Tag Archives: prevention

Rescheduled, delayed, cancelled: the knock on impact of the pandemic on routine health care

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Recently published figures show that waiting times for some non-urgent care across the UK have risen dramatically with the pandemic squeezing the already stretched resources of the NHS. Figures from Public Health Scotland, published in June 2021 found that when comparing to pre-pandemic levels, the waiting list size is 30.3% higher than the 12-month average prior to the onset of the pandemic (Mar 19 – Feb 20), while in England figures published in August 2021 showed NHS waiting lists in England reached a “record” 5.45 million people.

In addition to strains on acute NHS care services on the frontline, there are warnings about the additional public health impacts of delays to preventative healthcare measures like screening and routine medical care as well as concerns about a surge in demand when people who have delayed seeking non-urgent diagnosis and treatment return to hospitals.

At the outbreak of the pandemic many hospitals took the decision to delay or stop entirely routine pre-planned surgeries and preventative screening and diagnostics. Some even suspended treatment for more urgent care like cancer treatment on a short-term basis. While many of these services have resumed since the beginning of the pandemic, albeit with a backlog of patients now to be seen, significant strain on the NHS as we come into the winter months because of coronavirus is still anticipated.

In many areas this has led to a backlog of care, both for those patients already in the system awaiting routine surgeries, as well as those who are yet to be diagnosed but would have been through preventative screening programmes run by the NHS.

Delays in healthcare and routine screening

Even before the coronavirus pandemic took hold, many NHS hospital trusts were under criticism because of the significant length of waiting times for people who required routine operations. Doctors across the UK are now warning that these delays could be increased further unless the NHS receives additional support to increase capacity across all areas of care – not just urgent care in the coming months.

It has been suggested that delays in diagnosis and routine treatments could lead to an increased number of hospitalisations further down the line, requiring higher levels of care, longer lengths of stay, and increased hospital readmissions.

And despite the recent announcement of a new arrangement for health and care funding, commentators are quick to stress that the £1.4bn the new funding programme is expected to generate may not be enough to suitable address all of the concerns across health and social care, which they highlight has been chronically underfunded for a significant number of years, even before the pandemic exposed the frailty of parts of the system.

A reluctance to visit hospitals and use primary care services

Research from the Health Foundation found that there had been a significant reduction in the number of GP consultations since the start of the pandemic which has led to concerns about the care of non-covid patients, patients with long term health conditions and also the potential for delayed diagnosis. Primary care consultations also reduced and have remained low consistently since the beginning of lockdown.

Figures have also shown a reduction in the number of referrals, medical tests, new prescriptions and immunisations. While some of these reductions are the result of advice to delay routine referrals to free up capacity for hospitals to deal with the potentially large number of cases of Covid-19, routine referrals have still not recovered to pre-lockdown levels.

These figures, and other contributions from commentators and researchers suggest that government messages to ‘protect the NHS’ may have had the unintended consequence of discouraging people from seeking urgent medical care when it was required for fear of using services unnecessarily or for fear of contracting the virus when attending hospital or primary care settings.

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A potential future crisis for the NHS

Commentators are now warning that the treatment backlog which has been caused by the coronavirus pandemic, in addition to diagnostic delays and screening programmes, may lead to a future crisis of care or significant delays in care for people waiting to receive more routine treatment.

Delays in care have not only been reported in cases of physical health. There have also been significant delays in referrals for those seeking treatment for a mental health condition, an area of the NHS which was already facing significant delays in referral and transfer of care even before the pandemic. Research suggests that incidence of mental illness during the coronavirus pandemic increased. However, the numbers of people accessing services and being referred for treatment have not increased proportionate to this. People with mental health conditions may have been unable to access appropriate support through primary care pathways, which could potentially impact on their long-term health and care.

Finally, concerns have been raised about the wider social determinants of health such as employment and poverty. Public Health England (PHE) published a monitoring tool which looks at the wider impacts of the Covid-19 pandemic on population health, and it is likely that the knock-on impact of the virus could have far reaching consequences for public health in the future as the health implications of lockdown, lack of social interaction and rising unemployment could be significant. 

Where next?

While the NHS delivered some elective treatment during the course of the pandemic, the pressure of caring for large numbers of patients, many of whom were seriously unwell with COVID-19 has led to longer delays for the growing number of patients on waiting lists. Figures also show that access to elective treatment fell further in the most deprived areas of England during 2020. Tackling the backlog, and working towards the “levelling up” agenda to reduce health inequalities, both of which have been significantly exacerbated by the pandemic will be a key component of the work in health and social care over the coming months and years.

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Keeping our finger on the pulse: recent additions to our collection across health

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The health and care landscape has been changed in unprecedented ways over the past year. The coronavirus pandemic has not only highlighted strains within the system and required a response to a public health emergency unlike anything else that has been seen for decades, it has also provided an opportunity to push innovation in areas like digital infrastructure and partnership working, and encouraged decision makers to look at public health as an essential part of policy making in all areas.

The Knowledge Exchange database is full of reports, articles and documents which offer insight into these themes, published by organisations from across the heath and social care landscape. In this blog post, we’re highlighting some recent additions to our collection and some of the big themes being discussed within the sector.

Covid-19, “building back better” and a “health in all policies” approach

In March 2021 think tank IPPR published their report State of health and care: the NHS Long Term Plan after Covid-19. The recommendations form a £12 billion blueprint to ‘build back better’ in health and care and the report calls for an adaptation of the NHS Long Term Plan published in 2019 focusing on cancer, mental health, cardiovascular disease and multimorbidity. The authors believe the Long Term Plan needs to change to ‘build back better’ health and care post-pandemic, in relation to: ensuring a sustainable workforce; resourcing the NHS to deliver transformation; empowering integration; upgrading the digital NHS; funding and reforming social care; and levelling up the nation’s health.

Another report, from the Local Government Association (LGA), published in September 2020, provides specific guidance to local authority councillors on ways to improve the approach to population health and use of public health resources in dealing with the pandemic, highlighting the Health in All Policies (HiAP) approach to addressing health inequalities and improving wellbeing. There are a number of other resources which look at public health approaches to tackling other areas of policy such as youth violence and urban regeneration.

Build back fairer: the Covid-19 Marmot Review: the pandemic, socioeconomic and health inequalities in England, published by the Health Foundation and the Institute of Health Equity examines inequalities in coronavirus mortality, looks at the effects that the pandemic, and the societal response, have had on social and economic inequalities, the effects on mental and physical health, and the likely effects on health inequalities in the future. The report assesses the inequalities in the risk of COVID-19 and mortality and explores the impact of containment on inequalities in the social determinants of health, in terms of: early life; education; children and young people; employment and working conditions; a healthy standard of living; healthy and sustainable places and communities; and healthy behaviours.

Mental health

Mental health services have been under significant pressure in the UK for a number of years now, with children’s services (CAMHS) particularly stretched as the number of specialist practitioners is limited. The coronavirus pandemic has, according to many specialists, exacerbated existing pressures and placed even more demand on services. In April 2021 the All-Party Parliamentary Group on a Fit and Healthy Childhood published a report: The COVID generation: a mental health pandemic in the making – the impact on the mental health of children and young people during and after the COVID-19 pandemic  which explores a range of themes in relation to the impact of the pandemic on the mental health of children and young people. The report presents evidence from a range of sources on the potential implications of the pandemic on young people’s mental health and discusses the impact of school closures on children’s future health and well-being.

The Children’s Commissioner for England recently published a report  which looks at the progress made in improving children’s mental health services in England, and  the impact of the pandemic on the mental health of children. The report also examines the provision and accessibility of children’s mental health services in 2019/20, finding that access is still not adequate and not improving as quickly as expected.          

The other pandemic: the impact of Covid-19 on Britain’s mental health  explores how the mental health of people in the UK has been affected by the pandemic, drawing on a survey of over 4000 people. It describes the different experiences of groups across society and the highlights the disproportionate mental health impact on people who are exposed to higher levels of social deprivation, as well as on women, younger people and those who live alone.

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Structural reform

In August 2020 the Health Devolution Commission launched its final report, Building back health and prosperity. Among other themes, such as taking a “health in all policies approach”, the report found that devolving accountability and power to a more local level creates the potential to understand communities and places better, and to meet their needs.

One of the main focuses of the health and social care white paper published in February 2021 is around developing an integrated health and social care system and taking a ‘population health’ preventative approach to healthcare, while a report from the NHS confederation recommends a reformation of the framework for elective care and increased healthcare funding.

Digital transformation

Even before the pandemic, The King’s Fund was publishing widely on digital transformation. But their recent report Understanding factors that enabled digital service change in general practice during the Covid-19 pandemic  looks specifically at the impact of the pandemic on accelerating the transformation of the delivery of some services by GPs to focus more on digital delivery and whether this change can (or should) be sustained once the pandemic is over. It explores the challenges around trust, staff and patient digital literacy and the evaluation of digital tools in practice. Parliamentary Office of Science and Technology (POST) published their own review of AI and healthcare , providing an overview of AI in the healthcare system and its potential impacts on the cost and quality of healthcare, and on the workforce.

Final thoughts

The landscape of health and care is changing. The Covid-19 pandemic has placed unprecedented demands on a system which was already facing significant challenges. While in some instances this has led to innovation and accelerated the pace of change, it has also exposed some of the significant weaknesses of the system.

This blog highlights some of the big topics the sector is currently grappling with, but there is more available for TKE members on our database. Members can also sign up to receive our health Topic Update, which will provide fortnightly email updates of items recently added to the collection in health, easily allowing you to stay up to date.

If your organisation is not a member of the Knowledge Exchange and you would like more information, please contact us.

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Virtual reality: a game changer for mental health treatment?

Devolving health and social care in England: an opportunity to transform how we approach health and care?

Cross-border handshakes: what’s next for digital contact tracing?

Why are we still talking about healthy places?

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In recent years, there has been a wide ranging debate across the housing, planning, health and infrastructure sectors about the development of healthy places in both regeneration and newly approved projects.

In 2016, Town and Country Planning Journal published an article on building health and wellbeing into the built environment (Town and Country Planning, Vol 85 No 11 Nov 2016, Knowledge Exchange customers can login to view the article here) In 2017 and 2018 the talk was all about healthy towns initiatives, and a Design Council report in 2018 looked at the relationship between healthy placemaking and the impact on our communities. In 2019 the Town & Country Planning Association (TCPA) called on members to “reunite” health and planning. 

It is clear that everyone involved in placemaking agrees building places that promote health and wellbeing for all is of vital importance to our communities, The Covid-19 pandemic brought this into sharp focus, and the idea remains at the forefront of design policy, particularly in urban city contexts. But, over four years after the initial conversations and thought pieces, why are we still talking about it, and what actions still need to be taken to integrate the idea of a healthy place into planning to the extent that it just becomes the norm in the planning and design of our places?

Preventing avoidable disease

The phrase ‘healthy placemaking’ has been defined by Design Council as: “Tackling preventable disease by shaping the built environment so that healthy activities and experiences are integral to people’s everyday lives”.

Public Health England defined healthy placemaking as: “Placemaking that takes into consideration neighbourhood design (such as increasing walking and cycling), improved quality of housing, access to healthier food, conservation of, and access to natural and sustainable environments, and improved transport and connectivity”

Research has shown preventable diseases linked to lifestyle and environment are among the most significant threats to public health. Lifestyle-related conditions like heart disease and cancer, as well as being health problems in their own right, can also contribute to the development of other chronic conditions, exacerbate symptoms and create complications with care which are costly to the NHS.

Creating healthy spaces is not just about encouraging people to live more active lifestyles by facilitating active travel and improving the environment around buildings, although this is a significant part of it. “Healthy places” include approaches to improve air quality, reduce loneliness, allow people to age well in place, promote mental as well as physical wellbeing, reduce deprivation and inequality through projects like housing, infrastructure development, and high street regeneration.

Healthy places also have a preventative role to play in public health management, not just a health improvement role; such interventions are essential to help avert the onset of disease, improve people’s quality of life and reduce health inequalities. And evidence shows the return on investment from public health interventions is high and creates value of different kinds – economic, social and personal.

In short people who live in healthy places, tend to live healthier lives, place less strain on services and “contribute” more to society, both economically through work or spending and socially through community engagement.

Victoria Park, Belfast. Image: Fiona Ann Paterson

Enabling planning practitioners to think about creating healthy places

Research published in 2020 by the Royal Town Planning Institute (RTPI) explored local, national and international planning practices that enable the creation and delivery of healthy places. While a lot of research draws attention to the barriers to building healthy places – including a lack of funding, different requirements from developers and conflicting policy priorities – the RTPI report instead sought to identify important challenges faced by planners who try to integrate healthy placemaking principles in their decisions and then offer potential solutions to these in practice. Key themes emerging from the report include a need to improve collaboration, knowledge sharing and the skills of planners.

The report provides case studies looking at: the place standard tool; the livewell development accreditation; connecting communities in Tower Hamlets; health planning in South Worcestershire; and train station district rejuvenation in Grasse, France. It also identifies seven steps to plan for healthier environments

Across the sector there have been calls for planners to be allowed to be innovative, creative and take a “visionary” approach to planning to help make places healthier in order to address the convergence of challenges around public health, the climate emergency, and economic recovery from Covid-19.

How has the coronavirus pandemic changed how we think about healthy spaces?

The lockdowns  imposed as a result of the coronavirus pandemic have thrown the importance of quality space into sharp focus. Places that facilitate health and wellbeing among the people who live there, and places where the indoor living quality is as important as the outdoor space have become incredibly important.

The pandemic has highlighted what it really means to have a healthy space. It has also demonstrated how wider socioeconomic deprivation and inequality – linked to living conditions as well as other factors – is having an impact on infection and hospital admission rates, with those groups who live in more deprived areas being found to be at a higher risk of becoming seriously ill or being admitted to hospital with Covid-19. 

The 2018 Design council report found in its survey of practitioners that focus was given far more to outdoor space than to indoors, as it was easier and more cost effective to make changes that could produce demonstrable impacts (an increase in cycling, for example). But the pandemic and the increased time we have been forced to spend indoors has encouraged designers and urban planners to think even more creatively about quality space in their developments.

Where now?

Public Health England (PHE) which for many years was a strong voice in the conversations around healthy placemaking has been disbanded and will be replaced by a National Institute of Health Protection. It remains to be seen how, or if this new organisation will fit into the conversation going forward. But reflecting on recent reports on the significant public health crisis facing the UK in the long term, it is clear that the work must continue, driven collectively by those in planning, urban design and public health.

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A long way from home: county lines, serious organised crime and exploitation in the UK

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Gangs and serious organised crime groups are increasingly targeting vulnerable people, including children and young people to become involved in drug trafficking and other kinds of illegal activities. Police and local authorities assisted by third sector and charity partners are trying to stem the flow of vulnerable people leaving towns and cities and travelling elsewhere in the UK as part of a wider network of organised crime and exploitation. The aim is to break the chain of supply which is seeing organised crime move away from our inner cities to rural and coastal communities across the UK. From London to Liverpool, Glasgow to Cardiff, county lines practices have been growing, and solutions to prevent vulnerable people being targeted are needed urgently across the whole of the UK.

A growing emergency across the UK

Figures have shown a significant rise in the number of drug-related deaths across communities in the UK, with a significant rise in deaths among young people and among those in rural communities. While drug problems are widely considered an urban, inner-city issue, increasingly communities in rural and coastal areas are struggling with drug-related crime and deaths as new markets and channels for moving drugs across the country are opened up by organised crime groups and gangs.

Research has shown that, unlike in previous decades, these are not just the result of social, ad hoc sharing and transporting of drugs, but strategic and coordinated networks designed specifically to open new markets for drugs beyond city centres and expose more communities to markets of illicit materials, including drugs. The National Crime Agency (NCA) reports that the main driver of this “county lines” practice is fundamentally the demand and supply of controlled substances within the UK and the opportunity of “new” drug markets to make significant amounts of money. Analysis from the NCA indicates that an individual line can make profits in excess of £80,000 per year and can make thousands of pounds of profit from one single trip.

An easy target

One of the defining features now recognised as a key part of county lines drug trafficking is the exploitation of vulnerable and socially excluded people.This offers a degree of safety for those at the top of the network who avoid getting their hands dirty by delegating work to those further down the chain. Vulnerable groups, such as the homeless, care leavers or young people from disadvantaged backgrounds, are identified by county lines groups both as a target market for the drugs trade and for “recruitment”, involving them in the storage, transportation or selling of drugs in these new sites. This means that, on the whole, these groups are being disproportionately impacted. Many often don’t see themselves as victims or realise they have been groomed to get involved in criminality. Commentators and practitioners have stressed that an urgent and powerful response to safeguard these groups is needed.

A 2017 report from the Children’s Commissioner estimates there are at least 46,000 children in England who are involved in gang activity. It is estimated that around 4,000 teenagers in London alone are being exploited through child criminal exploitation or ‘county lines’. In March 2018, the Children’s Society published the second edition of Criminal exploitation and County Lines: A toolkit for working with children and young people. It summarised the risks to children and young people who become involved in county lines as including:

  • physical injuries: risk of serious violence and death
  • emotional and psychological trauma
  • sexual violence: sexual assault, rape, indecent images being taken and shared as part of initiation/revenge/punishment, internally inserting drugs
  • debt bondage – young people and families being ‘in debt’ to the exploiters; which is used to control the young person
  • neglect and basic needs not being met
  • living in unclean, dangerous and/or unhygienic environments
  • tiredness and sleep deprivation: the child is expected to carry out criminal activities over long periods and through the night
  • poor attendance and/or attainment at school/college/university

These challenges are also faced by other groups of vulnerable adults who are targeted in the same way. But while vulnerable children are subject to a compulsory referral process in relation to suspected exploitation, adults must consent to being referred, which research has suggested may be impacting the reported numbers of victims. This in turn indicates that the true number of vulnerable adults being exploited may be significantly higher.

Tackling county lines by working together

Partnership working between services which come into contact both with the county lines gangs and with the vulnerable people they exploit has been shown to be critical to facilitating an effective response and halting the spread and further development of county lines networks. However, it has also been highlighted that traditional approaches and mechanisms used to identify and safeguard vulnerable groups, particularly children, are no longer sufficient in the context of county lines child criminal exploitation (CCE), and that new guidance is needed to support practitioners in this field.

In September 2018 the National County Lines Coordination Centre was launched to crack down on drug gangs. The multi-agency team of experts from the National Crime Agency (NCA), police officers and regional organised crime units are working together, along with other partners in local areas, to build a national picture of the complexity and scale of the threat.

At a local level, pilot projects in several London boroughs, including Hackney, Islington and Lambeth and in other trial areas outside of London, such as Kent and Merseyside, have taken place. Evidence has shown that frontline services across the board play a key role in helping to identify and support those people at risk of exploitation from county lines gangs – not just police and prison service staff – but healthcare workers, social workers, teachers and youth work professionals from the public and third sectors. Working together as multi-agency partnerships, while challenging, results in the best outcomes and opportunities for intervention and support for children and vulnerable people who are at risk. It is essential that staff receive a high standard of training and that they themselves are given the time and resources needed to try and forge effective partnerships which in turn will help to identify and intervene with those at risk of gang exploitation more effectively and at an earlier stage.

Partnerships which include opportunities for staff training and guidance from third sector specialists like St Giles Trust and Safer London make use of the significant knowledge and experience held within the third sector and help local authorities to apply these to their own statutory responses. They also encourage the sharing of effective practice and knowledge on tackling exploitation across the whole of the UK, which is helping to create a more effective and joined-up approach to tackling child exploitation and the links to county lines practices. Maintaining this sharing of knowledge and skills across different sectors and professions will continue to be vital in helping to develop practice and responses that can react more effectively to exploitation in the future.

Providing a safe place and a route forward for victims of county lines exploitation

In a county lines context, better safeguarding and early intervention practices with vulnerable people serves a dual purpose: preventing the person involved being exploited and engaging in criminal activity; and disrupting the county lines operation, and subsequently the flow of illicit materials into our communities. The networks are, by their own design, elusive and hard to trace. Those involved are threatened and often trapped in roles within the network which they would otherwise be unable to escape on their own. Providing a safe space for these exploited people is an important first step in the process of tackling county lines and organised criminal networks.

Local authorities are working closely with partners to try and provide this support at a local and very personal level while trying to fit into the wider strategic process of the national response to county lines. These national and local responses are both vital in tackling county lines and the exploitation that comes with it.

TKE members can access more resources on County Lines via our website. If you are not a member, but would like more information on subscribing to TKE to gain access to more resources on a range of economic and social policy areas, get in touch with us to find out more.

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Treating violence as a disease: can a public health approach succeed?

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Knife crime, especially deaths of young people, has been making the headlines in recent weeks. And an approach which has a proven track record in Glasgow is now being adopted by the GLA, MOPAC and the Met police to try to tackle the growing levels of violence being seen on London’s streets. Learning from the experience in Glasgow, the police and other agencies are being encouraged to see violence as a public health issue, related to poverty, wellbeing and social deprivation and which, if identified and tackled early, can be prevented.

Contagion: a new way to think about violence

The Violence Reduction Unit was pioneered by Strathclyde Police (now part of Police Scotland), working with health and social care practitioners. Launched in 2005, the approach aims to make earlier identifications of those at risk of becoming involved in violence, and to take a more holistic view of the reasons for violence of all types. The long-term strategy looked at more social and wellbeing interventions to tackle gang violence in Glasgow, which at the time was among the worst in Europe.

The VRU in Glasgow took its inspiration from a scheme in Chicago, which sought to use a World Health Organisation (WHO) approach to tackling the spread of disease but applied it to communities in the hope of curbing the significant rise in homicides in the city. The approach was three-pronged: interrupt transmission, prevent future spread, and change group norms.

In addition to changing the approach to tackling violent crime, the VRU also used a multi-agency approach, involving social services, health care, housing and employment support, to give people a route out of violence and opportunities to find work or training opportunities. One of the key elements to ensuring the VRU is successful are the relationships these people build with individuals in communities.

Identifying young people at risk

Another important aspect of the VRU strategy is to intervene early to identify children and young people who are at risk of joining gangs or becoming involved in gang violence. Research supporting the creation of the VRU suggested that violence (like a cold) is spread from person to person within a community, that violence typically leads to more violence, and that one of the key identifying factors in someone becoming a perpetrator of violent crime is first being the victim of violent crime themselves.

In order to prevent this, staff from the VRU regularly go into schools and are in touch with youth organisations. They also provide key liaison individuals called “navigators” and provide additional training to people in the community, such as dentists, vets and hairdressers to help them spot and report signs of abuse or violence.

There is also a broad view of what a culture of violence is. Work in schools focuses strongly on contemporary issues such as sexting, bullying and gender-based violence. It challenges the attitudes and beliefs that underpin such violence, and encourages young people to recognise and reject these.

A new approach to drug abuse too …?

In November 2018, the Scottish Government launched its new drug and alcohol strategy. One of the notable additions to the strategy was the acknowledgement that (like violence) drug abuse and addiction should be seen, not as a crime, but as a public health issue – an illness which people need support and treatment for.

Looking at how drug abuse is tackled within the criminal justice system and the interactions of addicts, policymakers have identified that many have had adverse childhood experiences, are exposed to drugs and/or alcohol at a young age, and are also at significant risk of being unemployed and homeless.

Creating a holistic package of support which seeks to identify those at risk and directs them towards a range of services to tackle not just the addiction but other trauma or socioeconomic barriers earlier, will, in a similar way to the VRU, give people a sense of purpose and value, and help them to see an alternate route that will allow them to contribute positively to society and improve their own outcomes.

A new way to tackle social issues in the UK?

Tackling the spread of violence through communities is not an easy task, nor is breaking the cycle of crime that many find themselves trapped within, often as a result of family allegiances or geographic location. It is often the case that either you participate, or you become the next victim yourself. More and more young people are feeling the need to carry knives for protection, due to the high levels of fear of becoming a victim.

Identifying those young people who are at risk of turning towards a life of violence at the earliest possible stage is difficult, but has been shown to be effective in helping to tackle violent gang-related crime. Although it is not the only tactic available to police, used effectively in conjunction with other outreach programmes it can be an effective tool in preventative policing, helping to keep communities safe.

The outcome in Glasgow has been largely positive, following the roll out of the Violence Reduction Unit programme. Whether this approach has the same success in London, operating on a larger scale, with different economic and social variables, and in a very different budget climate, remains to be seen. In particular it is worth noting that the Glasgow approach recognised there were no quick fixes, and was based on long-term planning covering ten year periods.

It is to be hoped, though, that changing the way we think about violence within communities may offer a route to tackling it.

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“For many children we are the first point of contact”: supporting children’s mental health in schools

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A 2018 evidence review from Public Health England reported that one in 10 young people have some form of diagnosable mental health condition. This, the report suggests, equates to as many as 850,000 children and young people with a diagnosable mental health disorder in the UK. It also reported that half of all mental health problems emerge before the age of 14, and children with persistent mental health problems face unequal chances in life.

Research has also highlighted the impact of “key factors” like poverty and adverse childhood experiences (ACEs), including emotional trauma, abuse or neglect (which people living in higher areas of deprivation are more likely to experience) on an individual’s chance of developing a mental illness. However, an additional factor often cited in surveys around child mental health and wellbeing is the impact of school, including exam stress, and bullying. Mental ill health has also been found to have an impact on attainment, behaviour and a child’s ability to learn. As a result, teachers are often part of the front line of supporting adults for children who are suffering from mental ill health, with increasing pressure being placed on teachers and schools to identify and signpost children to other services.

Schools, as well as teachers,  are increasingly becoming a focus for the delivery of Child and Adolescent Mental Health Services (CAMHS) in their community. Often schools are at the centre of their local community, so it is logistically convenient to coordinate services there; it can for some be a less intimidating or stigmatising environment than attending a clinic at a GP surgery, for example. School is the primary developmental space that children encounter after their family, and children’s learning and development and their mental health are often interrelated, so it makes sense for teachers to take an interest in terms of attainment and progress in learning. In December 2017, the Department of Health and Department for Education (DfE) published the Green Paper Transforming children and young people’s mental health provision which highlighted the role of schools as key in promoting a positive message about mental health and wellbeing among school age children and young people.

Good work is already being done, but how can we do more?

Research has shown that there is already a lot of good and effective practice being done in schools around children’s mental health. Many schools already work in partnership with local health teams to provide in house CAMHS support in the form of mental health nurses and social workers who are posted on site for children to access. One of the major recommendations in a 2018 Audit Scotland report on child mental health in Scotland was to encourage more of this type of partnership working. The report stressed the importance of joint working between public services if child mental health is to be improved, and where possible to include as wide a spectrum of public services in the delivery of CAMHS support, including criminal justice and housing practitioners, as well as health and social care and education staff.

In some schools senior pupils and designated members of staff are being offered mental health first aid training, and wear lanyards to help students identify them should they ever need to talk to someone. While it is important – particularly for students who participate in mental health first aid programmes – to be made aware of the challenges the role may entail, it can be a rewarding experience for young people to participate in and can also be a vital in-road to support for some students who would otherwise feel uncomfortable talking to a member of staff.

Other programmes like those developed by the Anna Freud National Centre for Children and Families, Centre for Mental Health and the ICE PACK and Kitbag tools (which have been used widely in UK schools) look at resilience building  and promoting coping mechanisms among young people, as well as encouraging the creation of trusting relationships which focus on nurturing and normalising mental illness to encourage children and young people to feel comfortable discussing their feelings and thoughts. These programmes also integrate early intervention and prevention approaches, hoping to identify children and young people who are suffering from mental illness as early as possible and signpost them to appropriate support.

The specific role of teachers

Teachers need to remember that they are not health or social care professionals and that – as much as they would like to completely solve all of the problems of their students – they can only do what they can, and that is enough.

It is also very important for teachers to practise what they preach in as much as teacher self-care is as important as signposting children and young people who are struggling with mental health issues. A 2016 survey by the National Union of Teachers (NUT) found almost half of teachers had sought help from their doctor for stress-related condition. Teacher stress and burnout and those leaving the profession due to conditions like stress do not help to create an environment that is supportive of good mental health in the classroom. Teacher wellbeing is so important and building their own resilience is one way that teachers can start to embed good mental health in their practice. If you are doing it yourself it will be easier to help and show children how to do it if they come to you for advice!

Teachers simply being there and offering a safe space and first point of contact for many children is important. Listening and signposting can be so valuable for those pupils taking the first step and teachers should not be put off by any personal perception of a lack of expertise in mental health – a small amount of knowledge or understanding of what to do next is more than enough. In some respects, teachers should feel almost privileged that a student has chosen to come to them, someone they feel they can trust and talk to.

A poll conducted as part of a webinar held for educational practitioners found that rather than requiring more information about mental illness, what teachers actually wanted was more practical examples of how to apply support in the classroom and how to embed mental health into their teaching and the learning of their students.

A unique opportunity

Schools and teachers are on the front line of public services and have a unique opportunity through regular contact with children to help to build and promote resilience among pupils, and embedding this within the whole school can be an effective way of ensuring pupils feel the benefit without being singled out. Taking nurturing approaches to learning and teaching, and promoting the creation of trusting relationships is key to some of the already effective practice going on in schools. Sharing the learning and best practice that is already happening will be vital to ensuring that support for children suffering from mental ill health improves and adapts to changing needs in the future.

If you liked this article, you may also be interested in reading:

Writing and recovery: creative writing as a response to mental ill health

Addressing social mobility through education – is it enough?

The Changing Room Initiative: tackling the stigma of poor mental health in men through sport

Follow us on Twitter to find out which topics are interesting our research team

Zero suicide cities: learning from Detroit in the UK

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Suicide is the biggest killer of men under the age of 45. Yet people still experience stigma when seeking help for mental illness, despite high-profile discussions of mental health issues such as those by members of the royal family and sportspeople. And a report into the Government’s suicide prevention strategy in March 2017, suggested that although 95% of local authorities now have a suicide prevention plan, there is little or no information about the quality of those plans, or whether adequate funding is available to implement them.

The lack of progress made on improving suicide and general mental health provision has led to a growing frustration among professionals and resulted in attempts to create new approaches to tackle mental health issues, and in particular to improve access to support for people in crisis or at risk of suicide.

The idea of a “zero suicide city” was first adopted in Detroit in the late 2000’s, with others following its lead in subsequent years. With reports finding that around 14 Londoners a week took their own life in 2015 (735 in total), an increase of a third from the 2014 statistics, a report in February 2017 by the London Assembly Health Committee suggested that London too should take this approach.

So what can London, and other areas of the UK, learn from Detroit’s approach? And how can services act to reduce the number of people taking their own lives?

Zero-suicide cities

Poverty and high unemployment in Detroit are contributing factors to high levels of depression among city residents. As a result of these high rates of depression and very high suicide statistics, Detroit-based mental health professionals adopted a new approach to tackle the stigma around mental illness and use identifiers to highlight cases of crisis, or potential crisis. The focus is on preventative care, encouraging professionals to act upon signs of mental illness before a suicide or attempted suicide takes place.

Patients attending health clinics for other illnesses, including diabetes or heart failure, are also now screened for depression and other mental health issues before they are released. This allows people deemed to be ‘at risk’ to be identified as soon as they come into contact with medical professionals, who can then refer the patient to a mental health specialist if needed, rather than reacting to mental illness once it reaches crisis point.

In order to support this approach, a centralised IT system was created which means results are traceable, and surveys and information are standardised so they can be used and accessed across clinics throughout Detroit. Coordination with non-medical practitioners, including social workers, employers and family members, has also been key in identifying people at risk and signposting them to help at every possible opportunity. There has also been additional training for staff to improve recognition of identifying factors. Patients can email their clinicians or liaising staff directly and attend regular drop-in appointments. Up to 12,000 patients using mental health facilities are tracked each year in the city and some statistics suggest that the clinics reduced suicides by over 80%.

There have been some criticisms of the system however, despite the reduction in the number of suicides in the city. Critics highlight the fact that many of the poorest and most severely in need of help are not reached as they do not have health insurance and so do not attend those clinics involved in the scheme.

Ultimately, however, the scheme seeks to provide better preventative, coordinated and targeted care to those who are at risk or show some signs of mental health crisis. And some in the UK have suggested there are lessons that could be learned from this approach.

Whole system approach to suicide prevention in the East of England

Four local areas in the East of England (Bedfordshire, Cambridgeshire & Peterborough, Essex and Hertfordshire) were selected in 2013 as pathfinder sites to develop new approaches to suicide prevention based in part on the Detroit model.

Since then, Mersey Care, Cambridge and Peterborough Clinical Commissioning Group and Teesside councils have also become aligned with the programme and are continuing with their approach towards improved suicide prevention. The Centre for Mental Health evaluated the work of some of the sites during 2015.

The evaluation found there were a range of activities that had taken suicide prevention activities out into local communities. They included:

  • training key public service staff such as GPs, police officers, teachers and housing officers
  • training others who may encounter someone at risk of taking their own life, such as pub landlords, coroners, private security staff, faith groups and gym workers
  • creating ‘community champions’ to put local people in control of activities relating to promoting positive mental health and signposting to help services
  • putting in place practical suicide prevention measures in ‘hot spots’ such as bridges and railways
  • working with local newspapers, radio and social media to raise awareness in the wider community
  • supporting safety planning for people at risk of suicide, involving families and carers throughout the process
  • linking with local crisis services to ensure people get speedy access to evidence-based treatments.

However, subsequent research also highlighted some of the challenges. The marketing of the pilots was seen to be damaging and misleading with regards to creating “zero suicide areas”, rather than suicide prevention areas. It has also been suggested that although the campaigns serve to raise publicity and awareness, there is little evidence that the schemes actually reduce the number of suicides in an area any more than “traditional campaigns” to better signpost people to available support.

In addition, many of the projects struggled past the initial implementation stage to have long-term impact, as the buy-in from local GPs and other service professionals was not as high as was expected.

Final thoughts

Widening and improving access to support and services for people at risk of mental ill health or suicide is a big challenge for health and social care professionals. Identifying those people at risk is one of the key barriers and taking inspiration from schemes like those trialled in Detroit is one way for professionals in the UK to adapt their approaches in order to overcome these barriers.

Providing more opportunities for people to get help, and better training for professionals who may come into contact with people with mental illness are some of the ways that current schemes are trying to address mental health and suicide in particular.

However, as many of the evaluative studies from test sites in the UK have found, going beyond that to take mental health into the community, in order to create whole system pathways of care across multiple settings and professions, remains a challenge.

As the London Assembly report pointed out, another key aspect is creating an open environment for people to talk about how they are feeling. This week is Mental Health Awareness Week 2017 and the theme is ‘surviving to thriving’ – and emphasising that good mental health is more than the absence of a mental health problem. Whether in the workplace or in the home; with friends, family or colleagues; it’s important that everyone feels that they have a space where they can talk, and to cultivate resilience and good mental health.

If you enjoyed this blog, you may also be interested in our other articles on mental health in the workplace.

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Focusing on the end result: outcomes based commissioning in health and social care

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In March 2016, the government announced that it was pairing up with the Blavatnik School of Government at the University of Oxford to create the Government Outcomes Lab (GOL). The aim of this partnership was to create a centre for excellence in commissioning research and practice – to find new and innovative ways for the public sector to commission projects, provide on the ground support to local commissioning teams and become a world class research centre on effective models of commissioning.

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Payment by service vs payment by results

Traditionally, governments contract third-party service providers on a ‘fee for service’ basis – so commissioners prescribe and pay for a particular service that they believe will lead to a desired outcome. More recently however, commissioning teams have started to introduce elements of ‘payment by results’ or ‘pay for success’ when commissioning services – so providers only get paid in full if they deliver the desired outcomes.

Social impact bonds

Social impact bonds (SIBs) are a tool to help outcomes-driven providers deliver on their projects, by giving them access to financing and management support from “socially-minded investors”. The idea being that this will broaden the pool of skilled providers, encourage smaller more locally based providers to tender for projects (who may have been reluctant to previously because of cost and lack of support) and, potentially, increase the chances of the service being successful.

One of the primary aims of the Government Outcomes Lab is to consolidate and promote as far as possible the use of social impact bonds to align social value based commissioning with commissioning for measurable outcomes – to promote a social value as well as an economic value in the way providers deliver on contracts. There are now 32 Social Impact Bonds across the UK, supporting beneficiaries in areas like youth unemployment, mental health and homelessness.

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Benefits and challenges to outcome based commissioning

While to many people it may seem almost impossible to question the principle of outcomes based commissioning (to move from a system focused on process measures and targets to a system that is focused on improving the outcomes that matters to citizens and patients) the reality for commissioning teams, providers and service users is, in some cases, very far removed from this ideal.

In April 2012, the Audit Commission published its guidance on Payment by Results (PbR). This generated fairly positive messages around PbR but also advised commissioners to be aware of the risks:

“At its best, PbR can deliver savings and bring in new resources at a time when budgets are under great pressure. It also defers costs to commissioners to allow time to realise the benefits of change and preventative work….. However, PbR carries extra risks to securing value for money and requires higher level commissioning skills than more traditional approaches”- Audit Commission (2012)

Much of the literature on outcomes based commissioning models emphasises the importance of:

  • transparency;
  • agreed objectives;
  • agreed measurable outcomes;
  • communication and clear definitions of accountability between commissioners;
  • any social investors or third sector bodies with input;
  • providers;
  • and any secondary providers who may be awarded subsequent sub contracts

A more comprehensive list of pros and cons to outcomes based commissioning can be found here.

One high-profile intitiative which has faced more challenges than it has produced benefits is the “troubled families” programme. which aimed to support families with long-standing problems. The programme was heavily criticised for its payment by number (number of clients processed) rather than payment by specific outcome. The issue here appeared to be the lack of definition of outcomes and what was going to be expected of the provider in terms of service before they could be paid.

In this instance the organisations delivering the “troubled families” programme in some areas were being paid for the number of people who went through the service, rather than the number of people who completed the programme successfully, or saw notable improvement as a direct result of the input of the programme, and without taking note of the professional view of the quality of the service being provided (which was considered in some areas to be poor). This resulted in providers being paid for a service which, while many people used, did not actually achieve the expected outcomes. This is something which future commissioning bodies must take note of and act upon to ensure that any future agreements do not contain such massive loopholes with regards to payment.

Outcome Flow Chart

Outcome Flow Chart via Roma Learning Leaders

Outcomes based commissioning in health and social care

A number of different policy areas have begun to use outcomes based commissioning models with varied success (although as we have seen this can be as much to do with the quality of the provider and the transparency of the contract as it is about the implementation of an outcomes based model). Rather than focusing on inputs (e.g. number of doctors) or outputs (e.g. number of operations conducted, or amount of drugs administered), these commissioning models are based on achieving specific, predefined and measurable ‘outcomes’ (e.g. improved health).

In a specific health and social care context, outcomes based commissioning can, if done well, form a key part of a wider prevention agenda, as well as helping to improve personalisation of services. In Wiltshire for example, the council has employed outcomes based commissioning techniques in relation to its domiciliary social care teams. This example shows that when the right providers are selected and clear outcome measures are defined, the impact for service users can be significant, in a positive way: there is a strong focus on getting the best possible result for the customer in the way that suits them; with every visit having a clear purpose and a focus on achieving greater independence for the older person wherever that is possible (which is the overall wider outcome the commissioning teams were hoping to achieve – greater independence of service users and less reliance on the social care teams in the long term).

Some specific challenges in a health and social care context include coordinating payment for outcomes with direct (or personal) payment schemes and agreeing on realistic and well defined outcomes and time frames with service users (which if done well can have a very positive impact on the personalisation agenda of services) Attributing outcomes specifically to one set of interventions in health and social care can also be difficult, particularly if a service user is in receipt of a number of different strands of care, for example, primary care and domiciliary social care as well as having access to some remote telehealth facilities.

Commissioning for long term outcomes

If the issue of defining or attributing outcomes is a challenge for outcomes based commissioners, then the issue of planning for long term outcomes is even more difficult. This approach requires commissioners to have a long term view of the strategic aims of a programme, as well as requiring them to consider any factors which may influence or change these aims, and additionally to consider the scope of need in the future if other preventative measures are successful.

Advice for councils

The LGiU and academics at Oxford Brookes University, as well as many others, have published guidance for local authority commissioning teams, giving them some direction in relation to best practice in outcomes based commissioning. Some of the key “pointers” for councillors include:

  • Take time to get the right set of providers in place to deliver the new model and collaborate with them to get the best possible system in place – be thorough in research and consideration of tenders.
  • Be very clear what the likely outcomes are that any specific service is being asked to deliver.
  • Make the payment mechanism as simple as possible. Consider whether any rewards will be paid for good performance in delivering outcomes. Consider if payments should be made on each individual outcome achieved or for outcomes for sub-sets of the population e.g. hospital discharges.
  • Make use of the public, their opinions and data collected about them to assess the needs of the population and reflect this in the agreed outcomes.
  • Try to implement outcomes based commissioning as part of wider transformation within the organisation – in order to improve quality, reduce costs and improve efficiency (particularly in health and social care) other infrastructure and practices (such as IT systems and skills development in staff) need to be addressed in addition to commissioning models in order to bring about change.

Further reading about health and social care on our blog

Co-production in social care … a need for systems change

Why a holistic approach to public health and social care needs a wider evidence base … and how Social Policy and Practice can help

What’s happening to make big data use a reality in health and social care?

Telecare in the UK: lessons from Barcelona

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By Rebecca Jackson

Telecare is technology to help people live independently, usually in their own homes, for longer. Usually delivered as part of a package of care, telecare devices can include things like: bed sensors, to detect if someone is out of bed at an unusual time; fall sensors; medication reminders; and alerts on screens or over loudspeakers. Such devices have led telecare to be heralded as a new dawn in patient-centred, independent living.  However, despite initiatives  to drive its application forward, not everyone in the UK is convinced about the benefits of telecare.

Practitioners and carers are sceptical about the potential of replacing traditional care with digital models to save money and the impact that this could have on standards of care. In addition, many patients themselves are uncertain about the use of telecare and digital health solutions, with many who have telecare systems within their homes choosing to continue to interact with primary and home care services in the same way as before. Much of the academic and expert-led research and evaluation of telecare programmes in the UK by organisations such as the Nuffield Trust and the Kings Fund has found little to no improvement in service, reduction in cost or reduction in workload for care teams in areas where telecare has been deployed.

While telecare in the UK appears to have stalled, elsewhere digital health solutions are not only successfully integrated into traditional care models, but are having a positive impact on the people in receipt of care, and reducing the burden of work on care providers.

Lessons from Barcelona

In Spain, the law has guaranteed access to telecare since 2006. Economic austerity has led to individual local authorities in Spain being given control over their budgets and therefore their provision of telecare. The approach in Barcelona has been highlighted as an example of best practice in telecare.

The system there – a cooperative venture between an independent provider and the local authority – sees carers take a proactive approach to telecare. The system does not just monitor and provide assistance in times of distress, but proactively engages with service users at regular intervals to help carers provide reassurance and build relationships.

As well as the emergency measures, such as fall sensors (typically the primary use of telecare in the UK), calls are made to check up on service users, provide reassurance, deliver general public health information and to mark important occasions, like birthdays. This can help to reduce feelings of isolation and loneliness, which in turn can lead to better general health and wellbeing.

Calls can also be made to highlight important information, such  as weather warnings; safety alerts and local events which the service users may wish to attend. These calls are backed up by visits from the care team, who work for the telecare provider. These visits supplement visits from municipal care and social workers and the two teams communicate and share information via digital platforms.

Digital healthcare as an enabler

The case of Barcelona shows us how digital healthcare solutions, and more specifically telecare, can be used as an enabler – a tool to allow the local authority to pursue a joined up and preventative approach to healthcare which has positive benefits for recipients.

Such approaches could also have a significant impact on the UK’s 3.8 million unpaid carers. Telecare has the potential to reduce some of the burden and stress of caring for a relative, which in turn can have positive effects on the health of the person in receipt of care. It can also  form an effective part of reablement programmes – supporting people as they leave hospital or return to independent living.

However the approach to delivering telecare in Britain is as much about culture as it is about the technological infrastructure. Using telecare as part of a preventative, person-centred approach should produce better outcomes. In this sense, implementation of telecare in the UK still lags behind other countries. Key lessons could also be learnt from programmes in Norway and the Netherlands in relation to telecare in dementia settings.

Generally, the targeting of telecare services also differs – in the UK it tends to be aimed at elderly people with complex and diverse needs, while in Norway and the Netherlands the focus has shifted to those suffering from chronic illnesses.

Local solutions

In the UK, some local authorities have been experimenting with digital healthcare, although local authority budget cuts have meant that in many cases these have been cut back to focus delivery on the most vulnerable clients.

The lessons in digital healthcare that Britain can learn from places like Barcelona could be key to the successful roll out of digital healthcare solutions in the future. The Barcelona example highlights the enabling role that telecare can play in joining up health and social care and promoting a more preventative approach to healthcare.

Opportunities to develop telecare strategies and deliver them in partnership, as in the Barcelona model, show that it cannot be delivered in isolation, or be used as a replacement for existing carer-led services. Instead telecare has the potential to be a supporting tool to ensure effective care outcomes. It could also help care services in Britain to tackle the increasing demand of an ageing population.

Follow us on Twitter to see what developments in public and social policy are interesting our research team.

Read some of our other blogs on social care:

The local prevention of terrorism

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by Steven McGinty

Since the terrorist attacks in Paris there has been a renewed focus on preventing terrorism.  On a national level, the UK government has increased the defence budget by an extra £12 billion, and is expected to hold a vote on airstrikes in Syria. More locally, there has been fierce debate about looming police cuts, with the Muslim Council of Britain suggesting that it could harm trust with communities.

At the Knowledge Exchange, we recently received an Ask-a-Researcher request for information on the role and importance of local partners within the counter-terrorism and extremist space. We provided the member with a number of resources to support their work; but there was one that stood out.

Essential resource

The book was ‘The Local Prevention of Terrorism: Strategy and Practice in the Fight Against Terrorism’ by Joshua J. Skoczylis, Lecturer in Criminology at the University of Lincoln, UK. It was published in September 2015 and appears to be a vital resource for UK policymakers and academics.

The book explores the UK government’s Prevent policy, a key strand of the government’s counter-terrorism strategy (CONTEST) that focuses on stopping people becoming or supporting terrorism, as well as examining its impact on local communities.

Concepts and tensions affecting Prevent

In chapter 2, the key concepts are analysed that underpin CONTEST, and in particular the Prevent policy.  This involves looking at the idea of prevention, the relationship between Prevent and policing, and the relationship between communities and CONTEST.

An interesting point raised is that the narrative of CONTEST provides a powerful basis for which policies are based on. There is a critique of the phrase ‘international terrorism’ (often used in government strategies), with the author suggesting that the lines between international and local have been blurred, with terrorist attacks being carried out by local residents.

Prevent – an innovative counter terrorism strategy

One of the main arguments put forward is that the Prevent policy is an innovative approach to counter-terrorism. The author explains that Prevent occupies the ‘space somewhere in the middle, between extremism and violent extremism’. In essence, this space provides an area for honest engagement within communities, free from the security and intelligence community. This space allows local actors to be involved in the debate, including local authorities and Muslim organisations.

Delivering Prevent to Maybury Council

In the final chapters, the book reflects on Prevent’s impact on Maybury, a mill town in the north of England. Since 2007, several Prevent programmes have been delivered in the area, including Channel, an early intervention programme for young people vulnerable to be drawn into terrorism. Although, the majority have focused on community cohesion and awareness raising.

The book also discusses the findings of a report commissioned by Maybury Council into the Prevent policy. It highlights that the Prevent programme has been viewed as ‘divisive’ and has alienated members of the community that local agencies need to engage with. In particular, it suggests that focusing solely on Muslim communities, using surveillance measures, only breeds distrust.

The report also highlights the tension that exists between the national and the local delivery of Prevent. It explains however that Maybury Council have adapted their own policy to address local needs; although it’s noted that this may change as the government have introduced a more centralised administration process for Prevent funds.

Conclusions

At the end of the book, the author comes to several conclusions about the local delivery of Prevent. One of the main conclusions is that evaluation is crucial for establishing what policies and programmes are successful. It is important that an evidence base is developed and that good practice is shared amongst practitioners.

Our popular Ask-a-Researcher enquiry service is one aspect of the Idox Information Service, which we provide to members in organisations across the UK to keep them informed on the latest research and evidence on public and social policy issues. To find out more on how to become a member, get in touch.

Follow us on Twitter to see what developments in public and social policy are interesting our research team.