Linking doctors’ surgeries with local government

…in the context of non-medicinal treatment for a variety of illnesses & conditions

I won’t take too long with this one. It stems from this post:

The article above is here, and the “[Draft] Depression in adults: treatment and management (update)” is here.

NHS relations with local government – an ongoing issue since the former’s foundation.

This was discussed in the last major research study into local government back in 1969 – the Royal Commission on Local Government in England. It needs looking at again.

As someone who has suffered from depression for decades, I can think of a whole host of non-medicinal interventions that would have had a positive impact on me over the years – in particular those all-important formative years (the 1990s for me). I can also think of institutional policies that had a detrimental impact – including but not limited to central government policies (Section 28 and a very narrow curriculum on SexEd), a institutionalised religion (Church), and unstable and poor quality housing (University). There is only so much pills and counselling can do in the face of all of that. (I still haven’t forgiven each of those institutions – I probably never will).

So if the only tool that the NHS has got is medicines, inevitably that’s where the incentive will be for GPs who only have 10 minutes a time for each patient generally. And that’s all they could do. None of the dozens of professionals would ever get to a position where they were able to identify, let alone target the root causes.

Do doctors’ surgeries have the information from local councils and other service providers about non-pharmaceutical treatments?

Anecdotally, no.

Even though on repeated occasions at local council meetings I’ve asked councillors & officers to advertise these things on poster boards. Sometimes some have gotten through, most of the time they have not.

The problem is structural. It’s one thing asking a fire-fighting local council that has had its budget slashed by the Tories to ensure every surgery, dental clinic, and optician (i.e. places where people are waiting and might be looking for something to read to pass the time) has up-to-date posters and leaflets, but quite another to ensure everything is routine.

Now let’s look at another central government pilot that is also indirectly linked to mental health.

Above – Tackling Loneliness with Transport Pilot Fund – from the Department for Transport.

Questions: How are the pilots going to be evaluated, and how are ministers going to ensure that the successful ones are considered and taken up by cash-strapped local councils?

Slum clearances in the mid-20th Century taught us the negative impacts of low density housing that had poor public transport services (I covered it in this blogpost). It can also be the case that things like a bridge over a railway line or a river can open up services that communities were previously cut off from. Think East Chesterton residents who are now linked up to Abbey Ward in Cambridge via the Chisholm Bridge – which makes Cambridge United Football Club much more accessible by foot and cycle. It’s worth keeping an eye on their average attendances over the next year to see what if any difference the bridge makes.

Do we have a system where service providers & leisure providers regularly speak to the people who timetable bus and public transport services? Stagecoach confirmed to me a few years ago that they did not. How can anyone make such things more accessible if we can’t get the public transport right? This is a challenge that Dr Nik Johnson, the Mayor of Cambridgeshire & Peterborough faces with his emerging transport plan. But at least the Mayor understands the importance of transport on health, and has put the latter at the heart of his transport planning – especially with active travel.

Above – from Cambridgeshire & Peterborough’s Local Transport & Connectivity Plan

Having raised awareness and expectations, he now has to turn that into a coherent strategy which then he can make specific policies and area-specific projects.

Data, data, data – Cambridgeshire Insight

If you are a councillor or are interested in local democracy, you need to know about Cambridgeshire Insight. It has all of the evidence bases and the research that local councils and public bodies use to formulate policies. Let’s look at Cambridge from August 2019 (even though the briefing says 2016, click here and scroll to the bottom for the link).

Above – if I were a local council leader or senior official I’d be very concerned about the 28 where the “Public Health Outcomes Framework” says we are worse than the average in England. That said, the rest do not automatically assume Cambridge is doing well – it may well be that the whole country is doing poorly and the average is very low for the whole country. Let’s pick out some of those indicators.

The list includes:

  • Gap in the employment rate between those with a long-term health condition and the overall employment rate
  • Killed and seriously injured (KSI) casualties on England’s roads
  • The rate of complaints about noise
  • Statutory homelessness – Eligible homeless people not in priority need
  • Hospital admissions caused by unintentional and deliberate injuries in young people (aged 15-24 years) (female)
  • Emergency hospital admissions for intentional self-harm (male, female, persons)
  • Estimated diabetes diagnosis rate
  • Admission episodes for alcohol-related conditions – narrow definition (male, female, persons)
  • Cancer screening coverage – breast cancer
  • Cancer screening coverage – cervical cancer
  • Cancer screening coverage – bowel cancer

From that sample above, which are the things that the NHS can influence directly, which are the things that local councils can influence directly, and which are out of the hands of both?

When you look at things like diabetes and alcohol, you come across the huge lobbying power of the food and drinks industry. Or on road accidents, the motoring lobby. That’s not to say they don’t want ministers to do anything about it, it’s more that there will be some policies they will be fine with, and others that they will strongly oppose. During my civil service days the theme I noticed the most was a preference for ‘industry-led voluntary action’ rather than regulation by the state. Think voluntary food labelling schemes vs compulsory government-mandated ones. Or even things like increasing taxation on unhealthy foods/drinks to outright prohibition. Public policy then begins to look very, very complex indeed. As it is.

Hellllllllllllllll No!

It’s why I wrote about a revamped set of new improvement commissioners in this earlier blogpost. Bring together the leaders of all of the public service providers and very influential institutions responsible for a geographical area, and charge them with the task of improving the district/borough/city.

Labour tried to do this in the mid-2000s with their Local Area Agreements policy. I got thrown into the deep end in my civil service career when I got the results of the in-service Fast Stream assessment centre I had taken in late 2006 (the process took almost a year to get to that point) and was given two weeks notice that I was leaving for London to work on that policy. The whole policy and framework was scrapped in 2010 by the Coalition as far too bureaucratic. Which in the grand scheme of things it was, but the principle of bringing together service providers that were under the remit of different government departments into a single negotiated agreement *and a legal duty to co-operate* for me was a sound one.

How could local councils and doctors’ surgeries work together for patients with mild to moderate mental ill health?

Part of it is having standardised data collection and data sets – especially if it can be automated. For example running searches for the number of prescriptions for anti-depressants and having the data displayed on a geographical map by ward or sub-ward level might show that some areas have a disproportionately high percentage of prescriptions per 1,000 population. In which case local council executives may want to find out more – whether through comparison with other data sets (unemployment, population demographics, educational attainment) or consulting with ward councillors and the residents themselves.

Again such things need to be built into structures, systems, and processes so that the local statisticians and policy advisers can keep a watch on any changes and trends that emerge over time. In particular whether any policy interventions have proven successful. For example data on prescriptions for asthma medication might fall off dramatically following the introduction of a very regular electric bus service, restrictions on motor vehicles, and the improvement/replacement of housing stock. There may be correlations between the age of housing stock and specific health indicators (respiratory) or even the design/type of house. The same may be true in terms of distance from busy roads or access to large parks and green spaces. we won’t know unless we do the statistical analysis – and then publish and publicise the results.

While both the NHS and Local Government remain under-resourced by Central Government, and while the structures remain as they were for local councils – stuck in the 1970s, it’s hard to see where the substantial improvement for the public generally is going to come from. Something for opposition political parties to consider in the run up to the next general election.

Food for thought?

If you are interested in the longer term future of Cambridge, and on what happens at the local democracy meetings where decisions are made, feel free to:

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