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Archive for the ‘Health and Wellbeing Board’ Category

Jan
19

As CCGs consider their 5 year strategies to improve health outcomes and ensure maximum return on NHS funding, one of the questions that arises is whether we should incentivise individuals to be healthy. 

In South Yorkshire and Derbyshire a pilot scheme offering mothers £200 in shopping vouchers to encourage breastfeeding has been set up.  Breastfeeding has been shown to reduce cases of stomach problems, asthma and other respiratory conditions.  The business case is relatively straightforward: the cost of the incentives will be more than outweighed by the benefits realised later on. 

So is this, and other schemes like it, an approach that CCGs should be rushing to adopt?  Does the business case stack up, both on outcomes and financially?  Well there are other examples to learn from.  In 2009 a weight-loss scheme, Pounds for Pounds, was set up in Kent which offered participants cash payments of up to £425.  Less than half achieved significant weight loss and a high drop-out rate meant that evaluators were unable to recommend it as a way of tackling obesity.

However, a stop smoking scheme in Dundee had more success.  The NHS there ran a two-year programme offering smokers £12.50 a week to quit smoking.  By the end of three months, nearly a third of participants end up kicking the habit, more than twice as many as other smoking cessation projects achieved.

There are a number of arguments against this type of approach that I don’t intend to go into here, such as whether it creates perverse incentives, whether it is patronising, and whether it will simply result in paying people for something they were going to do anyway.  But there is one point that I do think is particularly important, and this is best made by Harvard University political philosophy professor Michael Sandel.

Professor Sandel’s lecture ‘Why we shouldn’t trust markets with our civic life’ (you can find it here) tells the story of a Texas policy that awarded children two dollars for every book they read.  He then asked the audience what they thought of the approach, and in discussion concerns were raised about the impact on the long term motivation of the children to read.

Sandel’s argument is that, when considering non-material goods, market mechanisms (e.g. putting a price on something, or using cash incentives) can actually change the nature of the goods. So if we pay children to read books, it can change their motivation to read and the types of books they read.  A key outcome of the Texas study was that children read shorter books!

He says that economists assume markets are inert, that they do not change the products that undergo market exchanges. This is likely to be true for material objects. However, for non-material values like learning and education and health, this is not true.  For us this means that the value of stopping smoking or breastfeeding or losing weight actually changes if we pay for it.  We risk eroding the intrinsic value of these things by paying for them.

For health the unintended negative consequences could be serious.  Will intermittent smokers start to smoke in order to receive the incentive to stop smoking again? Will obese people become morbidly obese to receive the incentive payments to lose weight? More importantly, will the value placed by individuals on their own health become a function of the return they receive for it, rather than something held as valuable in its own right?

Sandel himself says, ‘It is not about inequality and fairness but about the corrosive tendency of markets. Putting a price on the good things in life can corrupt them. That’s because markets don’t only allocate goods; they express and promote certain attitudes toward the goods being exchanged. Paying kids to read books might get them to read more, but might also teach them to regard reading as a chore rather than a source of intrinsic satisfaction.

‘Some of the good things in life are degraded if turned into commodities. So to decide where the market belongs, and where it should be kept at a distance, we have to decide how to value the goods in question—health, education, family life, nature, art, civic duties, and so on. These are moral and political questions, not merely economic ones. To resolve them, we have to debate, case by case, the moral meaning of these goods, and the proper way of valuing them.’

So for CCGs this approach is not something that can simply be adopted.  As leaders with responsibility for population health we need to carefully think through all the decisions we make, and the consequences that these will have not just on the balance sheet but on society as a whole.  Health and wellbeing boards are the perfect place to ensure these issues are fully debated on an individual basis, and it is our duty to ensure that this happens.

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Aug
12

The shift of public health to the council is a move which creates real uncertainty as to whose job prevention is.  By prevention we mean those activities which avoid the occurrence of disease.  Clinical Commissioning Groups (CCGs) need to actively formulate a view as to how they see their role in relation to prevention.

There are a number of options open to CCGs.  The first is to continue where PCTs left off.  This view makes the argument that it is impossible for any effective commissioning in health to take place that does not start with a full understanding of the health needs of the population.  A large proportion of the CCG budget is funding the treatment of disease that is preventable.  CCGs need to invest in the prevention of disease if they are to have any hope of being able to effectively commission healthcare in the medium to long term.  The fact that CCGs will be measured according to the outcomes framework reinforces the need for funding to follow outcomes not activity.

There are CCGs actively pursuing this option.  Directors of Public Health have been made part of the Governing Body of the CCG, and structures and ways of working have been developed that enable a real focus on prevention to exist at the core of the CCG.

The second option is for CCGs to make the decision that funding for Public Health has been transferred to the Local Authority, and that as such responsibility for commissioning any activity relating to prevention also transfers to the Local Authority.  Ensuring that there is effective investment in prevention is purely a job of holding the Local Authority to account for the choices they make.

There are many CCGs walking down this path.  These CCGs are watching the public health staff and the public health funding transfer out of the PCT, and are happy that there is one less thing to worry about.  They have little real interest in the offering coming out of the Local Authority in relation to public health, as they do not see the output as their responsibility.  Many GPs never really understood what Public Health either did or was supposed to do, and so the loss of it does not feel that great.

The third option is to sit somewhere in between these two extremes.  The key new component of the new architecture is the Health and Wellbeing Board.  This brings together the Local Authority (and Public Health) and CCGs.  It has a mandate to produce a Health and Wellbeing Strategy.  This strategy should outline (amongst other things) how the Local Authority and CCG (and other players around the table) are going to work together to tackle prevention.

The reality is that effective prevention requires a whole community approach.  The Centre for Disease Control and Prevention in the US has said for some time that improving health requires policy makers, health professionals, transport, education, housing and local community leaders to work together with a single focus.  In the US it runs a Community Transformation Grant programme to encourage this to take place (http://www.cdc.gov/communitytransformation/ ).

The Health and Wellbeing Strategy is a real opportunity for the prevention agenda to be tackled in a much more effective way than it ever has before.  The risk is that is by being the responsibility of a group it becomes no one’s responsibility.  CCGs need to grasp the opportunity to make this strategy effective.  They need to make it central to their own work.  It needs to be a document that sits at the foundation of the CCG’s operating plan.  CCGs may not have to directly invest in prevention, but they absolutely have to ensure that effective prevention occurs.

So whose job is prevention?  It is everyone’s and it is no one’s.  What it presents is another opportunity for CCGs to show leadership and drive the new architecture to make it work.  Ultimately CCGs are about serving a population, and letting prevention fall into no man’s land is a risk to their population’s health that CCGs should not be prepared to take.

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