The impoverishment of the NHS and the public health system in England is not the only depletion that has occurred in civil society that makes us ill-equipped to respond effectively to the greatest global health crisis in a century.
One of the first acts of the coalition government when it came to power in 2010 was to dismantle the regional structures that had provided a coherent mechanism for integrating and carrying out government policy within the English regions…the coalition also stripped the NHS of its regional management tier following the wide-ranging “reforms” of the 2012 Health and Social Care Act.
The result is the absence of any integrational, coordinating or management function at a regional level in England that could operate between Whitehall departments and the various bodies, often very local, that are charged with implementing government policy. The fact that some national bodies have adopted internal organisational boundaries that cover completely different geographical territories has also complicated the situation. This is notably and unfortunately true with respect to the key health bodies, NHS England and Public Health England.
I had been pondering what impact the reforms introduced since 2010 have had. Things like the move of public health from the NHS to local government can make it more responsive to local needs but also more at the mercy of local financing whims and at the cost of losing central control.
I am, by instinct, a localist but there is a lot to the argument that stripping out the middle tier and fragmenting other provision across the public, private and third sector has harmed our initial ability to mobilise against the pandemic.
Parkrun is a weekly five kilometre run, measured, timed and run by local volunteers so it is free to enter. There are currently 289 weekly parkrun events around the country.
I did try to help a few people (including those behind the petition) who wanted a parkrun in the borough. Unfortunately I drew the same blank as they did, the council would not allow an event without payment of a licence fee. I did wonder if there might be a creative way around the fee issue, perhaps finding someone who could fund it. Unfortunately parkrun themselves were opposed to this, a similar situation happens elsewhere and is often cited to them as a precedent. Their fear (a reasonable one, based on experience) is that aside from the sustainability of a parkrun that needs annual funding, is that extending the precedent reduces the chances of new parkruns being established and could jeopardise those already in place.
My intervention, therefore, only resulted in the continuation of a stalemate. Both sides were probably better informed, but it was a stalemate nonetheless.
The petition, then, can be seen as a last attempt to persuade the council of the demand for an event in the borough. Yet even without that I think there are compelling reasons for a parkrun.
You might think parkrun is something of an exclusive event, a freebie for runners who, frankly, don’t really need an organised run to go out and do a 5k. In fact parkrun is attractive to non-runners and helps increase overall levels of activity, a study in the Journal of Public Health found the majority of registrants were not regular runners, a third were overweight or obese and that it attracts more people from older age groups who, generally, are less active. The study also found participants reported positive outcomes to their physical and mental health, weight loss and sense of community.
I know the council needs to maximise revenue and minimise its expenditure. As a councillor it’s impossible to avoid the simple fact that there isn’t as much money as there was. I’m also fully aware that one of Wandsworth’s strongest features is the rigour it brings to financial management: it watches every penny.
But sometimes that means the balance sheet wins because it’s hard to put a price tag on common sense. I think this is one of those occasions. The council may forgo a £600 or so a year in licensing fees (though I’m not aware of any other event like parkrun who would pay it), but the benefits to the wider community far outweigh £600.
I’d love to see a parkrun in Wandsworth. If you’re a Wandsworth resident (the organisers are keen to keep the signatures local, they’ve turned down celebrity endorsements to do that) please consider signing too.
Last night was the first meeting of the ‘wider’ Health and Wellbeing Board for Wandsworth. And a bit of a milestone in the progress towards implementation of the government’s health service reforms. In fact yesterday was something of a health reform day for me, with a meeting in the afternoon between south-west London NHS sector, councils and primary care trusts in the afternoon.
I remain convinced that the Health and Social Care Bill present a magnificent opportunity, perhaps a once in a generation opportunity, to improve health care, and most importantly, the health of Wandsworth.
The move to GP commissioning has attracted the lion’s share of comment – and criticism – but to me this is a perfectly rational move, the GP is the one who knows most about the patient in front of them. And in practice the patient will see no difference – and nor will they care – if a GP refers them on, they get referred on. The commissioning process is neither here nor there to a patient concerned about getting better.
However, the most exciting changes are the move of public health to the council alongside the structural reforms that will help develop a much closer working relationship at all levels of health and social care provision.
The Director of Public Health gave a presentation on the health needs of the borough. What struck me most was how clearly the picture emerged that most health problems are not related to healthcare, but instead to lifestyle choices.
So on each indicator Wandsworth was scoring poorly it wasn’t down (in the most direct sense) to a council, GP or hospital letting people down, but their ‘decisions’ to smoke, drink too much, eat unhealthily or engage in risky behaviour.
This is the sort of area in which I feel my paternalistic and libertarian Conservatism traits clash. Part of me doesn’t mind if people smoke or drink, that’s their choice and – generally – it’s their health they are affecting. Indeed, morally it’s very hard for me to criticise anyone for bad lifestyle choices, in my past I smoked and drank far too much. And while I’ve avoided drugs, I can’t claim to have ever been troubled too much by healthy eating. If there is anything that puts me on the side of the angels it’s my attempt to undo some of the damage with slow trots around Battersea Park.
In the world of Nudge however, there probably needn’t be that conflict between libertarianism and authoritarianism. People are still able to make their own decisions, even if we think they might be the wrong ones. But we should make it easier to make the right ones and pushing them towards those choices where appropriate.
But even there, while I would argue the council is probably in a better position than the NHS to help people make those changes we still aren’t the best people. Those present from the voluntary sector were concerned that they were still not part of the process. Personally, I can see how we will be using them far more than we ever have, working at ground level to help bring about those small improvements that make a dramatic difference over months and years.
But, where we are, it’s hard to reassure them. We’re in the middle of reform and moving towards closer working between two very different cultures. We have the broad vision for where we want to be, but we don’t have lots of the detail filled in. I have my views, but it might not be the same as everyone else around the table (indeed, I might not even be there when the powers are formally transferred from the PCT to the council and GP consortia!)
It’s an exciting time. But however far advanced we think we are – and Wandsworth is further along the process than many, if not most, places – there is still a long way to go.
Where do you think we should be? Do you know any areas we make it ‘hard’ for people to do the right thing?
Andrew Lansley, the Secretary of State for Health, came to Wandsworth to launch the public health white paper yesterday.
I’ve been very remiss in not posting much about health on here, despite the fact that it’s probably the most exciting area of local government at the moment and presents a huge opportunity for local councils and communities.
The main point of the white paper is that public health will soon be a council responsibility again (it was stripped from councils in 1974). It’s a sensible move: it’s commonly recognised that the NHS actually plays a small role in the health of the nation. We might all think of health and think about our GPs and hospitals, but in fact it’s largely a result of our lifestyles and behaviour; the cumulative impact of even small changes (a slightly healthier diet, a little more exercise) would make a huge positive difference to our collective health.
The challenge now is how we carry this out and made sure that the decisions the council takes all take account of the public health impact. And the real challenge for (much of) local government will be a new way of working, like any government publication the white paper has a couple of mentions of Big Society, but it also has references to things like nudge and the influence of networks and all three are quite alien to the traditional directive approach of councils.
A further challenge will be measuring the impacts. While the white paper hints at how they are going to baseline public health (and offer reward funding for success) it is not specific, and it’s hard to imagine exactly how we are going to measure the impact on things like life expectancy which, by definition, won’t be felt for years.
But despite those challenges the collective reforms for health offer the biggest positive change for health and healthcare I’ve ever seen – moving decisions away from a centralised bureaucracy and as close as possible to patients and communities, which is exactly where they should be.