A bit of thinking on saving the country £200m…and much more…

The opinions which follow are entirely personal and do not claim to reflect those of or have endorsement by any organisation.

Folk will doubtless have read of the proposals by the Chancellor to cut £200m from the local authority public health budgets in year. We still await detail of what is proposed.

David Buck, from the King’s Fund, gives an excellent breakdown in today’s LGC (Local Government Chronicle) of why this is much more serious than initially suggested. David says that

“many unanswered questions remain, including how this relates to the transfer of children’s services from the NHS to local government planned for October. This will be worth more than £800m each year.”

David recounts that the proposal comes on top of a standstill in public health funding. Secondly, he says it seems to contradict the commitment to Prevention echoed in the NHS Five Year Forward View, and then, thirdly, reminds us that many of the services commissioned by Public Health are commissioned from the NHS. Despite the recent commitment to protect the funding of the NHS. This will impact on the NHS, and directly.  But David’s most telling point is to warn of wider consequences:

“Locally, it could easily create perverse incentives that lead away from integration. Why would clinical commissioning groups enter into pooled budgeting arrangements with local authorities, when they know their funding is safe and sacrosanct but local authorities’ money is not?”

David’s piece is here, and is well worth a read. Equally, Keith Cooper’s editorial comment in the same issue is extremely good at highlighting how this proposal will have a wider impact than just local government.

Apart from being really quite incisive sets of comments, it’s heartening how the local government press has taken enthusiastically to the potential which public health has as part of the local government family.

We are, I think, just beginning to articulate the possibilities that prevention could deliver for better lives, better health and a more sustainable public purse. It’s entirely right that the Government of the day usually has expected and should expect its public officials to deliver the “Four Es” – Economy, Effectivness, Efficiency and Equity – from public spending, especially in an era of austerity. I just think that there are much more effective and far-reaching ways of doing it than applying a poorly thought through £200m clawback.

This was highlighted yesterday and this morning with the launch of the ‘Smoking Still Kills’ strategy where the argument for preventative services is expounded; and the success to date of reducing costly and painful death and disease from tobacco is evident. Giving preventive activity time to embed really can yield differences. Locally our new approach to drug recovery is reducing the spend on residential rehabilitation and the cost to social care. There is money to be saved here, but we need to do some lateral thinking. Prevention can be made to work, but only if we see it as a system, and work as a system.

There is no way the current £200 million proposal can happen without impacting on the NHS

At an estimated 7.4% of in year public health spend, it is highly unlikely that Local Authorities will be able to achieve efficiencies across all areas of current public health spend without affecting the statutory Public Health services (e.g. sexual health, health checks ) or other NHS services which constitute a considerable proportion of the public health grant and service investment (e.g school nurses, health visitors). David Buck points out that not cutting NHS servics is a Government Manifesto commitment.

Page 38 of the Government’s Manifesto reads

“We will support you and your family to stay healthy. We are helping people to stay healthy by ending the open display of tobacco in shops, introducing plain–packaged cigarettes and funding local authority public health budgets. We will take action to reduce childhood obesity and continue to promote clear food information. We will support people struggling with addictions and undertake a review into how best to support those suffering from long-term yet treatable conditions, such as drug or alcohol addiction, or obesity, back in to work.”

As a public health professional this is inspiring. In fact, we have two social enterprises in Hertfordshire who spend all of their time getting people into work after battling drug and alcohol dependency. And they do a good job. I was hoping to expand this ethos more widely to mental health and other long term conditions but without being able to use public health money for investment, it’s unlikely the money will come from anywhere else. The current proposal  to cut £200m is not the way to help the local health economy’s existing plan for delivering those commitments, or prevention savings more widely.

Alternative Efficiency Proposals in the short term

Some colleagues and friends have been in discussion with me. And I have shamelessly purloined some of their ideas here. (You know who you are, and thank you.) If £200m really has to be saved from NHS spend this year, (and remember much public health spend is actually spend on the NHS) then I think  a more constructive approach would be to:

  1.   Give Hospital Trusts a £200m target to reduce avoidable costs from procurement and agency staff commissioning. The ‘Carter Report’ widely trailed in the news today suggests that Hospitals may not be gaining the £400m in procurement and agency savings alone they could reap in these areas[i].
  2. Give NHS Trusts a £200m target to reduce ‘interventions of limited clinical value’ in NHS provision. The Academy of Royal Collages Report (November 2014) suggests that 20% of all health care activity is effectively over-treatment as it  ‘brings no benefit to the patient’[ii] .This could be done without harming health outcomes.
  3. Introduce a Sugar Duty at 20 pence per litre in England[iii]. The impact nationally over twenty years would be to:
  •  reduce the cases of diabetes by just under 50,000
  • prevent almost 9000 cases of cancer
  • reduce strokes and cases of coronary heart disease by over 33,000
  • save the NHS at least £15million a year in healthcare costs for treating those diseases.
  • improve the quality of life for tens of thousands of residents.

4. Introduce the levy on the tobacco industry called for in Smoking still kills. This could pay for the cost to local government of social care, cleaning, litter, smoking cessation, tobacco control and other measures; and the cost to the NHS of treating diseases attributable to smoking like COPD, cancer and even Diabetes as identified by the recent report of the US Surgeon General.

All of the first 3 measures above are evidenced based (references in footnote below), would reduce costs, would bring clinical benefit to patients, would  improve health outcomes for citizens and would improve NHS productivity without reducing its capacity to prevent future demand. The fourth measure is argued for in Smoking still kills.

Additional Efficiency Proposals in the medium term

Obviously we would and could make further savings by doing things differently. Preventing diseases from escalating or worsening and treating as quickly and cheaply as possible continue to be options which we can explore further. Here are just five of my list of candidates for saving money while improving health:

  1.  Make greater use of pharmacy for minor ailments and long term conditions
  2. Drive down the cost of consultations and polypharmacy in multimorbidity by delivering models of care which address multimorbidity per se, rather than accumulating niche guidelines, treatments and consultations for multiple individual conditions. And please don’t say we’re doing that. The last 29 conversations I had on this with clinicians had one consensus point: we can do a lot better.
  3. Invest in self management – there are promising models here.
  4. Identify early high risk of escalating disease and disability and keep people at optimal levels of functioning through good pathways and practice.
  5. Learn from the five best countries in the world about keeping people with long term conditions economically active (eg in the workforce).

There are, with some thought, good implementation science and hard work, many places from which we could save sustainable sums that will be multiples of £200 million. And we could improve health into the bargain.  It wont be overnight.  The way to do it is focus the public health, local government and NHS workforce on prevention and quality, not chasing short-term cuts. You don’t even need to invest here;  just don’t cut to transform and save.

 

 

 

 

 

 

 

[i] Academy of Royal Collages (2014) Protecting resources, Promoting value: A doctors guide to cutting waste in clinical care http://www.aomrc.org.uk/publications/reports-a-guidance?view=docman

[ii] http://www.bbc.co.uk/news/health-33071066

[iii] The Children’s Food Campaign has  published a tool that allows people to view the impact a sugary drinks duty could have in their local area. The figures, available on www.childrenshealthfund.org.uk  show that the introduction of a duty on sugary drinks could reduce rates of diet-related diseases by tens of thousands, as well as save the NHS and public health budgets in England £300 million over twenty years.

 

 

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Mindfulness…useful, not a panacea

Thinking of using or commissioning something involving mindfulness?  Good, but have a think about what it is you are trying to achieve.

I like mindfulness, I think it has a number of applications. While it comes from faith traditions, Mindfulness type techniques are increasingly found in non-faith settings. Why? Because Mindfulness seems for many people to have salience and usefulness in a range of situations including living with chronic illness, coping with stress, and coming to acceptance of one’s own identity.

Pace, for example, say it has value for LGBT settings and people among a range of other techniques and tools. It has been applied in long term conditions like neurological conditions and in Hertfordshire currently this is being researched by clinical psychologists.  At its heart mindfulness points us to the need for balance in our lives and relationships, both interior and exterior. And we should welcome this as a good step. Try the Royal College of Psychiatrists site for some good resources.

Mindfulness and cognate spiritual traditions: the balanced life

You may not think to look at or listen to me, but silence and contemplation are things I try to practice for a period each day. (Ok, stop falling about laughing, I am actually being serious. The experience of being centred each day on the relationships and the things I value are essential to me. As a Catholic and someone with an attachment to the Carmelite tradition I call this an aspect of contemplative prayer. As a psychologist I call this focusing using techniques which are essentially similar to mindfulness.)

And in the 500th Anniversary of the birth of the Spanish Mystic Teresa of Avila  (the great Carmelite reformer) it seems a useful time to take a look at some of the stuff,  healthy and not so healthy, which seems to be trending on mindfulness. Like any good thing which is trending, it seems that in the midst to rush and take up mindfulness-based techniques, we are busy both forgetting some of the things about its origin and tradition we should bear in mind, and at the same time not overtly doing the work of finding a framework into which we can place mindfulness as one of the tools for a balanced life.

Lessons from the origin and tradition

Mindfulness is NOT purely a Buddhist concept.  Almost every major faith tradition has some form of focusing or contemplation with methods, insights or rules similar to mindfulness. I know it’s enduringly trendy to see Eastern philosophies and religions as more simpatico to our atomist 21st century ultra diverse lives, but even in Christianity alone I could point you to multiple Catholic, Anglican, Presbyterian and other traditions akin to Mindfulness, starting with Early Monasticism and working through Carmelite and Quaker mysticism.  The Practice of the Presence of God, for example, is just one offering from 17th Century France.  And the Jewish and Muslim traditions are just as rich. Rant over.

A good thing psychologists have done is extract what seems to be a core of Mindfulness based technique and apply it to settings without explicit religious or spiritual overtones. That means it can have a wider application for some who find the religious or spiritual overtones off-putting or difficult.

But there is something being missed here…most religious traditions which have had techniques analogous to mindfulness for any length of time have developed in tandem with them tools and tactics for when all does not go smoothly with meditation type techniques. And this happens more than you might think. Miguel Farias and Catherine Wikholm writing in  New Scientist  on 16th May 2015 point out a range of downsides to mindfulness for some people – increased stress, anxiety even significant emotional and psychological difficulties.

What’s going on here?  Simply the fact that Mindfulness isn’t for everyone and some people collide into what in one Catholic (Carmelite) tradition is described as the dark night of the soul ; a period of aridity, darkness, futility, depression and loss.  Another form of what is going on is that if you really deeply hate yourself or have many unresolved issues, then mindfulness can bring you face to face with things you really may not like about yourself, feelings you may not always attend to, or may even supress. And when they are there in front of you, it can sometimes be overwhelming.

Using mindfulness in someone who has a life-threatening condition can bring them to the reality of their mortality in a way which can actually be overwhelming and cause panic, not calm, if you don’t help and prepare. And for some people with long term conditions, mindfulness can bring them face to face with their frailty and limitations rather than help them cope.  Some research seems to suggest outlook and personality factors could be important in determining when mindfulness helps and when it doesn’t. But as yet the traditions built up over long experience seem to have a handle on this which psychologists applying mindfulness are still to fully reckon with.

Spiritual traditions have ways of dealing with these issues and experiences, built up over centuries. Mindfulness-based techniques taken out of faith settings may not have.   But they need to develop them. Techniques like recognising when some people should be steered away from Mindfulness, how to build support in if aridity or desert experience or painful things come up are all important. And some practitioners and teachers both from a spiritual and non spiritual background do not seem to apply these safeguards.

We can add to this the fact that despite some neuroscience and some experimental psychology studies, we still don’t really know exactly how mindfulness works. We still are not yet fully clear of the mehanisms of mindfulness in a way we can really explain. This means we still need to be open to learn about where Mindfulness-based techniques are and are not useful.

I believe Mindfulness is not for everyone, contrary to what some commentators say. If you absolutely hate yourself, then training to focus on that and being left to sit with that can be devastating for some people rather than a spur for development. There can be a core of mindfulness type techniques that are probably very broadly applicable (focus, being in the moment, dealing with various cognitive and interpersonal demands across the day by focusing on the present) but let’s not assume this is a panacea. We did that with Nudge and got disappointed, and sometimes ended up using nudge less than we should have, just because it didn’t do everything we wanted it to.

Integrating Mindfulness into a coherent picture

It’s interesting to me that all the teaching sessions I have been asked to do on mindfulness in the last year were focused on how to integrate mindfulness into a public health, or psychological, or religious worldview. The most recent one was a study day for a mixed group in St Albans Cathedral (psychologists, public health types, therapists, ministers and others) which showed roughly similar issues across these disciplinary boundaries:

  1. An interest in mindfulness
  2. A knowledge of some of the techniques, sometimes very advanced
  3. Limited or little knowledge of what science there is behind it or even how mindfulness interacts with the biology of stress
  4. A searching for how to integrate mindfulness with their worldview, professional values and practice

Being clear about why you use or commission mindfulness is hugely important. We are not in a supermarket here, and treating spiritual or non spiritual forms of mindfulness “type” work as a “pick and mix” risks instrumentalising the technique and ourselves, and trivialising the issues behind mindfulness.

Having an eclectic methodological disposition in practice of psychology, public health or pastoral care is all very well. But not examining the fundamental assumptions behind a tool or technique means you can end up at best being inconsistent between values and practice, and at worst harming yourself or others because of the dissonance caused by that inconsistency.  If you believe everyone should use mindfulness to look at themselves, you have to put in place things to respond and keep people safe when what they see is something they find distressing. Equally, if you believe stress at work is at least partly or even mainly due to poor psychosocial work environment (and there is some good evidence to support this as at least one major factor in workplace stress) then mindfulness as the only answer is a cop-out, placing the onus on the employee when the solution really requires the organisation to change or act. Using mindfulness to make people more resilient to systems which dehumanise or dysfunction – whether care, education or employment – is neither ethical nor sustainable.

Kate Williams, writing in The Psychologist says that she is ” a strong believer in MBIs and can see the benefits it can bring. Yet we must remain ‘mindful’ of how we promote and talk about mindfulness to ensure we carefully promote its use and application to mental or physical health issues whilst in the early days of its research. If we can avoid overstating mindfulness as a gold standard or panacea, those new to mindfulness can start to practise with realistic expectations, under suitably qualified courses, and can begin to experience the wonderful world of mindfulness meditation.”

So, use mindfulness, but think aboutthe developmental nature of this field.