I was surprised about his trenchant comments about successive government’s re-structuring of statutory health services and how much time is then wasted re-setting relationships and about our “obsession with hospitals”- especially politicians and the media.
The key factors in determining good health are not hospitals or drugs, but as he said “jobs, homes and friends”. And these are much more influenced by local government, community organisations and employers. Duncan made a telling point that if you ask older people what is important for wellbeing, they cite companionship, having a role, and friends; but professionally-led health systems think wellbeing is the absence of disease – a big gap in expectation and understanding.
These wider determinants are not news: we’ve known a long time. The voluntary sector, in particular, knows from experience that wellbeing is created by people relating to people. However, the power and resources don’t lie in public health solutions but in acute care. And here’s the problem.
As more health resources are commissioned to the private sector we fix into contracts how health is configured. Then, when we want to re-organise to put more resources into community solutions, it is tied up in contracts with all the added difficulty of commercial confidentiality and fragmented services. The hospital building under the Private Finance Initiatives is a good example, where we are tied into long “mortgages” for buildings when what we really need is more community-based services.
The voluntary sector is making good progress in promoting the idea that prevention is better than cure (see our ‘VCS Manifesto’ vote at the recent Health and Wellbeing: Making Equality a Reality conference) and that community solutions to loneliness and creating jobs, especially for excluded people, work well and are cheaper.
There are two dilemmas here.
First, we may save the acute services money by preventative work, but unless the costs as well as the savings are recognised and there is re-investment in the sector, we will not be sustainable. Harnessing the capacity of community action is a powerful tool in health but it isn’t free.
In addition, it isn’t solely a rational, disinterested argument about community/public health solutions working better and being cheaper; it’s an argument about not re-organising the commissioning of services in such a way that flexibility around new solutions is just not feasible. Market answers in health may be dressed up as prudent balancing of the books but they have much more profound implications for the sort of society we want.
Second, we don’t want to find ourselves on the wrong side of arguments about health spending. There are all sorts of moves in the NHS policy world about involving people, for example “The NHS belongs to the people ~ A call to action!” Quite what “belong” means when a private company has a health contract is not clear?
It is clear that money is tight in health. We’ve heard that new funding formulae may mean that northern Clinical Commissioning Groups will lose resources to the south. We need to keep a weather eye on where scarce resources are spent. ‘Follow the money’ is always good advice to see who gains and who loses. And although campaigns to save local hospital services might sometimes be ill informed, the general suspicion that “ours” is becoming “theirs” is not way off the mark.
There are big political and ideological issues behind much of this debate: we’d better tread carefully.