In my previous career as a management consultant, I regularly worked on the basis of the 80-20 rule (concept explained with real world examples of application) which is aimed at maximising efficiency. For many years, I was convinced the NHS needs to apply this concept more regularly to maximise the value citizens get from health and care services, but as years go on, I wonder if we actually commissioning inequality.
Since the pandemic, I’ve been working closely with my local charity network, comprising of grassroots organisations in one of the most deprived seaside towns in the country. We are focussed on helping the most vulnerable citizens to get the help they need to survive and thrive. So, for the first time, I have direct insights into the lives of the most vulnerable citizens e.g., the exceptions in the 80-20 rule.
Insight 1: 80-20 does not always deliver value-for-money
I realised that the UK government including the NHS and care sector do regularly apply the 80-20 rule when it comes to commissioning services. The NHS performance targets are about ensuring majority of patients get seen, treated and supported. The way services are commissioned are focussed on meeting as much of these performance targets as possible. It is actually incredibly difficult for charitable and community organisations to secure funding to support small groups of minority vulnerable citizens because they would fail the narrow value-for-money criteria. The minority groups by definition are in smaller numbers but they can require the most time and effort to reach and engage, especially those considered vulnerable.
What makes someone vulnerable can be driven by factors that include a lack of financial means, not having somewhere permanent and safe to live and having poor health and well-being. Individuals feel forgotten and can develop a high level of suspicion of organisations or individuals offering to help. Without dedicated resources to help them thrive, these minority groups go without and can end up in a cycle of perpetual crisis potentially requiring even greater amounts of public and charitable resources to support them.
Evidence from our work in the NHS and my work in my local community:
…90% of the individuals considered to have complex lives have referrals from the Criminal Justice system…
- In a research project to understand the journeys of complex mental health patients, we discovered nearly 90% of the individuals considered to have complex lives have referrals from the Criminal Justice system and nearly all of them have repeated interactions with urgent services including those with care plans in place. The research is ongoing, so it is not possible yet to estimate the average resource utilised per individual or to draw final conclusions, but it is clear, even though these individuals represent a small proportion of mental health patients, they require significant amount of unplanned resources and increases the risk to access for all other patients.
- At a local Integrated Care Board (ICB) event I attended on behalf of Citizens Advice, a prison officer shared with me that local research discovered that 60% of young offenders have a father in prison at some point in their lives. This link is consistent with the 2017 Ministry of Justice Analytical Summary which shows young offenders share similar risk factors including those associated with poverty, parental neglect or abuse. Young offenders with a family member who is also an offender or incarcerated are a minority, but the resources required to investigate their crime, prosecute them, then punish and/or rehabilitate them are significant, especially when there is strong evidence (Public Health England) to suggest effective ways to prevent offending in young people.
Insight 2: Equal does not mean fair
Equality of access to health and care services does not ensure that everyone gets their fair share of health and care services. To access health and care in most instances, you have to have the basic means to. Majority of the users of health and care services have the means to access the service e.g., skills and knowledge, transport, time off work, childcare, mobility, digitally enabled etc. Unfortunately, there are patients without the basic means to and will go without until they are acutely unwell and end up in urgent and emergency services.
Traditionally, patients access NHS services through the telephone or in-person. As the UK Governments progresses towards digital services, patients are encouraged to interact via the NHSApp without using the traditional means as it could significantly reduce administration burden for NHS staff. Since the start of the pandemic, the NHS has also successfully implemented video consultations which improves access for many patients. For the vast majority of patients, these are welcome additions that empowers them to manage their health and care interactions with the NHS. However, for those without access to digital devices, digital skills or the internet, they could face long waits on the telephone trying to access help or to secure appointments.
Evidence from Logan Tod & Co work in the NHS and my work in my local community:
…patients who cancel or do not attend their appointments are often from socially deprived areas and are aged 50 and above.
While supporting the NHS with elective recovery over the last 18 months, the team discovered that patients who cancel or do not attend their appointments are often from socially deprived areas and are aged 50 and above.
From my work with my local charity network, I found that citizens with complex lives, who sometimes have the highest health and care needs, lack the confidence to rebook appointments, attend video consultations and are unaware of how to make arrangements to get to their appointments. They may also forget their appointments as they can have complex lives and poor mental well-being. These scenarios are repeated for the same individuals across a range of government services including universal credit access and housing.
Insight 3: Health inequalities have increased since Covid
Data and research from multiple areas, place and regions all point to similar things. The current health and care provision fall short of addressing the needs of the population. In some cases, services commissioned are creating greater health inequalities as they fail to ensure vulnerable citizens are able to access them. Only recently the Head of NHS England acknowledged that patients are not always getting the care they deserve in particular for vulnerable patients with learning disabilities.
Early this year, Citizens Advice provided evidence of how the latest cost of living crisis was adversely affecting the most vulnerable the most. In my local Citizen Advice, 38% of clients we supported over the last 12-months are living with health conditions and disabilities, many with a maximum income of £799 per calendar month and their main issues were related to financial hardship and/or debts. We are already seeing the numbers increase as we enter winter where costs of fuel, food and housing continue to rise, affecting the poorest in my community the worse.
Evidence from my work in my local community:
…genuine concern their residents have deteriorating physical and mental health and in extreme cases will lead to preventable deaths.
- The Facing the Future report brings together all the lessons learned from the community response to Covid-19 in my local community and provides practical actions that can be taken by individuals and organisations to improve lives. The local community network had to take immediate action as part of their winter preparedness plans, to improve access to services for local residents requiring a complex range of support this winter.
Trend 1: Poverty is worsening
Trend 2: Core funding will be squeezed
Trend 3: Greater need but fewer services
Trend 4: Online-only services creating a digital divide
Trend 5: Affordable and suitable spaces are harder to find
Trend 6: Inequalities increased by COVID-19
Trend 7: Volunteering is changing
Trend 8: Integrated service access will be vital
Trend 9: Knowledge will increasingly need to be shared
Trend 10: Community connections will need to be rebuilt
Actions being taken this winter to prevent winter deaths and reduce health inequalities
- Organised support for local areas to identify, create and prepare warm spaces ready for winter including working with the local authority to provide free training and information to volunteers helping residents keep warm and safe
- Co-ordinated with the local fire service to conduct assessment of homes for open fire risk during winter
- Developing a digital solution to enable local community partners to provide holistic support with a ‘no-wrong-door’ access policy to individuals with complex needs to access support where they feel most comfortable
- Develop a robust data sharing framework to ensure residents receive continuity of support
- My local community organisations, including local health and care professionals in primary care, mental health trusts and acute trusts tell me they are more anxious and worried about their residents and patients now with long waits and reduced access to services. They believe many vulnerable residents are not seeking the help they need, and others may be let down as services are spread too thin to provide them with the full support they need in a timely manner. There is genuine concern their residents have deteriorating physical and mental health and in extreme cases will lead to preventable deaths.
A quick search online will uncover recent articles, research and statistics that show the worrying signs supporting these concerns. As the UK government looks for more cuts across all areas including potential capital spending cut, local government and commissioners will have to be more strategic with the services they commission to prevent health inequalities.
Commissioning to reduce health inequalities
In my local community, the ICB, voluntary sector, community organisations and individual residents have demonstrated the art of the possible on commissioning approaches and service delivery. The innovation NHS Trusts Logan Tod & Co have been working with are also piloting the use of existing data to improve allocation of resources and quality of care for their patients.
1. ADOPT TECHNOLOGY AND USE INDIVIDUAL CENTRIC INSIGHTS
Community organisations working closely together have begun to test the use of advanced technology and analytics like process mining to understand citizen journeys to help them manage their referrals, ensure individuals get the support they need and evaluate the impact of their intervention.
Innovative NHS Trusts have also deployed process mining to interrogate patient flow which supports recovery performance, improve safety and ensure quality of their services. By visualising the journeys for each individual, teams can spot opportunities to assess actual patient flow, reduce duplications and administer early intervention to reduce risk of deterioration. NHS teams can also begin to identify exceptions and personalise their interaction with each patient to prevent anyone patient from being left behind.
The NHS and community organisations are also seeking to adopt technology like System Control Centres that enables effective co-ordination, in particular when managing complex individual needs with multiple hand-offs from one team to another.
2. RETHINK HEALTH AND CARE
The NHS has launched the Universal Healthcare initiative in two regions to rethink health and care provision. The initiative aims to empower the local health and care system, local community organisations and residents to rethink and proto-type new approaches to delivering the health and care outcomes they want. It is easy to put this in the we-have-heard-it-before box but the cost of doing nothing or dare I say it, doing the same thing again will end up costing more.
The NHS has recently built a great track record at providing fair access to more citizens than ever before. This was achieved by rapid learning from the early Covid vaccination programme to improve access to all citizens in subsequent vaccination programmes. They made vaccination easy to access by vaccinating near people’s homes with very flexible walk-in appointments on weekdays and weekends and deploying mobile vaccination units that travels to hard-to-reach and places with low vaccination up-take. It boosted the attendance for appointments and gave many people a fair chance of getting vaccinated should they want it. Latest studies from the National Bureau of Economic Research, based in the US, estimates that for every 124 full vaccination courses delivered, one covid death was saved which equates to a cost of $55,000 per life. It is now widely accepted that more deaths are being saved because health and care organisations are not being overwhelmed by severely ill covid patients which could costs more per patient than the cost of vaccination in the first place.
At my local ICB public engagement events, they acknowledged the growing health inequalities and are championing the benefits of strategic commissioning to directly address the needs of vulnerable citizens and complex lives through the Core20PLUS5 approach. Crucially, the need to work with organisations and local leaders who understand local residents, are trusted by locals and have access to local communities. They also identified opportunities for the local population to transform their relationship with their own health and wellbeing to shift clinical needs towards living and staying well needs which has traditionally been much more cost effective than clinical interventions.
3. DO TANKS NOT THINK TANKS
The current cost of living crisis is the worst seen by my local community. This includes the challenge to providing warm spaces as charities struggle to heat their own space. Local community organisations have got together to co-ordinate and mobilise immediately to keep residents warm, safe and fed.
In recognition of the increasingly complex citizen needs, our local charity network tested a digital command centre solution during summer to manage referrals of citizens across multiple organisations which could become crucial this winter to ensure the most vulnerable citizens get the support they need. None of these actions require complex strategies or research, they are just practical, simple and directly addresses resident needs.
Logan Tod & Co is a not-for-profit data and analytics company helping organisations that deliver positive outcomes for society to succeed. The organisation supports the NHS to deliver Patient Flow Intelligence that uses advanced data science techniques to reveal actual patient flow across the health and care system, enabling the NHS to transform commissioning and improve delivery productivity, in order to reduce waiting times, improve safety and ensure equality of access.
As well as being a member of the 8fold team, Qian Huang is co-founder and Chief Impact Officer of Logan Tod & Co, and is also the founding member of the NHS Process Mining Centre of Excellence hosted by NHSE AnalystX. She shares her expertise of using analytical insights to solve health and care specific challenges and provides coaching to the NHS to develop in-house capabilities. She also works for her local Citizen Advice to deliver local community projects that improve lives through the use of data, analytics and technology.
To learn more about Qian’s work, please get in touch.