Universal Healthcare

I sit on a man’s back, choking him and making him carry me, and yet assure others that I am very sorry for him and wish to ease his lot by all possible means-except by getting off his back” 

(Tolstoy, 1991)

The NHS is Contributing to Health Inequalities

Covid made visible that people’s health is directly linked to their wealth (Marmot et al, 2020), and that the NHS is providing unequal healthcare, an issue identified in the Kings Fund’s evidence to the Joseph Rowntree Foundation (Buck and Jabbal, 2014)[1]

The NHS Constitution requires the NHS to provide comprehensive healthcare for all based on need. It starts with the words ‘The NHS belongs to the people.’ In fact it belongs to some of the people. Charlotte Augst from National Voices (2021) reminded us that the Pandemic has shown that the NHS is not providing universal healthcare.

Of course we know from the Marmot Review (2020) that poverty has had, and is having a disgraceful impact on health. But there is more the NHS can do to address the lack of universality of healthcare, it has been complicit in three ways:

  1. Medicalising poverty and providing ‘sticking plaster’ approaches, with the best intentions, that make the problem invisible. That means that those accountable are not held to account.
  2. Not being frank and open about the reality of the rationing of services, in effect creating a fantasy that the NHS is actually providing universal services when its not. The latter is depicted in one of the National Voices ‘I’ statements.(National Voices 2020)
  3. Providing services that are not accessible to all.

‘I statement’ National Voices (2020) p7 .

Medicalising Poverty

At the RCGP Annual conference in 2019 and 202, I urged General Practice to make visible the impact of poverty by providing details of how many GP appointments directly related to poverty rather than ill health. In our work in the Primary Care Quality Academy we have been finding that circa 40% of people who frequently attend general practice are there because they are struggling with life. Providing access to health because there is nowhere else to go, does not solve the problem. It’s a sticking plaster on the symptom. Whilst clinicians are doing their best to support people with the best intent, and social prescribers are picking up a large caseload from this; tit is not the best use of healthcare resources and hides the extent of the problem. In addition, the NHS does not measure or report where ‘poverty medicalisation’ is occurring. The result is noone knows how much healthcare resource is being directed at needs arising from poverty, and that lack of visibility means that (a) the problem doesn’t get addressed within the NHS and (b) no-one is held properly to account for the impact on people and health services (c) We have no idea of the knock on effects of resources directed to sticking plastering poverty on the ability of the NHS to meet health needs (see rationing below).

The Reality of Rationing

Charlotte Augst calls on the NHS to be frank and open about the extent and nature of rationing as a result of the workforce crisis and pandemic, which has lead to many services closed or postponed. The NHS needs to be clear with communities about what can and cannot be accessed, and open about the causal issues that are creating rationing (Charlotte Augst 2021). Again if the NHS fails to be transparent about the issues faced, then there is no accountability for those who have the power to create the policy to address these issues.

National Voices depicts this in one of their ‘I’ statements ‘I am not forgotten’

Service Design

 “We are not hard to reach but easy to ignore communities

Fatima Elguenuni 

The Vaccine programme has shown us that when the NHS wants to, and plans to reach the whole population, it really can – from Vaccine Buses to collaborating with faith leaders. The vaccination programme is going to the people. This is a salient lesson. People who are poor are not struggling to be healthy purely because they can’t afford heating, fresh vegetables, and have stressful lives. The NHS doesn’t always help them access services. If the NHS is going to address health inequalities it needs to ensure services are accessible universally no matter what the person’s means.

For example

  • Outpatient redesign in its move to digital options must collaborate on digital poverty with local government.
  • Primary care provision for a population has to address young people’s needs. Young people do not access GP appointments when they are in need. There is emerging evidence from our PC Academy that they end up in out of hours, or with no services. They are not getting the health care they are entitled to, and that Practices are paid to provide. In fact rarely do practices know if young people are accessing their services. The NHS should be providing primary care to populations in imaginative diverse ways beyond a GP appointments system for those that choose to use it.
  • Services have to address people’s life circumstances in terms of their ability to practically access the healthcare they need (considering for instance transport routes, caring responsibilities). Expecting people to come to the NHS when locations may not be easily accessible has been shown by the vaccination programme to leave people behind

Integrated Care Systems will know where communities, populations and people are and are not getting access to the healthcare that they need. Reducing inequalities means people securing the health services they need within their reach. That requires:

  • honest inquiry about what people need and what they are and are not getting (who is being left behind)
  • data and transparency on the impact of the NHS providing sticking plaster solutions
  • commitment to designing service that people can actually access no matter what their means

The NHS is awash with reports on how to reset and recover as a learning system. Something more fundamental is needed. What if the NHS really focused on meeting need not demand, and on ensuring the universality of health services?

You can see a webinar covering these issues here


Augst C. (2021) The pandemic has broken the promise of universal healthcare. Health Services Journal online. 13th January

Buck D. and Jabbal J. (2014) Tackling poverty: making more of the NHS in England. London: King’s Fund.

Department of Health and Social Care (2021) The NHS Constitution for England.

Department of Health and Social Care (2021) Integration and Innovation: working together to improve health and social care for all. Policy White Paper. 11th February.

Malby B (2020) Young People Need Primary Care Now. Becky Malby Learning Journeys Blog. Available at

Marmot M., Allen J., Goldblatt P., Herd E. and Morrison J., (2020) Build back fairer: The COVID-19 Marmot Review. The pandemic, socioeconomic and health inequalities in England. Then Institute of Health Equity. Available at:

Marmot M., Allen J., Boyce T., Goldblatt P. and Morrison J. (2020) Health Equity in England: the Marmot review 10 years on: The Health Foundation.

National Voices (2020) What We Need Now. What matters to people for health and care, during COVID-19 and beyond – new National Voices I Statements.

Tolstoy L. (1991) What then must we do? Element Books.

[1] “..there are problems in accessing health care for groups more likely to be in, or at greater risk of, poverty. In the paper we explore three particular areas; namely, families with children with severe disabilities, certain types of care for black and minority ethnic groups, and the impact of long-term conditions on people of working age. We find the NHS could do more to help people in these groups which could reduce the risk of poverty.”

What Now? This ….

There are 3 priorities now for Integrated Health Systems that will ensure the NHS and the people that work in it can proactively, purposefully and hopefully take the next steps.

Universal Health Care

Do you remember the NHS Constitution? The NHS providing comprehensive healthcare for all based on need. It was Charlotte Augst who first reminded me at least that what the Pandemic has shown is that the NHS is not providing Universal healthcare. Of course we know from Marmot that poverty has had and is having a disgraceful impact on health. But we cant blame the lack of universality just on poverty. The Vaccine programme has shown us that when the NHS wants to and plans to reach the whole population, it really can, from Vaccine Buses to collaborating with faith leaders. The vaccination programme is going to the people. This is a salient lesson. People who are poor are not struggling to be healthy purely because they cant afford heating, fresh vegetables, and have stressful lives, the NHS also doesn’t help them access services. If the NHS is going to address health inequalities it needs to ensure services are accessible universally. For example Outpatient redesign in its move to digital options must collaborate on digital poverty with local government as it does this; primary care provision for a population has to address young people’s needs, recognising that young people do not come to GP appointments. Services have to address people’s life circumstances in terms of their ability to practically access the healthcare they need. As @FElguenuni says “We are not hard to reach but easy to ignore communities” ICS will know where communities, populations, people are not getting access to the healthcare that they need. Reducing inequalities means people securing the health services they need within reach.

Meeting Complex Needs – revisiting the Grand Round

Now PCNs have found their feet they are turning to work on complex needs. The pandemic has generated an escalation in the need for mental health services, and this is causing real concern about the model of care. Previously I have written about the role of PCNs in supporting people whose needs are too complex for one service or one practice. Here is a reminder of the diagram of acuity related to people who turn up frequently. You can do the same for people with mental health needs.

Talking to GPs it is clear that there are a range of needs in terms of people’s mental health that PCNs have to address here are some examples:

  • People who are experiencing worklessness – where the PCN needs to ask for help from communities and other agencies. Their social prescribers will be able to provide information on the demand coming from this section of the population, and the PCN can invite others into determining PC and the NHS’s role here. Clearly multiple GP appointments are not the answer. Role: Codesign
  • Anxiety particularly in young people – where PCNs need to work with schools, IAPT services, and out of hours providers (where young people often present) to rapidly co-design / collaborate on supporting young people to manage their health, that address these escalating needs. Role: asking for help
  • People with severe mental health needs, possible recently hospitalised. Here the PC team need MDT support. Leaving PC to manage this on their own is not going to secure quality healthcare. Do you remember the Grand Round? The MDT needs to get together to review severe MH cases so that the whole system can learn together about how best to provide quality care. Role: Inviting an MDT review

Acuity should trigger a designed response in terms of bringing together expertise and responses. At minimum people with complex needs require MDT reviews across the system.

Preventing the Harm from Moral Injury

I was talking to a Dir of Transformation who reminded me of the legacy of Swine Flu. She was saying that we have to learn the lessons of that time, which was when the NHS expected the ICU team to just go straight back to normal work, the ICU team had really high sickness rates in the following year. I am seeing a range of responses in hospitals trusts to the transition from acute pandemic response to restarting full service as usual. At one end of the spectrum the F1s F2s are moving straight back to their departments and rotas with some support for pastoral care; at the other end, senior clinicians are encouraging the juniors firmly to take at least one weeks AL, are providing emotional and professional support and are then transitioning them back into their rotas over a 3 week period as services open up in a planned way. Clearly there has to be more than individual wellbeing responses, at the scale of the pandemic impact, the NHS needs to take a planned route to enable staff to recover physically and mentally from the exhaustion and shock of the last year.

There are a full range of experiences of NHS staff in the pandemic, but the experience across a whole system has not been accessible to the whole. This means that the moral injury of the rationing, the decisions made nationally that lead to the horror experienced in clinical settings, the inability to take comfort from family and friends, was experienced differentially across the system. Suzanne Shale in the BMJ calls for moral repair. Over the past few months one role we have played here at the Lab is to acknowledge the injury and bear witness to clinicians experience. This needs to happen locally and systemically. It is not the role of the hospital or the GP practice to repair on their own. One way is to use the Schwartz round model bringing people together across the system to listen to accounts from across the system to that the experience and stories can be shared and repaired as a whole.

Shale, S. (2021) Moral injury and the COVID-19 pandemic: reframing what it is, who it affects and how care leaders can manage it. BMJ leader Commentary.

Leading Through the Pandemic: Lessons for the NHS

Prof Becky Malby interviews thought leaders to inform and guide NHS leaders through the current context.

Interview 8: Julian Corner, CEO Lankelly Chase – Governance for Adaptive Capability

Over the last year alongside the Pandemic we have seen a crisis of Governance. Hierarchical governance where managers ‘manage’ upwards to ensure they can do the right thing; where the inequalities and dysfunctions of the current system are baked into the governance process; where governance is focused so much on financial accountabilities, risk management, and assurance that there is no space for strategy; has been found wanting. the rise of networks has already challenged the dominant model of governance. In this interview Julian sets out how Lankelly Chase is redesigning its governance model to better equip the organisation for its mission, to better reflect its values and to address the wicked problems that beset society. As we emerge from the next wave of infection, mindful of how hard the ‘old world bit back’ after the first surge, how can we rethink and redesign our governance systems to enable a more adaptive public sector?

You can read Julian’s Blog on the Lankelly Chase transformation here

Here is a checklist for Ethical Decision Making in Boards (a first step in determining whether your Board is making ethical decisions) Baxter, J., Fischer M., Malby R (2012) National Inquiry into Organisational Ethical Decision Making in the NHS. Interdisciplinary Ethics Centre & CIHM, University of Leeds

Interview 7: Tania Eber – The Power of Self Managed Teams. Lessons from Buurtzorg

I have been talking to leaders from across the globe about how to take a proactive approach to leading through the pandemic. At the same time, we undertook a survey of what NHS staff wanted to keep and what they never wanted to see again. From this we identifies 10 leaps forward – which, as it happened, mirrored the key cultural conditions evident in high performing health systems. One of these key conditions was being able to work well as a self-managed team. This week I am talking to Tania Eber who has worked with Buurtzorg on their fundamental commitment to self-managed teams and the benefits that has reaped for population health and for the staff what work there. You can find Tania at @TaniaODC

Interview 6: Charlotte Augst – The Answers are in the Community.

This week I have invited Charlotte Augst to talk with me about the Community Response and the new relationship being forged in some places between health services and local people. We cover the results of the survey that shows how much the NHS has appreciated and been surprised by how Communities have gifted their time and support.

Interview 5: Dr Brent James – Lessons from High Performing Health Systems. Building learning into the NHS’s future

This week I have invited Brent James to talk with me about learning systems. Last week I sent out a survey asking people working in the NHS what they want to keep from this time, what they never want to happen again, and the opportunities for the NHS. The results looked very like the culture and operational model of Intermountain Healthcare. I asked Brent how can we make sure the best of the way the NHS has worked well sticks. He said “Dont ask for permission just do it!”

Interview 4: Liz de Wet – The Personal Leadership Challenge

This week we move on from focusing on the systemic challenge of the pandemic to discuss how as leaders we ourselves are the instrument, and how in our practice we shape the future by how we engage with this context. Taking a more personal approach Liz de Wet brings her global experience in leadership practice in a more intimate conversation on how we lead.

Interview 3: Myron Rogers – How to Lead Adaptive Change

Last week I talked to Irwin Turbitt about recognising the adaptive challenge that this pandemic presents for the health system.  This week I am talking with Myron Rogers and we are going to discuss how to lead this emergent adaptive work. What principles and practices will we need to draw on?

In our discussion we touch on this vlog by Dayna Cunningham, Community Involvement Innovators lab at MIT, on her experience of the pandemic

Interview 2: Irwin Turbitt – The Adaptive Challenge

My second interview is with Irwin Turbitt discussing the adaptive challenge of the pandemic and how to harness the relationships generated in the crisis into a new collaborative effort in the future.

Interview 1: Prof Keith Grint From Crisis to Adaptive Leadership

The first interview is with Keith Grint, Emeritus Professor at Warwick University on the lessons from his work on leading Critical, Tame and Wicked Problems. We discuss the interplay between command and control and adaptive leadership, the role of soft power, and how to ensure you are the best decision-maker you can be.

What Now? Proactive Leadership Through the Pandemic – where to focus your effort

This video sets out how to avoid the trap of the ‘old world biting back’ as the NHS faces the coming months. I remind you of the value of the conditions created in the Spring of learning teams, professionals supported by management, collaboration between local authority and health to support people at home, decisions made in partnership with patients and carers, needs based care……. and ask the NHS, in a time where the energy is back to being reactive, and clinicians are already exhausted, to proactively design services to meet actual needs and to focus on supporting learning teams.

Young People Need Primary Care Now

Use the ARRS to support children and young people in schools

During the Pandemic schools and GPs have been worried about young people’s health, particularly those who have difficult home circumstances. In some instances PCNs and Schools have worked together to reach children who have had difficulty connecting to schools when isolating. But the problem for the NHS is much deeper. We have found that children and young people haven’t been accessing primary care, but PC hasn’t always noticed. If you run a demand led service then you deal with who turns up, and children and young people don’t turn up in General practice. Here is an example of the data we found:

(The colours are disease categories.)

As you can see between the ages of 7-24 these young people are not accessing primary care, but we know they have significant health problems. Schools have been crying out for support with their students mental health and wellbeing. Self Harm is increasing (McManus et al 2019), and with it the burden this places on young friends. In fact Helen Carr, Local Care Direct West Yorkshire said that across West Yorkshire 30% of the out of hours demand was for young people aged 16 and under.

General Practice cannot remain an ‘in-reach’ provision for people. Primary Care should be provided for the whole population which means general practice reaching into those people who don’t utilise standard appointments, proactively, to meet needs and prevent further harm. It is a moral and contractual obligation. It cannot be reasonable or rationale to persistently ‘spend’ PC funding disproportionately.

Right now there is an opportunity. ARRS funding can be used for social prescribing and if you have funding now where better to put it than in a specific health and wellbeing role supporting children and young people in schools. Right now, as our young citizens cope with the impact of the pandemic, they need support and PC has a duty to provide it.

That new role can reach out to schools – what does the school know about the health needs of young people in their care (when I was a school governor the pastoral team were overwhelmed with young people with anxiety, self-harming, drugs, poor family life..)? They can listen to the young people themselves about what they need and build a service around what matters to them.

Have a look at this example from Wharfedale Airedale and Craven Alliance – Gr8 Minds

Another from Cumbria Believe in Children

“We just appointed another SPLW to work specifically with children and young people. its a job share, one of them has counselling skills. their main aim for the next few weeks/month is build relationships with local services like Trailblazers (our new MH workers based in schools), CAMHS, CWS, police, youth groups etc etc” Central Cheltenham PCN

McManus, S., Gunnell, D., Cooper, C., Bebbington, P.E., Howard, L.M., Brugha, T., Jenkins, R., Hassiotis, A., Weich, S. and Appleby, L., 2019. Prevalence of non-suicidal self-harm and service contact in England, 2000–14: repeated cross-sectional surveys of the general population. The Lancet Psychiatry6(7), pp.573-581.

Back to Better

Sharing the health and care innovations made possible during the pandemic

Alongside the frustrations, difficulties and challenges of Covid-19, many great things are happening in the healthcare system. We have captured and classify them so that we don’t end up going back too old, less effective habits. We also bear witness to the many testing and difficult experiences.

You can contribute your experience and views by taking part in the survey here

What do you want to keep from this time? Lessons for the NHS – don’t let the ‘old world bite back*’

You can contribute your experience and views by taking part in the survey here

Alongside the frustrations, difficulties and challenges of the pandemic, many great things are happening in the healthcare system. We undertook a survey to help the NHS remember and build on them, so that we don’t end up going back too old, less effective habits. What we heard about what the NHS wants to keep was astounding.

The survey showed that almost overnight, for some people, the NHS turned into a high performing health system. NHS transformation boards have been working for years to lead the NHS into New Models of Care that mimic those that are already bread and butter in high performing health systems around the world – Intermountain, Nuka, Jonkoping, Buurtzorg – places that have been visited by countless NHS staff, and that have mentored, coached and supervised the NHS over many years. Yet within all the things staff wanted to keep, were all the key conditions of these very effective health systems.

Many will describe the digital innovation and yes thats part of it, but in reading the responses to the survey we found so much more:

What has worked has been relational conditions that underpin all high performing health systems, achieved by extraordinary professionals and communities, unleashed from the tyranny of mistrust and dependency creating control.

Whatever happens next NHS Leaders can proactively capture these vital changes and make them permanent. This is what it will take:

Valued Staff: Being valued as staff and having the energy to focus on the job.

It was shocking to hear clinical staff talking about the value of being able to access food and water 24/7; of having somewhere to go to deal with stress and grief; things just not available in the day to day NHS. Proper care for NHS staff doing difficult work has to stay.

21st Century Tools: Engagement with a new set of digital tools and ways of working

Rapid implementation of so many tools that have been on the periphery for a long time waiting for adoption. In Primary Care particularly Telephone Triage has worked well and video consultation is something respondents wished to keep. This has to stay.

Engaged Leaders: A visible and engaged leadership

NHS staff engaged by leaders that listen, who are visible and who collaborate. This has to stay.

Basics and care foundations finally fixed, reorganised. Sorted.

Data Sharing between NHS and LA; Getting software and hardware to enable staff to consult from home “inconceivable a month ago”; Meetings by zoom when they are needed to do relevant rapid problem solving; massive reduction in paperwork for discharge and referrals. All of these show the ‘back office’ systems now orientating to support effective clinical practice. This has to stay.

A joined-up local health system getting things done

Local collaborative problem solving has worked. Professionals working in different organisations or in siloed departments are suddenly able to work together. The discharge to assess debacle has been sorted overnight. Virtual rounds in care homes, collective redesign of pathways agreed, direct communication across boundaries. Local teams, leaders, charities, and businesses are finding a way through problems that cannot be solved nationally (and the centre should not wrestle control back). We are the most hierarchical centralised democracy in the western world and that has to change. Local decision-making to meet local need must stay.

Great Teams: We are working day-to-day as a real team

Overwhelmingly NHS staff talked about the value of time to connect as a team to peer review decisions, to support each other, to learn and to adapt. The value of being part of a team you know, where you can build relationships and work together is critical for good quality care. This must stay. The production line model of working has to stop.

Being Professional: A huge increase in ‘professional’ working behaviour

Professional practice requires peer review, evidence based decision making, learning, scrutiny and collaboration to meet patient need. This has been lost or conceded as risk management and contracting for tasks dominated. Professionals described the joy of learning together, moving out from specialisms to collaborate, taking peer reviewed decisions with confidence. This must stay.

Decisions based on needs and what’s best with proactive planning for the future

Prevention is back on the agenda. Clinicians are moving out of the reactive mode and thinking proactively about their populations needs and how to meet them from anticipatory care plans to chronic disease management. Thinking together across the system about how to intervene earlier. This must stay.

Patients as Partners: Mutual decision-making and partnership with patients

A significant change has been where clinicians have moved into a new relationship with patients and carers – more mutual, more respectful and more understanding (both ways). Informed shared decision-making. This must stay.

Community connections, collaboration and support

As the NHS demonstrated its human vulnerability and reached out for help, communities were there. This rapid transformation of the NHS’s attitude to communities in the deficit model of ‘needy’ to the asset model of communities with resources has to stay.

And so we come to the evidence on high-performing health systems (Baker & Denis 2011). They all have these relational conditions, as well as access to great data to inform their decisions. We have seen that it’s possible for the NHS to do this too.

We also asked what NHS staff thought should never be repeated. This is what they said:

Already the old world is biting back, the culture of the NHS beurocracy, power which resides in the hierarchy, the resistance to local devolution, is already back using transactional contracting methods. The NHS that has experienced first hand the power of being a real quality system can choose that future by paying attention to these relationships and conditions; or it can react like Pavlov’s dog to the bait of contracting. Choose relationships, Choose networks, Choose systems, Choose collaboration, Choose professional responsibility, Choose to be proactive and make the new NHS.

You can contribute your experience and views by taking part in the survey here

FOOTNOTE: These are conditions that I set out in 2016 (The Old World Bites Back) – suggesting that by 2020 health and care would be collaborating to meet population health need with systems leadership that invested in data and people, with a clear purpose in partnership with people and communities. The NHS has not managed to do it (as I predicted) by project management. It would be wrong to re-write the story of Covid and credit the current ‘transformation’ to command and control management for the crisis.

Survey Respondents:


Baker, GR., Denis, JL. (2011) A Comparative Study of Three Transformative Healthcare Systems: Lessons for Canada. Canadian Foundation for Healthcare Improvement.

* With thanks to Myron Rogers for the quote -whose interview on Leading through the Pandemic you can see here

Primary Care – doing the right thing

Three conversations this week showed how easy it is to get seduced into doing the wrong thing. All of these showed that if primary care focuses its change effort on fad or ill informed policy it will just make things worse. We have to take an evidence based view.

These were the conversations:

  • Helen Carr, Local Care Direct West Yorkshire about who is accessing out of hours and its young people
  • Ollie Hart, GP from Sheffield on twitter about Marmot 2
  • The Steering Group of the RSA Future of Health and Care the topic is in the group title!

Primary Care for Young People

You have seen this slide before – where we show that young people aged 7-24 are not accessing GP appointments.

What Helen told me was shocking. She said that across West Yorkshire 30% of the out of hours demand was for young people aged 16 and under.

Earlier in the week I’d been contacted by a network of PCNs who had decided to tackle the issue primary care for young people – which is really great. They were going to go to schools and tell them about social prescribing and the services they were offering. The data above tells us that walking into a GP practice is not what young people want or need. I suggested two things to the PCN Network to think about:

  1. Be clear that you are prepared to spend the allocation per head you receive for these young people on meeting their needs. It may well be that you need to offer something quite different from traditional services.
  2. Yes go out to schools but be prepared to listen first – what does the school know about the health needs of young people in their care (when I was a school governor the pastoral team were overwhelmed with young people with anxiety, self-harming, drugs, poor family life..); and then listen to the young people themselves – what is it that helps them live a good and healthy life? Where do they go for help? What would work for them?

Marmot, Poverty and Primary Care

When you read my blogs on people who attend frequently in Primary Care you will see that there are 3 main issues:

  • People who need continuity of care
  • People who need a multidisciplinary team to meet their complex needs
  • People who are struggling with life – not just loneliness, but poverty.

My vlog (at the bottom of this blog) on working with general practice and their communities, shows that when you ask communities they say that to live a good and healthy life firstly people need shelter, stable finances, family and friends, meaningful lives and work etc. But the Marmot Review 10 years on shows us how these basic needs are not being met and are undermining people’s health:

  • “For part of the decade 2010-2020 life expectancy actually fell in the most deprived communities outside London for women and in some regions for men. For men and women everywhere the time spent in poor health is increasing.
  • Put simply, if health has stopped improving it is a sign that society has stopped improving.
  • The fact that austerity was followed by failure of health to improve and widening health inequalities does not prove that the one caused the other. That said, the link is entirely plausible, given what has happened to the determinants of health.” (p5) And this is the graph that demonstrates this (p10)
“Analysis from the Institute for Fiscal Studies shows how the more deprived areas, with greatest need, had the greatest reductions in per person spending, shown in Figure 1.2. The cuts over the period shown have been regressive and inequitable – they have been greatest in areas where need is highest and conditions are generally worse. It is likely that the cuts have harmed health and contributed to widening health inequalities in the short term and are highly likely to do so over the longer term.” p9

General Practice is experiencing an increase in demand directly related to people’s social conditions. No amount of social prescribing and extended hours will solve this problem – it needs to be solved at source. I don’t know how many appointments are for poverty-created health needs, but we need to find out. As I said at the RCGP conference – primary care has to understand need so it can push back against policies that are sticking plasters not problem solvers. Once we know this we can work with local government, our political representatives and the public to help people. I would argue GPs have a professional duty to do so.

Another key issue here is the disproportionate impact for the minority ethnic population , and that leads me to the last conversation

Modelling the future to reinforce the status quo

I was at a meeting of the Advisory Group for the RSA’s Future of Health and Care work. One area that is generating a lot of attention is genome sequencing and the ability to predict people’s health almost from birth. However a few weeks ago I’d chaired a cancer conference for Inspire2Live (a brilliant organisation that brings the best of science, clinical knowledge and citizen leadership together) rather cleverly called “Evidence, Arrogance, Ignorance, Eminence’ – which rather sums up the NHS dilemma. These presentations got to the heart of the issues:

  • Bob Weinberg (Whitehead Boston Institute) – the more we investigate cancer the more it outsmarts us – the science is telling us (a) we have to stop over treating and be more nuanced in care and (b) prevention is more effective and for lung cancer the only solution is to reduce incidence. Presentation . Have a look at the impact of education level (thank you Bob)
  • Olufunmilayo Olopade (University of Chicago)  – the research on breast cancer is primarily from studies of white western women and it doesn’t translate to ethnic minority groups. Presentation
  • Patrick Connor (pharmaceutical company AstraZeneca) – whist science has almost eliminated some cancers, we need to take a differnt tack with others – improving quality of life, and working on prevention already working on new grants for collaboration. Presentation

No amount of genome sequencing is going to help if (a) our data for determining solutions does note reflect the ethnic mix of our population and (b) we don’t address the critical issues of living healthy lives …. we are back to Marmot. The future of health and care is in living well not treating disease accelerated by poor social norms (poverty, investment in education…).

Marmot, M., Allen, J., Boyce,T., Goldblatt, P., Morrison, J. (2020) Health
equity in England: The Marmot Review 10 years on. London: Institute of Health Equity.

Solving the Problems in Primary Care.

The solutions the DES was looking for….

After the push back on the draft DES what should PCNs be doing themselves to secure better quality primary care, reduce demand and improve population health?

I’ve written plenty of blogs on PC so this one is an update on key issues where you can make a difference without centrally prescribed solutions.


Whilst there are endless contributions about PCNs having to find their own purpose and NHSE not prescribing a sole purpose, the draft DES demonstrated the disconnect between what PCN CDs thought PCNs were for and how to deliver that, and NHSE’s approach.

To find out what PCNs think they are for I set up a survey which you can fill in here sharing your Purpose with colleague PCNs (and where you can see theirs) which will give you access to the emerging picture of how PCNs describe their raison d’etre and what they are focusing on.

The survey shows the following direction in terms of purpose:

“To develop integrated working and sharing across practices to provide resilience and allow for innovation and excellent community based care for patients.”

“Strengthened practices, empowered community, support of the vulnerable”

“Joined up working to address issues one at a time across the PCN to improve care”

The responses so far focus on working collaboratively to:

  • Meet complex needs through integration, and secure access for marginalised people
  • Improve the quality of care for the whole population,
  • Support sustainable general practice and a resilient workforce
  • Empower communities

On the whole these mirror my proposal in terms of domains of work with reference to other health systems internationally:

  • Complex Integrated Care
  • Reducing unwarranted variation
  • Collaborating with Communities

Any purpose must be described in a way that you would know if you’d achieved it – these PCN ones signal direction but they are not quite there yet in terms of specificity along the lines of some famous ones (e.g. RNLI – a charity that saves lives at sea).

Without purpose PCNs will, like the rest of the system, be reactive rather than proactive. And it’s being reactive that has generated the crisis in PC.

So NHSE should be heartened from those that have participated so far, that the direction of travel they describe will secure quality primary care. But the next year is crucial – the same PCNs have been wise in where they are focusing their efforts, getting member practices on board, collaborating on complex needs, securing a workforce to meet needs. Disrupting the formation of these collaborative networks will mean these PCNs will not achieve their purpose (that and unsophisticated metrics for monitoring see below on averages). And this was the push back on the Draft DES – PCNs need space to understand the problems they face and build the relationships to collaborate.

Step one is to get a clear purpose and determine your focus for the coming year. Then direct your development money at achieving that. Assuming yours will be along the lines of those above here are some updates:

Meeting Complex Needs – Acuity

I’ve talked before about ‘know your list’ – if you know the patterns of people using your services (and other services e.g.A&E) you can start to be proactive in meeting needs. This means you have to differentiate your list. In the blogs on Frequent Attenders here and here we identified that people who turn up frequently are not all the same sort of people. We share how you might differentiate the ‘type’ of FA. Our proposition is that in all practices there are varying degrees of ‘acuity’. Here is an example of the range of complexity for the whole system and how to differentiate within a practice

One Surgery devised a project to improve how they triage, care for, and provide continuity to patients who attend their surgery the most (>30 attendances in last year), using an Emis code within our Care Plan template to trigger a “Patient Access Contract”. Over a 12 week period for 25 people with the Access Contract, the data shows a reduction in all appointments of 43% (67 less appointments for 25 patients), a reduction in the number of clinicians involved by 45%, and a reduction in OOH contacts by 56%, suggesting that improved continuity can reduce demand on appointments and improve care. This is the first iteration of their innovation in reducing the number of people who attend frequently. They are going on to explore even better ways of identifying and proactively securing continuity.

The only health warning on this is the regression to the mean –  we know that a % of people who attend frequently do just stop attending frequently in the subsequent year, so this is a great start and its good to look even deeper for the patterns over time.

Care Homes

There was a fair degree of uproar at the care home requirement in the draft spec. However the direction of travel was supported. You can find an overview of ‘what works in care homes’ here and I’ve popped a googledrive with evidence summaries here (if you have more do send and I’ll add). It triggered the sharing of multiple examples of dedicated teams of nurses, ward rounds, paramedic hot lines, GP alignment, and concerns that the DES would disband the best practice that has emerged.

People who live in Care Homes have increasingly complex needs and need continuity. Staff working in Care Homes are in the lowest 10% of the pay scale, are often on zero hours contracts, and there is a high turnover of staff (Roy Lilley, Gimme Strength 15th January 2020). It’s tough working in care homes, and even tougher if you are trying to navigate the different requirements and care plans of practices where the residents are registered. We know aligning care homes to practices improves the quality of care for people who live there – and they spend less time in hospital. As above in the section on acuity – having continuity makes a real difference as does valuing and supporting people who care for these folk. So given this is known, why isn’t primary care doing this everywhere? My experience is that many Practices have found ways of working with their CCG and Local Council to solve the problem. But there are examples where this is not happening – often a mix of a lack of imagination about funding and Practices being intransigent. It doesn’t require a DES, it requires learning from those who have worked it out, and for a collaborative approach to funding. Proactive management improves people’s lives, reduces overall costs and reduces demands on general practice overall, but it does need the CCGs to find ways to fund it. My sense is that PCNs can solve this one without a DES – and should.

Here are a couple of amazing examples:

“For several years we have a LES for GP care home rounds and one care home per Practice. It works, our practice does weekly rounds and we have the lowest rate of unplanned admissions for dementia patients in the county.”

“We have GP weekly ward round. GPs are supported by community nurse practitioners from community services. We were one of the care home vanguards. Secondary care geriatricians support weekly MDT. We have case management and pharmacist support. We have developed fantastic relationships with care home staff we support & help each other. It reduces overall demand for GPs.”

Social Prescribing

To help people struggling with life you need to recognise their assets, and make the most of the assets in your community to generate a network of local people (volunteers) who can help each other, lead by practice/patient/community champions who will nurture and value and grow the volunteers. See this blog.

Social prescribers can help that happen if they have skills in community building, and they should have. Without that SPs will be inundated with the need for appointments with people who need ‘connecting’ – and they will never meet the need. As we are seeing, SPs are finding that their appointments are filled quickly. Sucking up what should be the role of community building into the NHS won’t work. You can see more in my blog on this here.

SP came out of fantastic examples of success. These had at their essence, community building; face to face appointments for people who need help navigating the system; support to be able to make personal choices; help with their coping strategies; and leadership of this combined system. Those transactional models that are emerging will increase demand and will not reduce workload. Just a reminder from my SP blog

Metrics that relate to the transactional model (number of appointments) mirrors the problems in general practice. We provided a set of metrics for SP based on models that have worked and have demonstrable impact in terms of people living well and reducing their demand on the NHS. This is what we found in The Asset Based Health Inquiry. How best to develop social prescribing? (page 17)

“We suggest metrics along these lines that get to the heart of the intent of a primary care model of social prescribing:

  1. Increase in numbers of friends
  2. Proliferation of citizen-led not sector-led lifestyle support.
  3. Primary care ‘coverage’ to touch the whole population in a way that is more fairly and equally distributed.
  4. Reduced demand on general practice, meeting people’s needs and better overall health.”

Reducing Unwarranted Variation – Understanding Primary Care

Underneath all of this is a fundamental difficulty in understanding Primary Care. This blog isn’t long enough to go into the details – I’ll ask Nick Downham to help us out here – but one thing is for sure, getting all practices to the ‘average’ of them all is not securing quality nor will it solve the problems in PC.

I had a rather odd experience recently where a practice was below average on out patient referrals one year and above (a bit) in the next year and the CCG wanted to know what the problem was. The average had gone up because all the PCN practices had improved!!! It wasn’t a problem, the average had changed. Somehow getting to average will solve A&E admits, referrals etc. etc? Of course it doesn’t. There needs to be a fundamental change in understanding at CCG level about what they are commissioning for (it seems to be reduced A&E admits rather than people living healthy lives, and there is a belief that will reduce secondary care costs), how the metrics they use relate to what they are commissioning for (A&E admits are not just about PC nor are all A&E Admits bad, AND you need to understand what sort of A&E admits you need to reduce and by how much – i.e. what’s good practice and what’s possible). Another GP practice challenged this narrative to find that the A&E admits their CCG wanted to reduce wasn’t anything to do with their practice.

So another blog to follow on how you reduce unwarranted variation in primary care but the starting place has to be:

  • What is the need for PC that we are trying to meet?
  • How much of that is best provided by health?
  • What is all the evidence about how best to meet that need?
  • Are we using that evidence to develop our own responses to need?
  • Are we doing all we can to not make our own work?
  • Have we got metrics in place that help us understand what we are doing and whether its’ working?
  • Are we peer reviewing our work and learning together about how best to delivery primary care?

At the heart of all of this is data. PCNs are getting a range of support to meet needs, but they need help understanding population need, understanding variation and acuity, differentiating their list, understanding if what they are doing is making a difference. As yet there is no additional provision for data support to understand all these key factors. If there is one thing that will help PCNs get off the ground its data.