Doughnuts

A friend has just got a really swanky health economics job and we’ve just had a fun chat about doughnuts and donuts. In the end we both agreed donuts are great (in moderation though………. we believe in public health) but Kate Raworth’s book: Doughnut Economics- seven ways to think like a 21st century economist, is even better: http://bit.ly/2t2lfdd

I’ve had a stab at applying Kate’s ‘seven ways’ to health and care as I think they provide a framework to think differently about how we organise and deploy health and care resources…..what do you think?:

Change the goal: yes, lets focus on what matters to people not arbitrary 4hr/18 week targets in health and access thresholds in social care. There’s plenty of evidence to say people are a) willing to wait for the right service at the right time to get the best outcome:  and b) as taxpayers, pay more for health and social care as long any new tax is hypothecated https://www.health.org.uk/news-and-comment/newsletter-features/new-poll-shows-support-for-tax-increase-to-pay-for-health-an

See the big picture: This is about system thinking and many places have already embraced the integration of health and social care (although not many health bodies are willing to allow health budgets to merge with  adult social care budgets!) There maybe more scope to widen the current ‘closed’ system and spread the impact of social care budget pressures. Afterall the system should absolutely contain education, housing, employment, transport, criminal justice, regeneration etc etc etc. have a look at what Cheshire West Integrated Care partnership are up to in this area:  http://bit.ly/36qKDXv

Nurture human nature: wider system engagement would mean that the 80% of our lives, that we live outside of health and care services, can be brought to bear to keep us well; in safe places to live, in sustainable housing/communities with some friends and useful things to do which pay the bills. https://www.kingsfund.org.uk/publications/vision-population-health

Get savvy with systems: we hold masses of data on eachother and people expect us to use it to provide care (and plan services?) https://understandingpatientdata.org.uk/ but we are loath to do so because we misunderstand public concern (some of this is our fault http://bit.ly/2RsH1jz ). Risk stratification should be the starting point (see below)

Design to distribute; the outcome of savvy systems should be more appropriate resource allocation and who can argue with resources allocation based on need? Joint Strategic Needs assessments provide a good place to start this conversation. https://www.cheshireeast.gov.uk/council_and_democracy/council_information/jsna/jsna.aspx#overview

Create to regenerate; The recovery movement where people have struggled with mental health and substance use are some really good examples of regeneration https://www.mentalhealth.org.uk/a-to-z/r/recovery

Be agnostic about growth: Now, I’ve proposed increased taxation which requires people to be in work to have the resources to pay which in turn means we need to ensure jobs exist. However, doughnut thinking suggests we value jobs differently so caring/volunteering could/should have greater value then jobs which define existing definitions of a successful economy. As Kate Raworth says: ‘we know full well that we have the know-how, technology, and financial means to end poverty in all its forms should we collectively choose to make that happen’……we are all economists now.

So what…..well, as described above some of this stuff is being implemented or at least thought about already. Why not audit where you are with Kate’s ‘audit’ or better still ask C.Co to give you a hand…….It may give you a fresh perspective. You don’t need to go all misty eyed about the future funding model for health care, you could focus on a service , a pressure or an opportunity?

Where we started out wasn’t where we ended up

We’ve recently completed  a commission in the North of England, which in common with the way in which strategy development can take place, where we started out wasn’t where we ended up. Initially focussed on ‘preventing mental ill-health’ we ended up proposing some far reaching wellbeing measures within strategic planning for housing, jobs, green spaces and recommending a ‘place-making’ approach. We moved from health is healthcare to health is anything but the work of the NHS and care providers. We will post a link once the strategy is signed off.

Now this isn’t new, indeed we took our lead from the https://thrivenyc.cityofnewyork.us/ and the work of the West Midlands Combined Authority https://www.wmca.org.uk/what-we-do/thrive/thrive-at-work/ and the Liverpool City Region https://liverpoollep.org/wp-content/uploads/2018/11/Alan-Higgins-Public-Health-England.pdf whom are all on the same page, although its interesting to note how easy it is to retreat into what we know when you start to examine the transformation work outlined…….many of the actions relate to health and care service redesign, missing the opportunity to focus on place making as set out in their vision documents.

So what is place making: Research by the University of Wisconsin Population Health Institute (2016) has found that only 10 to 20 percent of a person’s health is related to access to care and the quality of services received. In comparison, over 40 percent of the factors that contribute to the length and quality of a person’s life are social and economic, while another 30 percent are health-related behaviours directly shaped by socio-economic factors, and an additional 10 percent are related to the physical environment. Over the last several decades, a growing body of literature has emphasised the importance of “place” to people’s health, with a frequently cited finding suggesting that a person’s postcode can be a larger determinant of his or her health than any other factor, including genetics.

We certainly found this in our work where there was real appetite to understand the funding flowing into the area from public sector, residents, the community, and local business and to consider how best this could be invested in the wellbeing of residents. We didn’t get as far as https://en.wikipedia.org/wiki/Zero-based_budgeting to model if the area was receiving the funding that its needs demonstrate and/or indeed to recommend a % of the area budget to go into something like Participative. Budgeting (PB) https://pbscotland.scot/blog/2020/1/6/exploring-local-authority-activity-towards-mainstream-participatory-budgetingnbsp as they do in parts of Scotland,…….here’s where we would need the support of someone like C.Co. to help us with http://www.socialauditnetwork.org.uk/getting-started/what-is-social-accounting-and-audit/ and the sums behind PB

So lots of people are interested in place based working and indeed some LAs have appointed Place Directors but usually this is to differentiate their work from a bunch of folk called People Directors who largely focus on children’s and adult social care services but actually they both have resources at their disposal which will provide wellbeing outcomes. In our work we spent some time talking to Place colleagues working on town centre masterplanning or large regeneration schemes to look at the flexibilities they have to do things differently. From this small sample of folk it would seem the issue is more about Place people seeing the potential to link with People people rather than prescribed process and do’s and don’ts .

So why blog, well because this is interesting and because it feels like the right thing to do and therefore we should recommend this approach. We would however, want to pursue this approach in partnership with providers such as C.Co who ‘get-it’ and who can add value to the process. We can offer a review, policy development inc financial modelling (via C.Co) participative budgeting and all the documentation to put in front of decision-makers.