We need to consider alternative models of health delivery that focus on addressing the place based social determinants of poor health aided by the development of mechanisms to ensure effective coordination between multiple agencies and stakeholders, writes Charlotte Alldritt
The UK is experiencing a significant slowdown in health improvement, driven by place based health inequalities – a point we argue in our latest report, Beyond sticking plasters: A whole systems approach to health and social care. These inequalities are largely determined by local area variation in employment deprivation, education, skills and training, and access to quality housing.
Reflecting on our report findings, mayor of Greater Manchester, Andy Burnham, said:
“CPP analysis has shown that housing is one of the most important factors in variation in life expectancy. We need to consider radical new ways to narrow this inequality – maybe, even, the right to housing becoming a universal entitlement.”
Addressing these social determinants requires cross departmental action and resourcing as well as improved coordination at a local level. If better health is the goal, then place based investment and coordination in education, skills and training, increased access to quality housing and active labour market policies to reduce unemployment and low pay may be just as relevant as more funding for local hospitals and GP surgeries.
This point is particularly relevant as health spending (narrowly defined) accounts for an ever increasing share of total government spending.
Our analysis finds that the greater the geographic fragmentation of health and care institutions in a local area, the higher the rate of unplanned hospital admissions and delayed transfers of care
Cross departmental strategies in central government are not doing enough to make collaborating easier or more effective while funding and accountability incentives are not sufficiently aligned to allow for integrated “whole place” approaches to supporting health at a local level.
Against this backdrop, it is crucial that local areas can deliver a coordinated suit of complementary activities to tackle the wide ranging determinants of ill health, while continuing to cure and rehabilitate those who are unwell. This is not an easy task and made harder when the different institutions responsible for ensuring good health do not geographically align – ie their areas do not share common geographic boundaries.
One of the major contributions of our report is to estimate the implications of such a coordination challenge. Our analysis finds that the greater the geographic fragmentation of health and care institutions in a local area, the higher the rate of unplanned hospital admissions and delayed transfers of care.
- If the local authority you live in does not geographically align with the Clinical Commissioning Group, delayed transfers are, on average, 32 per cent higher.
- In a local authority where the different bodies responsible for healthcare do not geographically match up, there will be around 15 per cent more unplanned admissions to hospital and 30 per cent more people will be delayed in being discharged from hospital.
The challenge posed by misaligned institutions and structures may be exacerbated by recent policy developments. The emergence of regional teams and regional geographies covering both NHS England and NHS Improvement functions are intended to promote integration, but instead these may add yet another layer of complexity to already complicated and fragmented local health systems.
The way forward is to consider alternative models of health delivery that focus on addressing the place based social determinants of poor health aided by the development of mechanisms to ensure effective coordination between multiple agencies and stakeholders.
This does not necessitate yet more top down structural change but does require a recognition of the role of place in determining health outcomes and stronger accountability mechanisms for health at a local level. In the context of devolution, there are already innovative examples in operation today, such as the approach being trialled by Greater Manchester.
Evaluating the success of these new models and understanding how to build on them at scale and at pace is the next key challenge. Ultimately, shifting away from the current narrow model of healthcare towards a broader social model of health will require policy change at a national, regional and local level.
The next phase of our work in 2019 will explore in detail what changes are required and what the possible costs and benefits of such a transformation could be.