the governing body, at least inviting ideas and maybe having a few brainstorming sessions.  But there’s surely scope for getting more ideas by involving the public.  OK, maybe 90% of the ideas would be rubbish or things you’d already thought of, but that other 10% could make all the difference.  And how to resource it?  Why not use the volunteers already interested in such issues to do much of the facilitation and writing up?

Another part of the solution is adopting a different sort of approach to managing strategy and change (such as the distributed leadership and collective responsibility I talked about before).  There’s still a role for the top-down, hierarchical, bureaucratic approach of public bodies like the council and CCG – those aren’t automatically bad things.  However, in an environment of collective responsibility they also need a part of them that can be fleet of foot.

Might things get so bad that this could happen?  I suspect it may get so bad that an urgent injection of Treasury cash is needed.  But could it become so dire as to drive such radical thoughts as these?  I’m not holding my breath.  But I still think it’s worth pushing for.

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