The benefit of budgets – now we’re really talking patient power

Guest Blog by Dr Iseult Roche

Five million people are expected to benefit from new personal health budgets by 2018. It is hoped this will enable patients with chronic conditions to obtain ownership and independence over their own care.

Social services have previously used Personal Budgets, where approximately  650,000 people benefited from them, and they have been introduced as a “right to have” for people with continuing care needs in the health service this year.

The innovative concept to extend their use in health and social care has been announced by  Simon phbthumbStevens, the NHS England chief executive.

It is anticipated health and social care budgets could be combined and budgets will probably  come from funding awarded to councils and clinical commissioning groups that are successful in delivering localized,  integrated and well managed care and achieve good outcomes for those allocated the budgets.

Simon Stevens, in The Guardian,  is quoted as saying “We are going to set out the biggest offer to bring health and social care together that there’s been since 1948 – a new option for combining them at the level of the individual.”

Although some doctors and patients alike may have some concerns over how patients will manage these budgets, and certainly vulnerable people may well need support to manage their budget effectively, this is a significant step forward in patient-centred care. Helping promote patient involvement and shared management of their own care (which surely in the longer term will be of benefit and may promote health compliance and health understanding) in a chronic health condition is vital.

See the comprehensive 2020health report: Personal Health Budgets: A revolution in personalisation

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Accident and Emergency: ‘but not as we know it Jim’

By Gail Beer, Director of Operations at 2020health

A recent survey by The National Audit Office found that one person in four is unaware of out-of-hours care offered by GPs and that one person in five in England is unaware of the new NHS 111 urgent phone service. (BBC 11th July 2014)

The report highlighted a number of reasons why people don’t use the out-of-hours services and the impact this has had on A&E services.  We have heard all this before and it should, by now, be obvious: people access services in the way they find easiest.

One comment really resonated with us, from Dr Cliff Mann, of the College of Emergency Medicine, who said, “Rather than persuade patients to find their way to services, we need to provide a range of services where the lights are on 24/7.”

Screen Shot 2014-07-15 at 17.13.45In our recent publication ‘Going with the Flow’ (2020health, 2014) we made much the same point.

For years, various initiatives have encouraged patients to use centralised out-of-hours services, call NHS Direct and now NHS 111 – yet we have failed to encourage patients to use these facilities. The plethora of ways to contact your GP, an out-of-hours GP, or summon help and advice when you are taken ill in the middle of the night are confusing and can cause anxiety.

Are you a minor injury, in need of urgent care, needing to see your GP, are you a ‘walk- in’?  When you need help or need reassurance, negotiating your way through the complexity of the system is daunting.  With help seemingly not at hand, it is easiest to go to your A&E where you know the door is open.  People are prepared to travel and wait in these busy departments, with the usual dramas that they offer, rather than stay in the comfort of their own homes waiting for the GP.

We have lost confidence to care for ourselves and there has been a real loss of confidence in the OOH service. The public express fear about what happens at night if they need medical care, especially as many still have a problem with getting to see a GP at short notice, so many just go to their A&E.

In our report we highlight that we have lost the current battle to encourage people to stay away from A&E. Let’s embrace the fact that people want to go to a 24 hour campus. Let’s structure the ‘Out-of-Hours’ services to make sure that we offer reassurance and treatment to those who can go home or need to be followed up by their GP  and provide the care required for those  needing admission and urgent intervention.

We are where we are and the public have, to date, rejected the initiatives.  Maybe they just don’t get them and when they do they don’t like what is on offer. As with any discerning consumer you vote with your feet.

So what to do?

We could start by stopping calling them ‘out-of hours’ services; in all my years as a clinician, ill health never timed itself to be ‘in hours’. The very term implies risk and causes anxiety. It is not out-of-hours for the sick, it is out-of-hours for the professional.

Stop changing the numbers and names of the services; make them simple to understand, let them do what it says on the tin.  Accident and Emergency is a clear signpost, albeit that the professional may have a different perception about the function of an A&E from that held by the public.

Accept that the local hospital is at the heart of the community and that, for those needing care out of GP opening hours, it seems obvious to go to the local A&E.  In ‘Going with the Flow’ we advocate that we stop telling people not to go to hospital, start simplifying the message and enable more strategic planning.  Recognising that it is impossible, and indeed unsafe, for all hospitals to do everything, we suggested that we classify hospitals into ‘Blue’ and ‘Red’.

Blue Hospitals, being specialised, would provide for serious A&E cases and complex trauma, with emergency surgery readily available.  You would be taken there by ambulance or helicopter or referred on by another Dr or paramedic. Heart attack and stroke services would be located in these units,   24-hour consultant cover in A&E would be provided. The public would know the designation by the simple labelling of specialised hospitals as ‘Blue’.

Alongside them would be ‘Red’ General Hospitals, providing a 24/7 emergency service in one place, including OOH GPs, with the support of nurse consultants, emergency nurse practitioners, paramedics, social care and pharmacists and of course some hospital Doctors. These hospitals would be treatment or triage centres  and could treat and manage a large range of conditions, from the simple to the complex, admit,  give advice, run education programmes on health, and follow people up, refer them on or  refer them back to the GP.  People think about ‘their’ local hospital and ‘their’ local GP.  We need to build on these sentiments and encourage the involvement of the neighbourhood in a meaningful way. We must accept that not all A&Es would look as they do now but they could be something more,  tuned into what the public want in order to allay their fears.

To enable this reorganisation to Blue and Red hospitals to happen will require some brave decisions: not least integrating services with the care record at the core, and building a service around the public and the 24-hour world in which they live.

And yes, this does go against the flow of current thinking, but the public don’t like or get our current thinking. We haven’t made a coherent case for closing or indeed changing A&E departments, the OOH service is obviously missing the point with the public, so let’s give them what they want but make it better than they have now. In that way we can begin the process of focusing on the other big issues around, like  Long Term Conditions, obesity and social care   We’re clouding the issues  with A&E and OOH and it appears the public think it is clouded enough already.

 

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Walking is free – why are we paying for alternatives?

Several papers lead on the story today that taking regular exercise reduces your chances of developing Alzheimer’s disease, here from @lauradonlee in the Telegraph and Sophie Borland in the Mail. Seven different lifestyle factors (weight, smoking, blood pressure, healthy diet etc) were reviewed, all of which are common sense but not previously specifically linked to Alzheimer’s prevention.

The thing is, exercise is vital for health. If exercise were a pill, it would be the most cost effective medicine ever. And therein lies a vital message for the NHS and the public – unless we all build more exercise into our day, we will suffer avoidable disease and have to pay more taxes for the treatment. And we are talking easy stuff – walking part of the way to work, taking a walk at lunchtime etc. To state the obvious, exercise is free, and it seems bizarre that we have forgotten how important it is. Social prescribing - an approach that seeks to improve health by tackling patients’ social and physical wellbeing – has more recently tried to remind us of how crucial physical activity is. Social prescribing (to dance classes, walking groups, knitting socials and cookery clubs) is a low cost approach, but really we should be aiming for a no-cost solution where people are signposted to groups and organisations that have realised they are interdependent ‘assets’ – individuals who have got together, shared their experiences and understanding in order to help each other.

I think we should be asking the question, if there is a free solution to a medical problem, and an individual is able to exercise, why should the tax-payer fund the solution that costs? It may be that after lifestyle changes the problem remains in which case medication is required and should be provided as usual. But in the first instance, if they can’t be bothered to walk, why shouldn’t they pay for the costly alternative?

Just as a reminder, the list from Boots on the benefits of exercise:

  • Reduce stress
  • Ward off anxiety and feelings of depression
  • Boost self-esteem
  • Improve sleep
  • It strengthens your heart
  • It increases energy levels
  • It lowers blood pressure
  • It improves muscle tone and strength
  • It strengthens and builds bones
  • It helps reduce body fat
  • It makes you look fit and healthy

Why not?

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The NHS can’t stretch to gastric band surgery for all

Baroness Young of Diabetes UK has just been speaking on BBC Radio 4′s Today programme in response to the draft advice from NICE that everyone who is obese and has type 2 diabetes (the former often causes the latter) should be offered bariatric (gastric band, weight-loss) surgery – that’s about 800,000 of us. It’s covered here by Telegraph Health Editor @lauradonnelly with a useful timeline and BMI calculator. Baroness Young’s main complaint is the fact that not enough is being done to prevent people becoming obese, or offered support to lose weight once they are, and that bariatric surgery which has been a last resort is now being proposed as a solution for all. Of course there is then the cost – at £5,000 a pop, where would the money come from? @SarahBoseley rightly points out in the Guardian too that there is already a queue of potential patients to see the psychologists who need to counsel them on the serious implications of surgery.

Note it is draft guidance and NICE will know that about 8,000 weight-loss operations were undertaken last year and that we can’t overnight increase capacity 100 fold. As with all surgery, it has its risks and many will decline the offer. Added to this it doesn’t tackle route causes and you can still overeat even after surgery.

The reason we keep coming back to this subject is that there is no effective national strategy for what is an epidemic. The government launched their obesity strategy back in October 2011, and it included:

  • Responsibility Deal – a voluntary set of pledges for business around alcoholfoodhealth at work and physical activity
  • Public education
  • Environment & physical activity
  • Councils – moving public health to Health and Wellbeing Boards in the hope that they would ‘do something’

There are lots of examples of organisations taking action, which is great, but it is a drop in the ocean. Whilst it accurately recognises that causes of obesity are multi-factorial, we have an obesity crisis and this good will approach only means the troops are ready for battle, the real action hasn’t begun. Where is the COBRA meeting for obesity?

Whilst Diabetes UK want more weight loss classes, the reality is that most causes of obesity lie outside the NHS and to win the fight of the flab we have to have a serious cross-departmental strategy that enables prevention and action at every front-line including:

  • Food industry – especially fast food outlets and misleading labelling
  • Drinks industry – remembering a bottle of wine average 700 calories
  • Town and country planning – that encourages walking and cycling
  • Public Health planning – tackling the determinants of health
  • Incentives / penalties – no stone should be left unturned
  • Education – our Well’s Family Challenge report with Sainsbury’s showed a woeful lack of understanding of what constitutes a balanced diet.

Just a word on exercise however. As anyone who wears a pedometer will know that you can’t combat fat with exercise. I walked 11235 steps (8.2km) the other day and that only used up 309 calories – less than a mars bar. Exercise is great for fitness, pointless for weight loss (it makes you more hungry!)

2020health are now compiling our report on Obesity which will be launched in the early autumn. My recent blog on the subject of sugar is here.

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Do you ‘RESPECT’ your elders?

Guest Blog by Gemma Harling, PR Consultant

Everybody is getting older, this is a fact of life, however this does not prevent those in the younger generation from judging the elderly, the term ‘respect your elders’ falling on deaf ears.

Part of getting older is the use of mobility aids to regain the movement and freedom of the younger days past, but there has always been a stigma attached to the use of these products, associating their use with being useless and frail; however it seems that the stigma is mainly in the minds of the users.

A recent survey, conducted by Stair-Lift-Comparison.co.uk, showed that 33% of the 350 users that took part believed that there was a stigma attached to the use of mobility aids, with over a third believing that mobility scooters attracted the greatest stigma.

One mobility product user said: ‘In spite of our “modern and educated” society, there is a strong stigma attached to anyone who uses any form of mobility aid.

Nowadays, mobility aids more prominent in society, often seen in town centres with more establishments catering to the needs of these users.

Jason Tate, Director of Stair-Lift-Comparison said: ‘It is human nature that the more familiar we become with something, the more accepting we are.’

Mobility aids have also made their way into pop culture; the recent film “Up” featured a somewhat grumpy protDIZZEE RASCAL AND ROBBIE WILLIAMSagonist seen on a stair lift at the beginning and with a walking stick throughout the film which doesn’t debilitate his ability to go on an adventure.

Dizzee Rascal and Robbie Williams were seen with a parade of mobility scooters in the video ‘Goin’ crazy’ and more recently we were re-introduced to wheelchair bound comic book hero Charles Xavier, played by James Mcavoy, in Xmen: Days of Future past.

The survey also showed that 81% of those that took part believed that society is becoming more accepting of mobility aids: probably due in large part to this growing presence in society and in pop culture.

The growing acceptance could also be linked to the growing number of people over 65 in the UK.

It seems as if the older generation as a whole are steeping away from the weak stereotype and are being seen as respectable figures in society. For example, there are more older celebrities gracing our screens than ever before, with actors such as Morgan Freeman and Helen Mirren dominating Hollywood.

Elderly people are also prominent on our TV screens, we have Dot Cotton in EastEnders, Mary Berry showing us all a thing or two about cakes and recently we had an incredible spry OAP, Paddy Jones, whose technically difficult and awe inspiring dancing made her a favourite of this year’s Britain’s Got Talent.

Such figures prove that being elderly isn’t the setback it used to be; particularly with the use of mobility aids.

A parliamentary report shows that the number of UK citizens aged 65 and over will nearly double from the current 10 million to 19 million by the year 2050.

This means that the stigma may soon eventually disappear as more and more people are reaching the age where mobility aids are needed, and eventually will be using them in an age where they will be accepted.

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School food, backs, work and nurses – what we are thinking…

Why do we make food so complicated? New DfE guidelines for school food are supposed to be simpler, will be mandatory for some and not others but we are are unclear as to whether they have  closed loopholes. We visited a ‘healthy school’ recently to look at general well-being and found whereas the lunchtime menu was indeed healthy, pizza and donuts were served at break-time! (Ofstead didn’t check the break-time service) . Christine Blower of the NUT is right, quoted in Graeme Paton’s comprehensive piece in the Telegraph: it is a “missed opportunity that the standards will be legally enforceable only in those academies and free schools opening from this month”.

ankyspondthumbYesterday and today we have launched reports which both highlight the importance of early diagnosis and employee support so people can remain in the workplace. Ankylosing Spondylitis: hard to say, hard to see, need to hear focuses on the back condition that few have heard of despite its most famous sufferer, JFK, and being twice as prevalent as MS or Parkinsons. It is under-diagnosed and under-treated – Huw Irranca-Davies has written of his personal experience as the forward to the report for which we are very grateful.

The Daily Mail covered the joint report with the NRAS yesterday on Rheumatoid Arthritis,Screen Shot 2014-06-15 at 23.04.04 ‘Invisible disease – Rheumatoid arthritis and chronic fatigue’ which detailed the wide-ranging and significant impact that chronic fatigue has on quality of life and work for people with RA, not least on the capability for work. 50% of respondents of working age said that they were unemployed. 71% of working age unemployed respondents said fatigue had contributed to their inability to work.

Care in the community requires district nurses but as Denis Campbell importantly reports in today’s Guardian, numbers have fallen by almost half in the past 10 years. My impression is that their role remains isolated and unreformed with few examples of the sensible use of technology in place to e.g. enable easy, real-time access to patient’s records. Interestingly the article quotes DH as saying that they are committed to training 10,000 more ‘front-line community staff’ without committing to nurses per se. The chief nursing officer has her work cut out.

 

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At FPA we are absolutely clear that Sex and Relationships Education (SRE) needs to begin, as part of a school’s PSHE curriculum, at Key Stage 1

Guest Blog from the Family Planning Association

CANWL42UChildren and young people learn about sex and relationships from a variety of sources, both formal and informal – from parents, health professionals and teachers, to friends in the playground and a vast array of media outlets.

Unfortunately these sources can vary in their accuracy and not only are many children given misinformation; sometimes images or messaging can cause confusion and distress.

While the term ‘sex and relationships education’ can be daunting for parents and teachers, particularly for teachers if they have not had any specialist training, evidence supports the principle of starting age-appropriate SRE from age five.

Research repeatedly shows older pupils reflect on their own SRE as starting too late, with too much focus on biology and bypassing the real-life context of sex, sexual health and relationships.

Ofsted reinforced this in its 2013 Not yet good enough report and the Department for Education has emphasised the statutory requirement to provide a balanced and broad school curriculum, and the need for SRE throughout all key stages. David Cameron, Nick Clegg and Ed Miliband have all publicly stated the importance of SRE.

We know that teachers want to deliver accurate, informative and useful SRE, and help pupils to make the transition through puberty, adolescence and into adulthood, but that sometimes they lack the confidence to tackle the issues involved and aren’t equipped with specialist knowledge.

Equally, through our Speakeasy course, we know that parents want the best for their children; to help them develop the necessary skills to successfully navigate all different kinds of relationships. But often, especially if they didn’t have particularly good SRE themselves, it can be a difficult process and many are embarrassed or unsure about where to start and what to say.

In fact, parents on our Speakeasy courses have told us they were surprised at how little is contained within the elements of SRE that is taught in schools – and that they expect schools to be doing much more to prepare young people for life ahead.

SRE is most beneficial as a lifelong process starting in early childhood, with information – from both parents and schools – that equips them with the capacity to gradually develop the skills and values they need to explore, develop and express themselves within relationships.

This should be based on qualities such as mutual respect, trust, negotiation and enjoyment.

Specifically at primary-age when we talk about SRE, we mean learning about topics such as our bodies, life cycles, keeping safe, feelings, relationships and celebrating difference – for example challenging stereotypes around gender and sexuality.

And it’s important to prepare children for puberty – before it happens – so they can be ready for the changes they will face. We can take it for granted that it can be a worrying time for children, intensified if they aren’t given information about things like periods and wet dreams before they happen.

Making the link between relationships and other aspects of health and wellbeing is also essential, for example talking about body image, resilience and self-esteem. Children need to know how to keep safe both in real life situations and online, for example when talking to strangers, and using new technology and the internet safely.

Sadly it’s still a common myth that talking about sex and relationships will encourage young people to have sex. Research has shown that good SRE, especially when linked to confidential advice services, can actually have a positive impact on pupils’ health outcomes, such as increased use of contraception and delay in the onset of sexual activity.

The latest National Survey of Sexual Attitudes and Lifestyles, involving over 15,000 participants and published last year, further highlighted the effectiveness of SRE in reducing teenage pregnancy.

When discussion of sex and relationships is normalised from the beginning of a child’s education we stand a much better chance of helping young people to experience healthy and happy relationships as they grow, and stay safe from harm.

Young people deserve nothing less than a solid foundation to equip them with the knowledge and skills to achieve the healthy and happy relationships we all wish for in life.

For more information on FPA resources for teaching SRE, visit
 www.fpa.org.uk/yasmineandtom

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