‘One of the things I was most shocked by this year, was seeing a report that showed a man rough sleeping with a stoma bag. In what kind of country can someone have such good health care, but still be on the street?’
Jo Bibby, Director of Health, the Health Foundation
Access to health care is important, but it’s not the majority of what keeps us healthy. In addition, the social determinants of health, things like family, employment and housing, heavily shape our health and affect how we experience health care. People might receive great care, but once they leave hospital they may not live in an environment that supports their health, which will impact on their long-term recovery.
So how can the NHS influence and improve health beyond the direct provision of health care services?
At our Annual Event on 23 May 2019, our morning sessions explored why it’s so important for the NHS to think and act beyond its boundaries to deliver better care for patients, and how it can broaden its work to more widely influence population health.
Jo Bibby, the Health Foundation’s Director of Health, introduced the morning plenary, and talked about how the Health Foundation is promoting cross-sector action on the social determinants of health. This was followed by talks and case studies from a range of speakers. Here we summarise key learning from the plenary discussions.
1: The NHS has the power to influence health in four main ways
Dominique Allwood, Assistant Director of Improvement at the Health Foundation, introduced a framework for thinking about the main ways that the NHS can work to influence population health across traditional boundaries.
This includes a role for the NHS in improving health in the way it:
- designs and delivers clinical care
- employs and supports its own staff
- acts as an anchor institution within local communities and economies
- plays its part as a partner and leader in the health and care system.
2: The NHS must take inequalities into account when designing services
NHS services can have a considerable effect on people’s health by being mindful of the social determinants of health when designing pathways of care.
‘We need to think about how we understand inequalities in the communities we serve’, said Dominique. We’re seeing increased awareness of these inequalities within NHS trusts, but now need to see that knowledge being used in how we redesign and shape services. A positive example in action is Pathway, which works to improve care and outcomes for homeless people who are admitted to hospital.
3: A place-based approach can help with understanding complexity
Kieron Boyle, Chief Executive of Guy’s and St Thomas’ Charity, talked about how the charity has been working across traditional boundaries to find joined up ways of tackling some of the big health issues affecting local communities within Lambeth and Southwark.
‘Cities are places of overlapping worlds, with rich ethnic and cultural diversity, and high levels of income inequality’, he said. This creates complexity and plays out in health issues such as childhood obesity and multiple long-term health conditions – both areas of focus for the charity’s work.
Kieron added: ‘Social context seems to be critical. There’s clearly an income ingredient to these challenges. Kids from poorer backgrounds are three times more likely to be obese. To address these issues we need to work with many different actors across boundaries.’
To try and deal with the layers of complexity, the charity is taking a place-based approach, using systems mapping and knowledge gained from lived experience to build a strong understanding of the issues at play. It is then using this evidence base to inform action at different levels, from ‘hyperlocal’ work within neighbourhoods (such as investing in the local community centre or working with shopkeepers to influence what food is available to buy in convenience stores), to engaging with national newspapers about how they frame the problem of childhood obesity, or working internationally with food producers to try to reduce sugar content.
Kieron argues that by being deeply attentive to place, we can get under the skin of the big issues, giving us a deeper and more laser focused understanding which can help to inform national policy.
4: Think about health inequalities within the NHS workforce itself
Dominique talked about the importance of the NHS being a ‘role model employer’, thinking about creating healthy work environments and providing access to good quality employment. She said organisations need to think about the differences and inequalities that exist within their own staff groups, and target support and health interventions accordingly. She gave the example of one hospital that has worked with staff in bands 1 and 2 to coproduce interventions aimed at less privileged staff groups, which have had a really meaningful impact on wellbeing and reduced levels of staff sickness. Interventions have included initiatives such as cookery classes, monthly weekend walks and other social events aimed at improving health and wellbeing and increasing social connections.
5: Future staff can be trained to think across boundaries
Helen Crimlisk, Deputy Medical Director, Sheffield Health and Social Care, spoke about what the increasing need to work across boundaries means for the NHS workforce. With new roles being developed in the NHS there is going to be extra demand on the people providing training and placements. ‘The current model is strained beyond belief’, she said, ‘and we have to think differently about how to train the staff of our future’.
She suggested that in order to navigate the system we’re developing for the 21st century, students and trainees will need to be comfortable working across boundaries with professional and non-professional experts, in both statutory and voluntary settings. She sees an opportunity to develop educational opportunities around this, creating placements within third sector settings, as Sheffield Medical School currently do. These ‘social accountability placements’ help students to ‘see and experience the intersectionality between illness and the social determinants of health, as well as seeing some of the innovation which is inherent in the frugal and fragile systems of the third sector.’
6: True coproduction stimulates cross-boundary working
The discussions highlighted the importance of lived experience in creating personalised and coproduced care, both in the delivery of services and also in learning and teaching. Helen said: ‘We know that the presence of patients, service users and carers working alongside clinicians has a positive impact on culture. It enables us to access patient experience more easily, it provides peer support for patients, and it provides a methodology for stimulating quality improvement, using techniques like experience-based codesign.’ Kieron also talked about the importance of ‘surfacing different voices’, observing that ‘neighbourhoods are full of rich solutions and can also direct you to where the real issues might be’.
7: The NHS needs to overcome barriers to being a good system partner
It can sometimes be frustrating trying to make the case for partnership working where the outcomes will be seen beyond the walls of health organisations, or as often is the case, beyond the timescales of funding. Dominique said that the Health Foundation is currently exploring how it can help organisations to make the business case for this kind of work and explain the wider value to health. There was recognition that current commissioning systems are still very ‘silo based’, which inhibits partnership working across sectors, but also hope that new opportunities might come about through the new Primary Care Networks if they are well supported.
8: Values are a key uniting factor in making partnerships work
Kieron talked about the importance of shared values when building strong partnerships across organisations and sectors. It’s teams, rather than organisations, and individuals, rather than roles, that can make or break a united approach to a problem. Building strong, trusted relationships is key, so that people feel able to think creatively and ‘blur boundaries and budgets’ to overcome the structural barriers that would normally prevent them working together. As Helen says, ‘we need to foster the trust necessary to make these changes, enabling staff to thrive not just survive and communities to do the same’.
This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.
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Charlotte Augst, CEO of National Voices, on how patients have an important role in shaping how the NHS works in the future.
Reshaping care on the ground requires teams to come together across sectors and work differently. It’s not always easy.
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