20
Examination of witnesses
Professor Sir Sam Everington, Fatima Khan-Shah and Ed Davie.
Q123 The Chair: Good afternoon, and welcome to this session of the Integration of Primary and Community Care Committee. This afternoon, we are very pleased to have with us as witnesses, Fatima Khan-Shah, Professor Sir Sam Everington and Ed Davie, who between them represent a large selection of the areas which this committee is studying.
We will take it in turns to ask you questions, but there might also be supplementaries. I remind you that we always have a time constraint. We know you have a great deal to say, but if you could say it as succinctly as possible, that would be much appreciated.
I will start off with the first question, which is about social prescribing. What benefits can social prescribing bring to the rest of the health service, and what kind of evidence is available for those benefits? Sam, it is a long time since we worked together, so I will start with you.
Professor Sir Sam Everington: I will focus on seven benefits. First, it shifts the emphasis on what is the matter with somebody to what matters to them. Same word, but a very big difference. Rather than seeing somebody as a disease, you see somebody as a whole person. This is really important and a big part of social prescribing. We called it social prescribing 30 years ago, because—I say this sort of secretly—it is a secret conspiracy to re-educate all the doctors and nurses without them realising that we are doing it, but using their language. That is really important.
Secondly, it is about holistic care. In Professor Marmot’s research he will say that something like 80% of healthcare is not the traditional thing that we have learned to do as a doctor. Typically, it is about a job, education, environment, and the creative or spiritual side. If you cannot offer that 100%, certainly as a GP, you cannot offer holistic healthcare to patients. By that I mean that often getting somebody a job—we do that at Bromley-by-Bow; we have 100 different projects, jobs advisers and educational courses—is the best thing we can do for their health.
It is also about giving a challenge to biomedicine. If you look at the figures now on admissions of over-65s to hospital, 10% to 20% are as a result of adverse effects from drugs. As soon as you give doctors an alternative prescription, you are reducing this sort of harm. You are giving them the knowledge, skill and expertise in this wider type of prescription.
There is something about saving the NHS money, particularly at this moment in time. Social prescribing encourages people to invest their time, their money, their family's time and money, and the community in supporting them in their healthcare. This is really important in a system that is basically free in this country. We know that if you manage your own care, you will get better outcomes. We encourage all our patients to measure their blood pressure and manage their diabetes, and we see much better outcomes. This is an important feature, and the argument for us is that it saves money.
We talked about the education of doctors and nurses, but we also need to recognise the enormous shortage of doctors and nurses in this country. It will not be sorted in the short term. Practices like ours have a massive mix of teams of social prescribers and of pharmacists. I no longer do drug prescriptions, drug reviews or anything like. I have a pharmacist who does that, who does most of the paperwork.
With social prescribers, we have completely changed how we are managing terminal care. Some 47% of people with terminal illness die in hospital. That is shocking. When I worked for Simon Stevens, one of our vanguards reduced that to 14%. In our practice, as I say, we have a multidisciplinary team, including a social prescriber, a psychiatrist, palliative care teams, a whole raft of different people, who personalise the care around that 5% of complex care patients and give proactive care. The social prescribers are intimately involved in that and are crucial to it.
It gets you to behave differently. I give my mobile phone number to all my terminally ill patients. They can ring me at any time. They can text me. They text me in the middle of the night if somebody dies. I have explained it to them. I am holding their hand virtually and physically throughout the whole process. Again, there are much better outcomes.
Finally, there is lots of research to show that this has enormous benefits. You are talking about somewhere between a 20% and 30% cut in the use of NHS time. DIY Health, one of our projects, which teaches parents how to manage minor ailments called, reduced attendance in primary care by 30%, and, staggeringly, equally reduced it by 30% in casualty. I can give you lots of evidence, but it is around 20% to 30%. Re-attendance at the Royal London Hospital with knife crime—this will interest Lord Kakkar—was reduced from 30% to 1% with social prescribing. An absolutely stunning success.
The Chair: Thank you. Miss Khan-Shah. Thank you for the Fuller report.
Fatima Khan-Shah: A key element of the Fuller report focuses on the potential of personalisation and how that can tailor health and care to the needs of individuals, recognising the different facets that make you who you are. For example, I am not just a woman; I am a woman who is of a certain culture, a certain ethnicity, a certain faith. All those attributes impact my lived experience of how I utilise care. It also harnesses the different, wider determinants of health. Health is not just determined by the fact that you have access to healthcare. It is about your quality of life, by where you live, by the kind of house you live in and the access that you and your loved ones have to the different opportunities to improve your overall health outcomes.
One benefit of social prescribing is that it de-medicalises a medicalised model, and it supports what patients and communities tell us all the time, which is that they want the skills and expertise to manage their own health and well-being. Sometimes that needs to be done in a venue that is accessible or culturally friendly to them, and via a mechanism that is appropriate for them. Sometimes, for young people, it is not in a GP practice. It might be via a virtual medium or via an app. For older people, it may be in a culturally appropriate community centre if they are living in an inner city area such as Tower Hamlets.
One of the really important things about social prescribing is that it does not just focus on what matters to the individual; it also focuses on who matters to those individuals, because we know that sometimes health is not determined just by the individual but by the people who are part of their lives—the people cooking the meals for them in their kitchen, for example, and the social contact they have, which is why some of our models in West Yorkshire, such as Looking Out for Our Neighbours, has been so impactful; because it goes beyond just dealing with the general attributes of health and well-being and deals with things like social isolation, which really impacts people's health outcomes.
We have seen some fantastic examples in West Yorkshire, as well as in the other elements of the Fuller report, where social prescribing has harnessed people's engagement back into the community. The benefits have not just been for their health outcomes; they have been for the wider economy and the community as a whole. One of the best things about working in West Yorkshire is that we recognise that health is wealth, and we have to work in a much more integrated way with our local government—hence my new role as the West Yorkshire inclusivity champion with Tracy Brabin, our mayor, to influence things beyond just the health and care system to improve the outcomes for our local communities from cradle to grave.
The Chair: Integration is very much the theme of this committee, as you will know. Mr Davie, give us your thoughts.
Ed Davie: I would just very slightly challenge the concept that social prescribing de-medicalises things, because, by definition, the word “prescribing” suggests a medical model. Lots of the things that social prescribing does, which is essentially two elements—a link worker who connects people with services and support in the community—has been hollowed out by cuts to local government and to the public health grant, which has been reduced by 24% since 2013. A lot of the voluntary and community organisations and local government services that were available—libraries, sports clubs, youth services—are just not there anymore. We have then medicalised it by saying that we will try to re-provide some of what has been lost in our communities by calling it social prescribing and situating it, generally speaking, in primary care in GP practices.
I am not against social prescribing. I think it is wonderful that it is available somewhere. I would just slightly question the concept that it is de-medicalising things. There is lots of fantastic evidence, as my colleagues on the panel have said. The World Health Organization, for example, says that more than 50% of health outcomes are driven by social factors. People have referenced poverty, discrimination, their housing situations. Anything that can address those social factors, whether it is social prescribing or something else, has to be welcomed and has to be of assistance in resolving health outcomes.
As my colleagues have said, there is lots of very good evidence about the efficacy of social prescribing and things like social prescribing. The National Association of Link Workers and the National Academy for Social Prescribing have a lot of good resources. Rethink Mental Illness, the national mental health charity, has worked with NAViGO in Lincolnshire on a particular social prescribing model, the evaluation of which will be published soon. That has really positive results, most importantly for patients and people in communities but also, as people have referenced, in reducing the demand on healthcare services, which is obviously very welcome and frees them up to do the clinical things rather than things that are social in nature.
Q124 Lord Kakkar: Sir Sam, thank you for your very detailed explanation. You spoke about your multidisciplinary team, which is well established and very effective. How do you ensure that it is appropriately funded, given the multiple sources of funding that inevitably attend those different skillsets and specialist practitioners?
The Chair: Can we take Lord Watts’ question at the same time?
Q125 Lord Watts: Professor, your model seems to be dependent on offloading some duties and responsibilities to allow you to do other things. How do you manage that? How did that come about? It seems that a lot of GPs would have difficulty coming to terms with that and letting go of some things to enable them to do others.
Professor Sir Sam Everington: On the funding question, Tower Hamlets has an £11 million local contract with the ICB and City and Hackney has £15 million. We are about the only areas in the country that have this. That is what has driven this completely different approach from the multidisciplinary team to shifting type 2 diabetes into the community.
If you want to make some of this integration happen, the one thing to do right at the top of the list is ensure that the ICBs have a local contract with primary care and do not just rely on the national contract. It is very easy for an ICB—I say this having been a chair of a CCG for 10 years—to say, “Well, that’s okay. Primary care's all sorted. There’s a national contract”. A sophisticated ICB that really understands integration should in a sense have a contract with everyone who is relevant, because then, using its intelligence and data, it can say, “Actually, we think we should invest here. We’ll get better value for money”.
If you do not feel that level of responsibility, which a lot of ICBs do not—often, to be quite blunt, they see themselves almost as a pass-through of funding for the acute sector—you will not get the level of integration you need. It is that contract that is most important.
On the question of the team, as Lord Kakkar will recognise, everyone in the medical profession was absolutely terrified by the Bawa-Garba case. It was not just about one doctor getting done for manslaughter. We all knew in the medical profession that it was a system failure. I work in a practice that is CQC outstanding. I am not a brilliant GP, but I am brilliant because of my team. We know, and I often describe this, that in maternity in this country, for example, everything comes back to the strength of the team. How do you work effectively as a team?
One thing we do that is not done elsewhere is that we have protected learning times. We let every general practice close for half a day a month, and the doctor, nurse, receptionist, social prescriber all learn together. Then there are the clinical meetings, the MDTs. Every week you are sharing things. You are in a WhatsApp group. It is that different approach to education and learning as a team that allows you as a doctor to feel that you can let go and give people permission to take greater responsibility.
One of the most important roles of a GP now is to support people to upskill and to take the burden of fear of doing that away from them. It is quite often just me saying, “That’s okay, you can go ahead and do that”, and over a period of time you upskill everyone. If you are talking, communicating and learning together, you are picking up problems and issues along the way. It is fantastic, too. That is the other thing you have to persuade doctors of; it just makes your life so much easier if you have a team to support what you are doing.
Q126 Lord Altrincham: Following the contract question, is there anything about the geography of where you are in Tower Hamlets that makes it much easier to do this than other areas? You have worked in different areas, and some of what you have said has effectively been commenting on others' work. Is it something to do with where you are as well, or can it be solved by contract?
Professor Sir Sam Everington: When I came to Tower Hamlets as a GP 32 years ago, it was incredibly deprived. I have to say that the quality of general practice was pretty awful. It is always a lot more challenging in deprived areas. You have to ask: how do we turn that around and get some of the best outcomes in the country? The answer is all the sorts of things that I have talked about.
Can you deliver this in other areas? Absolutely, yes. Do not forget that the beauty of social prescribing is that it is for everybody. It is not just about deprived areas. Everyone is deprived in some part of their life, whether they go through a bereavement, stress, anxiety, whatever it is. I spend quite a lot of time in my family home on the west coast of Scotland, and the local GP there has single-handedly set up a food co-op, preserved the post office, set up a community fund and community transport. This is social prescribing. A friend of mine in Leicester has a police station in her waiting room as a small practice. If you meet the two policemen there, they will tell you two things. One is that they are liked by the community. This is a new experience for them. The bosses love them because they reduced the crime on the local housing estate to 20% of what it was. It is different everywhere you go. It is based on people's passions and needs. It is entirely applicable to any type of community, whether deprived, rural, whatever, in the country.
During Covid, we expanded our social prescribing offer threefold. That was a plus side of Covid as we learned to do social prescribing at a much greater rate virtually.
The Chair: Thank you.
Q127 Baroness Finlay of Llandaff: I should declare that I am in the BMA, I have been a GP myself, and I trained with Julian Tudor Hart, who pioneered one of the early models of social prescribing.
You have answered this question in part, because there does not seem to be a single model. It is about an approach and an attitude towards a community. How is it being successfully integrated in other areas, and what are the specific barriers that mean that, despite all these years of experience, we do not have that attitudinal and relational approach that underpins a lot of the working, as well as the outcome for people across the society you are responsible for?
Professor Sir Sam Everington: Probably the biggest barrier is the barrier that you and I know about in the NHS, which is just getting things changed, quite frankly. I suppose the biggest thing, certainly on the commissioning side, is the variable ability to make difficult decisions and shift funding.
The second thing is to hold your nerve and not crisis manage all the time. That is the problem I find consistently. Social prescribing is longer term. We started social prescribing about 30 years ago. This sort of change takes time, and you need to encourage the commissioners to hold their nerve, which is very difficult when they are getting these political pressures all the time to deliver tomorrow.
When you and I trained it was all about anatomy, physiology, biochemistry. There is a major issue about retraining or training doctors in a different way. There are still doctors being trained in this country the way you and I were trained all those years ago, and that, to me, is not fit for purpose. I am a professor at Queen Mary University, and we are starting apprenticeship training. I am leading that with Amanda Doyle nationally, and we are completely re-looking at medical education, which is a big problem.
You are consistently having to convert people. In Bromley-by-Bow, we have people and Governments from all around the world visiting. In the very early days, we learned that you have to get people to taste, smell, feel it. It is not just about writing a plan; they have to feel it personally. We consistently have people coming around and seeing all the various projects, going away and doing something they are passionate about.
Baroness Finlay of Llandaff: You described the medical model of letting go and trusting others in the team to relate and refer back to you. You also said—and it was music to my ears—that you give people your mobile phone number. My guess is that your experience would be like mine: that it has never been abused.
Professor Sir Sam Everington: Quite the opposite. I often end up by texting people and saying, “Are you are okay?”
Baroness Finlay of Llandaff: Exactly.
Professor Sir Sam Everington: It is most obvious when it comes to terminal care, particularly in my community.
Baroness Finlay of Llandaff: Why do you think our colleagues have moved away from that kind of personalised approach? I find it really difficult to get other colleagues in medicine and in nursing to have that trusting relationship with patients when those patients are really very ill.
Professor Sir Sam Everington: In general practice, it is very obvious in a way. You are there for 32 years. If you make a mistake, you have to pick up the pieces. Continuity of care is a very important part of what you do. I think people are worried about the workload. The workload is very high. I have never known it so high in 32 years. They are very worried that the more opportunities of contact there are, the more work there will be. I think you just have to show them and see what it does when you do it. We are not going to give our mobile phone numbers to everybody.
Baroness Finlay of Llandaff: No.
Professor Sir Sam Everington: Absolutely not, but is really important particularly with that top 5% where proactive care is critical. All you can do is show them. To be quite honest, it is much more satisfying as a doctor when you are closely involved with somebody and their family with terminal illness and you see the success and the amount of patients you are keeping out of hospital. For most people at least, what worse place can you be with a terminal illness than in hospital? Think of the opposite: being surrounded by your loved ones. Think about the lesser bereavement of families. Families are terrified at the thought of managing death at home. You hold their hand, you give them the mobile phone. They do not blue light, they just ring you and relax, and the pride they feel at the end of the day is extraordinary.
One of the first things I do when I go to certify the death—almost straightaway, because in my community it is very important to be buried within 24 hours—is sit there and say something very simple such as, “Your mother would be so proud of you today. You’ve given her the best gift in life, and that’s a good death”. We know that the bereavement is far less, so it is a complete win-win for the whole system. As you well know, even though it is so obvious, getting the commissioning side to shift the way they commission is often really tough.
Baroness Finlay of Llandaff: Can I turn to you, Miss Khan-Shah?
Fatima Khan-Shah: As someone who supports a palliative end-of-life pathway, sadly I did not get my GP’s phone number, but I was in a position where I had the information, expertise and capability to facilitate a good death at home that met the cultural and faith needs of my loved one. That goes beyond the usual medicalised needs. It is things like making sure they have access to anticipatory medication, good district nursing, people from the faith community there to support someone on that journey. If it is not a good death, it stays with you for a very long time, and we hear that from carers all the time.
Going back to the question about some of the challenges and barriers, we heard in the Fuller stocktake about being perceived as being part of the team. If they work in the voluntary community social enterprise sector, there have been barriers to even being in the same estate as the GP practice. Having access to the same level of information and data was a massive issue that we heard about continually, and that ability to share information was really difficult without specialised information sharing agreements.
There were also things like just having access to certain information about what VCSE organisation is still in operation. Sam talked about the sustainability of the voluntary community sector. It is very difficult if organisations that are ceasing operation because of the cost of living funding crisis to then socially prescribe or refer people. It is really difficult if you do not have that real-time information.
It is important to recognise that this is an opportunity for us to be quite proactive about the way we support people. Sometimes the message is not just about the message. It is about who is the champion of that message, and if it is someone you cannot relate to, who does not understand your culture, your heritage, your way of life or your lived experience, those messages will not impact you, so there is a real role there for the VCSE.
In West Yorkshire, we developed a memorandum of understanding where we made a commitment to the voluntary community sector, which was very clear about our expectations, and that has been really impactful when it comes to practical elements of social prescribing and other elements of integration.
Q128 Lord Kakkar: Mr Davie, we turn now to the question of mental health services and how they might be better integrated with the wider community and primary care services available in England, and whether you can draw to our attention any particular barriers and how those have previously been addressed.
Ed Davie: Baroness Finlay mentioned Tudor Hart, who of course coined the term and described the concept of the inverse care law where communities with the greatest need are the least well served. I go back to my previous point about how local government funding and public health funding have been massively cut over the last 13 years or so. The heaviest cuts have fallen in the poorest areas. Blackpool, for example, one of the most deprived places in the country, has had the largest cuts to its public health and local government budgets, which means that when you try to socially prescribe for mental health or anything else, there is much less capacity in the community and voluntary sector and in local government to serve those needs.
On your specific point about the integration with mental health services, Mersey Care mental health trust has an excellent service that socially prescribes directly from the trust rather than just in primary care. That has been an excellent model for addressing the social and wider needs of patients, often with serious mental illness as well as other conditions. That has been a really successful way of addressing some of those needs through the mental health system.
Q129 Lord Kakkar: I should declare that I am chairman of King's Health Partners, which includes the South London and Maudsley NHS Foundation Trust.
In South London, there are examples of how data is being used to drive the opportunity for better delivery of mental health services in the community with earlier identification of vulnerable populations and so on. Is that seen more broadly in England? Where do you think the opportunities are to use data more effectively to model populations and understand how there can be further integration of the understanding of vulnerability with regard to mental health problems and the need for mental health services?
Ed Davie: I was involved in it for a long time. I was Cabinet member for health and adult social care in Lambeth, and a member of the South London and Maudsley Council of Governors, so I was involved in some of that excellent work, which takes into account people's social circumstances and other pressures that can then be addressed if they are well measured.
However, in this country, we do not tend to code for social need as they do in the United States. Kaiser Permanente, for example, codes for various social needs, including housing and poverty. It also has a very interesting model called Thrive Local, which it has been testing over the last few years, where physicians can socially prescribe, as we call it, and refer to agencies in the community to address people's housing, employment, food or transport needs. It is properly integrated using an IT system that feeds real-time information from the not-for-profits in the community which Kaiser often philanthropically supports back to the physician so that they can make decisions, see the information and say, “This person presented with depression, but they were out of work and they had housing problems. I’ve referred them to community providers, who have now sorted out or helped to sort those situations out”.
In an ideal world, the depression symptoms are also alleviated, but that is all linked up with a computer system that enables the physician and the voluntary sector to do that. I do not think that approach is as widely available in the UK. There are some examples of good practice, but it would really help to better integrate the IT and information-sharing between mental health services, primary care, the voluntary sector and local government in order to get better outcomes in the way we all want.
Lord Kakkar: Sam, in your local experience, how has the integration between mental health and other services been achieved at the community level, and how much of that has been driven by a proper characterisation and understanding of the local population and its needs?
Professor Sir Sam Everington: I need to declare that I am a non-executive director of East London NHS Foundation Trust, which is a mental health trust in east London, CQC outstanding. A very big part of what we now do is social prescribing; it commissions Bromley-by-Bow, for example. The link with social prescribing and mental health is critical. Antidepressant prescribing doubled in the 10 years pre Covid. It increased significantly under Covid, because it was much more difficult to provide alternatives. Social prescribing is vital.
On de-biomedicalisation, I would say to Ed that mental health is a classic example of how you can overmedicalise the problem. If I am dealing with patients with depression, as I was this morning, looking at their diet, exercise and other social prescribing is vital. There is good evidence that volunteering, for example—somebody helping somebody else—can improve mental health. However, in the pressure of general practice and the 10-minute consultation, it is very easy to immediately jump for the easiest thing you can do.
When I worked for Sir Simon Stevens, one vanguard had a mental health cafe open seven days a week. What is stunning is that it reduced acute admissions by one third. We have cafés in our mental health trust and a number of our users then come and work in our organisation. This all revolves around social prescribing and having an absolute focus on the wider determinants of health, which is critical in mental health. It is not a challenge to biomedicine; we love good biomedicine, and we do the best biomedicine in the East End of London. But you cannot be successful with patients unless you take the social prescribing and holistic approach.
It is vital that data is shared. The east London care record was streets ahead of the rest of the country. I looked this morning at an MRI that was done on a patient yesterday. Their follow-up from the acute side was going to be in three weeks. It was for a suspected brain cancer, but it was normal. The ability to share that information across the systems allows problems to be sorted as quickly and effectively as possible, which is what patients want. Confidentiality is often what professionals worry most about. Patients want that quick and effective care. The sharing of information is vital.
We have the Discovery East London programme. We have GPs based at Queen Mary University of London who take all the data from the 2-million primary care database in east London and are doing the most amazing research and real-time data use. We found Covid increasing during one of the Covid periods two weeks earlier than the national system. How? Because we saw all the GPs coding “Possible Covid”. This shows the amazing possibilities, particularly for research. It is incredible. Once you connect that with DNA and a whole raft of personalised information about patients like their job or their social situation, it will be fantastic.
Lord Kakkar: This is all very impressive, and what has been achieved is very objectively verifiable. The question is how this is achieved in the funding envelope that your local commissioning system, contract and so on can deliver. Has it meant that less is done of other things, and how has that been reconciled over time?
Professor Sir Sam Everington: Don Berwick from the States says, “Assume plenty”, which is a really good philosophy. There is lots of money in the system, but I will not be asking for more until I have guaranteed that we are using the money most effectively. It is about giving the evidence to the commissioning side and making some difficult decisions about where you shift funding or where you disinvest, which is tough. It is difficult, but imagine the saving and the reduction in pressure on the NHS if all the areas of this country did virtual wards in the community, as we are with terminal care. You would have to put the business case together and get the confidence of the commissioners, as well as giving them confidence in the ability to make those decisions.
Fatima Khan-Shah: In West Yorkshire, we have met the mental health investment standard, so there is parity of esteem in us making sure that we put our money where our mouth is when it comes to mental health and well-being. An example that Lord Kakkar might find helpful is the independent review that we did into the impact of inequalities on our communities and staff. We did a specific deep dive, because the data was indicating a particular issue in relation to the South Asian women community and black men. As part of the action plan of delivery we ensured that the interventions were not just clinical or to do with the mental health trust but were practical: working with local governments, having citizens advice bureaux in our hospital trusts, and empowering schools and community centres to have access to independent advice earlier, rather than waiting for the necessary intervention later on in that journey.
Q130 Baroness Osamor: My question is for the three of you. To what extent are new integrated care systems and primary care networks facilitating the effective involvement and contributions of VCSE organisations and mental health services?
The Chair: We have already heard from Ms Khan-Shah about some of this, so perhaps a brief response to that.
Fatima Khan-Shah: Thank you for that important question. The first thing was the memorandum of understanding that I alluded to with the voluntary community and social enterprise sector. We also have a mental health collaborative, which has been established to ensure that the focus and the momentum remain with the mental health sector, while recognising that sometimes the interventions need to be made by people who are trusted and understand those communities.
It is crucial to involve community influencers, support patients in meaningful public involvement, and amplify the lived experience of communities we do not hear from enough in our decision-making. Decisions get taken in forums of power by people who have no insight about what it feels like to be from that community, and that can perpetuate the inequality. It is important that we give the power back to those communities and devolve care as close to people as possible. We have a mantra in West Yorkshire of subsidiarity, which means that the resources and the money are devolved as close to people as possible, because we know that will make the best outcomes.
We have place-based arrangements that also have VCSE and mental health representation equalling that balance of power, while ensuring that the decisions we make are impactful for our communities and that they are followed up. Sometimes we receive a decision, or a business case for a decision, that sounds amazing, but we do not follow up what happens afterwards and whether it is making the impact it should. We need to close that loop and make sure that the interventions are having the right impact and that we are not just hitting the target and missing the point, but the outcomes that sometimes take longer to come to fruition are monitored too. Sometimes that means that we have to take courageous decisions, but we do that in West Yorkshire because it is the right thing to do.
Baroness Osamor: Are there any changes you would make to the formal requirements placed on ICSs to enable greater engagement and influence for VCSE organisations and mental health services?
Fatima Khan-Shah: Yes, one brief one. Sometimes the funding we get, through the health commissioners in particular, is very restricted in what we can do with it, and it is very short term. What is instrumental is a longer-term sustainable funding arrangement that enables us to deliver the outcomes we need, which will take time. If I had a magic wand, that is the one I would definitely go for.
The Chair: We will certainly note your magic wand.
Q131 Baroness Redfern: My question has partly been answered. Professor Everington has already alluded to data sharing and how it is working in his area. Why is it not being rolled out elsewhere in the country?
Professor Sir Sam Everington: That is a difficult question to answer. As you know, about 10 years ago around £11 billion was lost from computer programs, and one of the things we learned from that lesson was to get the systems locally to talk to each other. Do not try to invent a big, magic system, which is what we did with CareDoc data.
Baroness Redfern: Are people frightened of sharing too much?
Professor Sir Sam Everington: Enormously so. There is a great debate about this in general practice at the moment. Some of it is understandable, because, quite frankly, there are a lot of notes that are mixed up and have other people's notes in them, which is a real safeguarding worry, so you can understand their concerns about sharing that information. I believe, as I did 32 years ago when I gave my patients all their notes to read when they were in the consulting room, that this has to be opened up, full stop. It can be opened up by getting people to use the app much more and access their notes that way.
I would love to see the Government do what I can do. I am one click away from the acute sector information. It would surely not be difficult for the patient to go into my notes, as they can now, click once and get into their hospital notes too. It just needs the will, the local systems and a focus on IT. I would argue, as a commissioner for 10 years, that your best investment and best value for money is in IT. I am a member of the ministerial infrastructure board, and we call it the infrastructure board on purpose; it was the London Estates Board. Any money you put into IT is streets ahead, because infrastructure is IT. We need people to recognise that and basically steal ideas. We always argue at Bromley-by-Bow that we are great magpies. We have stolen lots of ideas and used them. We encourage people to come and steal our ideas too.
Baroness Redfern: I am pleased you mentioned pharmacists and how they are helping you with your workload. How much has that helped?
Professor Sir Sam Everington: It is fantastic. The letters that come in every day are dealt with by the pharmacist, and anything I have to see as a GP is handed on to me. All the drug reviews are done. We have halved the GPs’ work of repeat prescriptions by having a pharmacist. I worked hand in hand with them when we started having them three years ago. It is much safer. Most GPs will describe being busy doing repeat prescriptions at the end of a very busy surgery, which is not good. It is not safe. Having a pharmacist who does that is fantastic. There is more repeat dispensing, which we know is far more popular with patients, so they are not having to chase their prescriptions all the time when it is quite obvious they are going to need it for the next six months or year.
Having pharmacists makes things safer and takes a significant amount of time away from GPs. I argue that the focus for a number of years has been on there not being enough GPs, which is true, but if I am being really challenging I would say that there are plenty of GPs; we just need to get a lot of other people into the team to take a lot of the GP work away from them, which is entirely possible.
Q132 Baroness Wyld: Professor Everington, on your point about patient access to data—speaking as someone who carries their entire medical record in the app on my phone—something has been bothering me. Is there is a risk that we are asking patients to do too much and effectively become their own clinicians? Is there a risk, therefore, that that will lead to inefficiencies? If I can see my test results before my GP gives me a call, or does not give me a call, or if I can see my hospital record and I spot a minor abnormality which then provokes a desire for further investigation, is there the possibility of a vicious circle? In the past, the art of being a doctor would be to manage what the patient knows, not to tell you your profession.
Professor Sir Sam Everington: It is a really difficult issue. On principle, the more people manage their own care, the better outcomes you get. When we started shifting type 2 diabetes out into the community 10 years ago, we found that when people managed their care and accessed their information, you got better outcomes. We also know from a study carried out that if you measure your own blood pressure, it is five millimetres lower than when it is measured by a professional. There is clear evidence about that.
You also highlight the increased fear it can cause. When I get a blood test result, I will put a comment next to it like, “This is stable, nothing to worry about”, or, “I need to see you”, although if I have a worrying result I am much more likely to ring somebody and just say, “I have this result”. You do not want to people to sit in fear. Also, if I can get you to manage far more of your care, I have more time to spend on people who are not IT literate and would struggle much more with those sorts of systems, so there is a win-win.
You are quite right, however, that at the back of our mind is always the worry that we are putting too much on people, and inappropriately too much, but as long as you have your door open and they can get hold of you very easily, I am less worried. It is keeping the door open. We use an incredible system in general practice called Accurx, which enables patients to get hold of us easily.
Baroness Wyld: So the balance is right in terms of opening things up.
Professor Sir Sam Everington: You have to make sure that in doing it you are not creating barriers. I always say to a patient at the end of the consultation, “Any problems, don’t hesitate to contact me”. With that sort of attitude, you keep the door open, which is the important thing.
Q133 Lord Kakkar: I should declare that I am chairman of UK Biobank. How much of a concern is it for general practitioners that they are the data controllers and that a substantial liability attends that legal status, and how might that be overcome?
Professor Sir Sam Everington: That is difficult, because you feel a great responsibility there. I declare that I am a non-executive director for NHS Resolution, and it often comes up as an issue of concern. There are risks. My attitude always as a GP is do the right thing. As a doctor, you will know that if you are sticking purely to the rules of confidentiality, you would not have a conversation with a relation but there are moments when you make the professional judgment that it is absolutely in the interests of that person to have it . It is the same with the data. The important thing to keep in mind is the best thing for the patient.
The Chair: Mr Davie might have particular issues about the mental health side on this.
Ed Davie: Obviously, we need to balance the importance of patient confidentiality and safeguarding, particularly when it comes to mental health but in relation to other data as well. I agree with the previous point that, in general, the principle should be that we share as much data as possible and empower patients. You find with people who suffer from mental illnesses that they are disproportionately the ones who suffer from a power imbalance. They are the poorest people from certain racialised communities and other communities. We should try to empower them as much as possible in the decisions we make with them, not do things to them. Bearing in mind certain caveats, we should share as much data as possible, but there is a whole legal framework and a minefield around that which I am not an expert in.
The Chair: We will not ask you to speculate on that.
Q134 Baroness Finlay of Llandaff: What is the one change that you would like government to make to better integrate particularly mental health services and voluntary community and social enterprise with the wider health service and with other community services, rather than leaving it isolated. Integration applies to all the services. Your wish list, please.
Ed Davie: We need to empower public health teams in local government. I mentioned that the public health grant had been so massively cut that it disproportionately falls in areas of greater deprivation and need that are underserved anyway, which then hollows out wider services.
A couple of years ago, the Office for Health Improvement and Disparities found a small amount of money, about £20 million, for the 40 most deprived local authorities to fund one-off, one-year programmes with the Better Mental Health fund. The Centre for Mental Health, which I represent, has just evaluated it and the evaluation is about to come out. Even with that relatively small amount of money, we found huge innovative benefits to local populations in the prevention and better management of mental health conditions.
We will see a lot of benefit if we shift away from the clinical model to assist clinicians to concentrate on the clinical matters, empower communities and get more of an approach that addresses the social conditions in which people live—the poverty, the discrimination, the poor housing and the poor environments that they are living in—and with the right investment and the right structures around them via public health teams in local government, which is the right place. We can build on some of the innovations that we have talked about and the very good approaches that we have heard about.
Fatima Khan-Shah: Simply, we need to bring to reality the aspiration of the Fuller stocktake report and the Health and Care Act 2022. An example of how integrating the VCSE, local government and social care could be the reality is a partnership collaborative approach we have with the West Yorkshire Combined Authority, our health and care sector in the north-east and Yorkshire, and Yorkshire Sport. We had 132,000 volunteers providing 9 million hours of work to the value of £1.4 billion. Our accumulative budget in West Yorkshire is £5.4 billion, which is incredible.
If we bring the aspiration to life, it is not just about the health and care outcomes, which are obviously my priority, but business sense. But we need to break down some of the barriers we have just described in culture, data sharing and the models that we have explored. The possibility is there and the examples exist. We just need to be courageous.
Professor Sir Sam Everington: Ninety per cent of people visit a general practice in a year. We need the social prescribing budget ring-fenced to enable it to develop over a number of years. We need a school nurse in every school. We run the school nursing in Tower Hamlets as a social enterprise; the GPs run it. We only have one sixth of a nurse in every school, and they need to be on every governing board. We have not talked about social prescribing for children, but it is critical, and we are doing pilot projects on it. We need a local contract, but an integrated local contract. We started primary care networks 10 years ago in Tower Hamlets, which is where the Government got the idea from, because we worked out that we could be far more effective if we commissioned a group of GPs together. They had to work together, solve problems together and share staff together. Imagine what you could do in mental health, for example, if there was an integrated contract between the mental health trust, primary care and social care.
The voluntary sector is grossly underused. At Bromley-by-Bow, we are two governance structures: we are a primary care partnership and a charity. In the past, there was a government drive for social enterprises—people who were contracted for in the health service. We need something that drives it all. We have to look at that wider partnership. I always like to say at Bromley-by-Bow that we are a partnership between the church, the private sector, the state sector and the voluntary sector. It is that integration that gives you fantastic outcomes. But to do that you also need to challenge the voluntary sector, because lots of voluntary sector organisations are often sitting on massive capital assets and not delivering the 10% return. I am not talking about money here. I am talking about delivering that 10% of social capital or social revenue.
Baroness Finlay of Llandaff: I keep hearing from people that lots of people are involved in their care but they do not know who is in charge. How do we get that sense of responsibility back and the single point of go-to so that they do not get mixed messages?
Professor Sir Sam Everington: Having that in primary care is essential. There was a very interesting study in Norway, where I am partly from, which shows a categorical link between continuity in care and pick-up of cancer and other long-term disease. You have to do it around primary care. As consultants over the years have become increasingly specialised, the generalist is in primary care, so attention and focus needs to be paid to primary care.
You see it in our MDTs. One of our senior nurses proactively manages the 5% terminally ill, complex-care, housebound patients we have. Our patients know that they will go through Siobhan for their needs. Siobhan will ring them up every week, visit them or whatever is needed, and pull the GPs in individually when needed. I am often involved at the end of life when there are issues with drug prescribing, pain relief and all those sorts of things, but at any moment people know that Siobhan is the person who is important to them. People have to know who that person is for them. We put a lot of emphasis in our practice, particularly in mental health, in making sure that people see the same doctor every time, so when you put in your request for your appointment we ask for more details because that briefs us much more effectively, and that will include who you want to speak to.
The Chair: Thank you. I think you will gather from the interest of all my colleagues that we could go on talking to you for a very long time, so, on their behalf, I would like to thank you very much for the ideas you have brought to us today and for your time. This is a public broadcast, so you will have a transcript to correct for transcription errors only. Can I also emphasise that if there is anything you feel you have not had the opportunity to say, or that would be useful to the committee, we would be only too pleased to receive it. Thank you very much for your attendance.
