Neil Churchill: living within our means locally

One thing struck me particularly about this prediction from the Nuffield Trust and Institute For Fiscal Studies.

That was the fact that the figure involved - 2.4 per cent in real terms - is close to the rate Derek Wanless thought we could manage with if patients were “fully engaged” in our health.

None of the figures I have seen suggest we have come close to that state of nirvana. Indeed, alcohol and obesity projections look frightening and emergency admissions for diabetes and asthma suggest that treatable conditions are still being allowed to deteriorate to the extent that they repeatedly need acute care.

Even if we assume that the NHS becomes universally superb at secondary prevention, it won’t be enough to live within a long-term cash envelope of 2.4 per cent growth. So we need to look at the environments around NHS organisations in which patients spend most of their time.

Much hope has been invested in health and wellbeing boards. However, at a seminar this week there was an audible sigh of relief when a speaker said they were not a solution for all ills. With social care funding already on its knees, many people expect the boards to become gladiatorial contests over who pays for the scraps that remain. But at the end of the day, a strategic response to care requires the government to address the funding gap.

Commissioners will do well to get boards to focus on other big ticket items more responsive to local decision making, as well as make the most of the Sisyphian job managing social care.

What other big ticket items are there? First of all, we need a guide to help spot healthy councils. As funding for public health is passed over, how do they plan to spend it?

Healthy councils will put public health budgets to good use and go further, for example reducing accidents by giving pedestrians priority for the 500m around schools or preventing asthma admissions by tackling traffic pollution in urban areas.

Unhealthy councils, by contrast, will succumb to the temptation to divert the cash into other projects. In recent weeks I have been depressed to hear tales of such plans from councillors who know the harm that will be done in the long run. I agree that the pot holes in my road need filling, but I don’t want it done from the public health budget. Though I admit it’s easier to be sanguine in the flat-cash NHS or charity world than it is in cash-starved councils, where there are already signs of desperation. Where, let’s not forget, more than 80 per cent of cuts are yet to be felt.

I also hope that local people will rescue the excellent concept of healthy schools. The national Healthy Schools programme has been abandoned by a coalition in obsessive pursuit of the 3 Rs, despite the fact that it was voluntary. Yet children’s health is strongly influenced by their school environment. Make healthy options accessible and we step forward in the fight against obesity.

School is also a promising route to promote self-management. Asthma is the most common childhood condition, and systematic reviews show that school-based asthma education improves self management and asthma outcomes. But now schools will only choose to become healthy schools if governors want it. They might step up if they are encouraged to see the benefits.

Mental health is quite rightly given equal priority to physical health in the mandate to the NHS Commissioning Board but many key local services are not funded by NHS organisations and are being cut back. Yet mental health problems can raise healthcare costs by half as much again, making this another big ticket item for local planning. 

Indeed, patients are more likely to stay well if they have appropriate access to emotional and psychological support. Social prescribing can make an important difference as it is within the power of CCGs to deliver.

Finally, we can’t lose our focus on inequality. Quite why major reports on inequality are only commissioned in the dying days of Labour governments I do not know. Elements of Michael Marmot’s report into the social determinants of health require national action but local responses are effective, too. Community engagement among excluded groups has been shown to be effective at improving health outcomes.

Our experience at Asthma UK shows that many repeat users of accident and emergency are being lost to primary care. Effective community engagement is one way to rebuild those links.

For the NHS to thrive on 2.4 per cent a year, we need health to be everyone’s business. National policy isn’t currently setting much of an example. Local policy can and should do better.

Neil Churchill is chief executive of Asthma UK.