17
Examination of witnesses
Julia Weldon, Tanya Rumney and David Buck.
Q135 The Chair: Welcome to this second session of the Integration of Primary and Community Care Committee this afternoon. Two of my colleagues from the committee are online today so I hope that is clear to our witnesses who are: Julia Weldon, from the Association of Directors of Public Health; Tanya Rumney, who is from the British Dietetic Association; and David Buck, from the King's Fund. Thank you very much for attending.
In the usual way, we will take it in turns to ask you questions and people may put in supplementary questions as well. First, Tanya Rumney, in your experience, what have proved to be the most significant socioeconomic determinants of health and health inequalities?
Tanya Rumney: Thank you for the opportunity to speak to you today. Obviously, the current cost of living crisis is a concern, and it is going to make it more difficult to address health inequalities. We are seeing an increasing number of people who are expressing anxiety over their ability to access affordable food, and this will ultimately affect health outcomes. We have seen long-term challenges around the cost of healthy foods, with many people from lower socioeconomic groups forced, potentially, to choose lower quality foods as a result of being unable to access affordable foods. The outcome of this is going to be that they may develop more lifestyle-developed chronic diseases, such as type 2 diabetes, and these require long-term health interventions.
The Chair: Would you like to continue, Julia?
Julia Weldon: Thank you for inviting me today. I am representing the directors of public health across the UK, and I am a director of public health in Hull. First, it is important to set the context of health inequalities—avoidable, systemic differences between populations and groups. They are determined by the conditions in which we are born, grow, learn, live, age and work. These are best described via the worsening inequalities in life expectancy and healthy life expectancy that we have seen over recent years: a gap of 10 years’ life expectancy between the most deprived and least deprived in the country and of 19 years of healthy life expectancy.
Those in the most disadvantaged parts of our communities have that double jeopardy of shorter lives, lived in poorer health. Those inequalities cost families and individuals hugely throughout their lives. A recent publication set out the cost to society of those inequalities: £31 billion in lost productivity per year, £4.9 billion of cost to the NHS, and between £20 and £32 billion in lost taxation and welfare costs.
The really important message to get across in terms of the significant inequalities is that they are determined by social inequalities. It is important that we have cross-government and cross-sector public health policy that considers health in all policy and that courageous decisions are made around those things that disrupt those inequalities and enable people to have healthier lives.
The Chair: Can I come to David and also ask about the effectiveness of health promotion strategies?
David Buck: I would agree with much of what has been said. Critically, those factors, such as access to decent housing, a good job—and, obviously, the income that that gives people—educational outcomes in early years, et cetera, all cluster in communities and place. This is the really critical thing: the concentration of risks. These do not occur randomly, and they occur in the same people over generations. Breaking that cycle is really critical, and hard.
In terms of health promotion, it is not a counsel of despair; there are lots of things that can be done. Health promotion, depending on how you define it, can be about supporting individuals. We know that there are lots of effective interventions for individuals and individual services—I am sure Julia has examples of this—but if they are not implemented with an eye on health inequality reduction, they can inadvertently widen health inequalities because we know that people need the capability, the motivation and the opportunity to change behaviours. In very difficult lives, health behaviour change is often not the first thing on people’s lists. Services that are more holistic and connect clinical interventions with social interventions are likely to be the most effective and the most long-standing.
We are jumping ahead, but this is the potential in integrated care systems. If integrated care systems can pull that off at the individual level, there is certainly not a counsel of despair here. If you include in health promotion, those wider, big, structural policies, then you need these policies to be layered and coherent with each other. That is obviously a role for national government, a role for local government and local systems, and a role for individual services. There are many aspects to this. I am sure we will get into some of the details.
The Chair: We will talk more about health promotion as we go on. Baroness Tyler has the next question, and she is online.
Q136 Baroness Tyler of Enfield: I will start by declaring an interest: I am a non-executive director at the Royal Free London group of hospitals in north London. As part of that, I chair a joint population health committee with the North Middlesex University Hospital.
I would like to ask how better integration can help with health promotion strategies, the sorts of things you were just talking about and reducing inequalities. In asking that, I am particularly conscious of the fact that public health expertise is dispersed very widely across a very wide CIS health and social care system involving local government, the NHS nationally, the NHS locally—now with the ICSs—and the UK Health Security Agency. Does having such a wide dispersal of expertise on public health issues help or hinder the integration?
Julia Weldon: That is a really good question. First and foremost, integration means more than the NHS, or even public health teams, integrating with themselves; it is much wider than that. There is absolutely no doubt that we have been operating a really complex system. Since 2013, when public health moved into local authorities, public health responsibilities have dispersed across a number of organisations. We lost something during that period around how we work together. We have, however, rebuilt that. We have excellent relationships—certainly in Yorkshire and Humber—with our public health colleagues and the organisations that you spoke about. We have also now coalesced around our integrated care systems.
One of the most important messages that I can give as a director of public health is that public health responsibility does not sit with me, it sits with every single individual who is working in that integrated system with communities right at the very heart. When we talk about inequalities, it can often make us feel like there is nothing we can do. There are, as David said, really good examples across the country of things that we are doing together; for example, family hubs, community hubs, combating drugs, and the homeless work that people are doing. Often, however, the investment is fragmented, short-term and with prescribed outcomes that do not give that local flexibility at place.
For us all to work together in the way you described in the question, we need clear and coherent national policy, devolved decision-making at ICS level and at place so we can really work with those communities right at the heart of everything we do and deliver, at a local level, the things that we need.
David Buck: I have two points. The Royal Free is actually a really good example. Some time ago, it put together a service between local government, clinicians and the community on behaviour change, particularly in those clinical areas where we know that secondary prevention is really important such as diabetes eye-care, et cetera. It was well evaluated, effective and seen to be cost-effective. It focused on underserved populations—and this was some time ago, I should add—so this is, I hope, where integration will change things. It was funded by the charity, everyone loved it and then the budget came to an end and who was going to pay for it? Was it local government? Was it the NHS? It fell, it was not recommissioned. This was some time ago now, before integration policy, but this is what we need to avoid.
I also know that the Royal Free is trying to re-establish some of this through Making Every Contact Count. Critical here are the funding mechanisms, the funding flows and the accountability, so that this joining up does not become my job or your job, or more likely, “It is not my job, it is your job”. It becomes a joint endeavour.
We know that local government in particular has had huge real-terms cuts in its public health budget so it comes to the table with lots of expertise but not very much funding. In the scheme of things, the NHS comes to the table with increasing expertise. We have more directors of population health. One of my big hopes for the future is new directors of population health and public health working together locally and becoming a common force in the conversations that need to happen. That is the first, rather long, point.
The second point is about integrating public health expertise. We have been working around the country, in the London ICS and also the North East and North Cumbria ICS, on that very point of how we bring the public health family together with integrated care leaders, because there is no doubt that the huge expertise that lies with directors of public health and their teams is exactly what is needed to influence integrated care systems in particular to be on a path towards prevention and population health. Things have become fragmented. In the best places, we see that fragmentation coming back together in integration. The challenge is whether that is happening everywhere and happening fast enough.
In the areas we have been looking at, there have been explicit agreements about where, and on what topic, the public health family, wherever they sit, will lead, where they will follow and where they will collaborate with other members of the ICS, where they will both advocate for each other and, most importantly, advocate for the health of their populations, locally, regionally, and nationally. Some of this is almost coming back together despite the structural change, particularly with the ending of Public Health England. This is not an inquiry about that directly but obviously that caused lots of short-term challenges. We see the best places coming together, in a way.
The structures are critical but, whatever the structures, it is for the leadership on all sides of the house to come together because we can get over structures. If integrated care systems are allowed to be what they can be, those structures can be really supportive. If they do not become what they can be, they can get in the way and be another layer of management or bureaucracy. We are still positive about the future that is possible through integrated care systems. We should be, because they have not been there for a year yet and they have been reviewed once already.
Tanya Rumney: What I would add to that is that dietitians as a profession have lots of expertise in many areas where health promotion strategies are aimed, but often, we are not included in the conversations. Part of this could be as a result of our small workforce—there are only 11,000 dietitians—but we saw a real opportunity in being included in the GP contract. It is important to highlight that even with the addition of dietitians to the GP contract as part of the additional roles, less than 10% of PCNs have employed a dietitian, which is only 100 dietitians. That is a real missed opportunity. I am highlighting the idea that dietitians are the experts from a nutrition point of view—the only regulated profession in this space—yet are often not included in the conversations about developing the priorities and policies.
Q137 Lord Watts: What kind of integration is needed for health promotion and tackling inequalities? Perhaps you could give us some examples of best practice adopted nationally to achieve that aim.
David Buck: One example—this is a bit of a bee in my bonnet—is that we are all well aware of the challenge of multiple long-term conditions and the fact that conditions cluster in people. That is one reason why we have been pursuing integration policy to reflect the reality of people’s lives rather than how we would like to organise our services. The same thing, further upstream, can be said about health behaviours. We know that 6% to 7% of adults are perfect on the four main health behaviours; that is, we neither smoke nor drink to excess, our diets are great and we take all the physical activity that the Government say we should. That is 7% or 8% of the population, although maybe the numbers have changed a bit since we looked at this.
Most people have combinations of health behaviours. If we look at people in isolation and look just at the single behaviour, we are missing a trick with how people actually experience health behaviour. This goes back to the point about more holistic health behaviour support services. Some time ago, we did some research work looking at how those are developing. There are lots of good examples around the country, as ever, but that is not systematic. One of the dangers of the NHS rediscovering prevention, which is a great thing, is that it does not work alongside its partners, particularly in local government, in developing services. Julia’s colleagues have responsibility for lots of health promotion services. That is one area where I would love to see more development, more systematic work and more systematic services. It goes back to relying on how we incentivise this and get the funding right to achieve it, and that is more holistic health behaviour change services.
As I said, we have lots of evidence that people need the capability, motivation and opportunity to change and they need those services around them. If you have three or four health behaviours, it is harder to be clear about the evidence on which to do first. Do you do the one that is most significant to your health? Do you do the one that is easiest to change? Do you do the one with the strongest evidence? That is something we need to learn more about. Colleagues such as Tanya working together much more closely—I am sure Tanya does—with other behaviour change support is really critical. We see that developing, but that would be a real step forward systematically and at scale.
Lord Watts: Do you know where your deprived communities are, and do you know which measures need to be addressed to deal with that effectively? Does that information already exist?
David Buck: We are very fortunate in this country to have lots of information about where deprived communities are. Directors of public health are at the heart of that, with local knowledge about the health conditions they have and the behaviours they face. The NHS is increasingly engaged in that through things such as population health management and bringing all that information and data together so that, behind the scenes, the council data and NHS data are connected. That tells us a lot about what people are experiencing or likely to experience. You can look at current hotspots, and potential hotspots in the future, to start to think about the physical location of services. Obviously, a component of this is also digital. In short, yes, that is in the system in most places and is being used already to varying degrees. My colleagues may need to come in and say a bit more about that.
Julia Weldon: Perhaps I will answer the first question and then answer that one. I want to give you some examples of how integration supports health promotion, perhaps giving you one at national level and one at a more local level across the age groups.
I will start with tobacco. Tobacco is the biggest cause of inequalities in the country. Although we sometimes think it is, the job is not done. In places such Hull, we still have 20% to 25% of adults smoking, compared with 30% in the rest of the country. Policy is massively important in this area. Courageous policy over the 2000s around smoke free, tobacco pricing and tobacco packaging reduced the number of children and young people aged 11-15 taking up smoking by 15%. That is really significant because if you do not start smoking at a young age, you do not start smoking after the age of 21. We need that integrated, courageous policy to continue for tobacco, and I recommend the Khan report to you in that regard. Working together at the very top, policymakers making decisions, implementation at a local level and support from local communities are essential.
There are other examples of what happens and the example I am going to give started at the time of Covid and during the response to Covid. Integration often comes organically rather than being devolved downwards or expected. The integration between the voluntary and community sector and the rest of our place was incredible during that period of Covid. We really found the work that it did was fundamental to us being able to reach our most disadvantaged communities. What that has helped us to do is build something in Hull we call Building Forward Together, which is a voluntary and community sector right at the heart of our community, with an equal and reciprocal relationship with our health and care and public sector services, working together for the people of Hull.
Finally, I will give you an example of a regional piece of work. We will talk about ICSs later. The integrated care system in Humber and North Yorkshire put public health right at the very heart. Professor Stephen Eames, our chief executive, talks about using the North Star Architecture to reduce inequalities. In terms of putting resources where its mouth is, it has given us £1.2 million to develop a tobacco centre of excellence across Humber and North Yorkshire. That will help us drive down the harm from tobacco that we see in my region. I am really grateful for the courage that the chief executive and the senior team have shown in doing that.
Tanya Rumney: To follow on from David’s point about the services, we need to commission services that address health inequalities with long-term funding because, quite often, dietetic services are funded in a way that you only get short-term funding to address the health inequalities.
Baroness Redfern: Following on from what Julia said regarding people smoking, particularly in the Hull area, do you have a problem with young people vaping?
Julia Weldon: It is a question I often get asked these days when I talk about tobacco. Vaping is an important issue for us. It is a really important tool to reduce adult smoking, but it is beginning to be a concern in terms of children and young people being targeted by commercial companies. You will have seen recently that there has been lots of discussion in the press. We really need legislation for reducing sales of vapes to young people and legislation about how they are packaged. As I said, it is a really important tool. We know that it is one of the most important tools in reducing tobacco harm and helping people to stop but vapes do contain nicotine and some of the products that are sold are not regulated. It is a really important question.
Baroness Redfern: It is the flavours, is it not? Are you saying that you are seeing more young people taking up vaping?
Julia Weldon: We are seeing some young people take it up. It is certainly a worry. It is difficult to estimate how many young people are taking it up, and the majority are not. It is not the norm any more than it is the norm for children to smoke. Commercial determinants of health are really important, as important as social determinants. Big commercial companies will do what they can to promote their products. If they look like sweets and they are named like sweets, they will be interesting to children and young people. This is where legislation can help.
Baroness Barker: The rationale for moving public health to local government, back in the Act that did that, was that the first people to know and see problems are not the health service, it is other people. Therefore, to try to tackle it, we ought to be working in other ways. You said in an answer to an earlier question that in 2013, when we moved, we lost something. The first question is, what did you lose?
You said that during Covid, you suddenly started to be able to work brilliantly with the voluntary and community sector. My second question is: to what extent and why was that? Was it just that the NHS woke up to the fact that there was a load of voluntary sector people doing things and it was forced to do so because of circumstances? I am trying to dig underneath what we really mean by integration. What different people believe integration is and how it happens has been bothering me throughout our inquiry.
Julia Weldon: I will try to answer those questions succinctly because I know we have to keep an eye on time. We were talking about the complexity of the organisations, in terms of public health, when I talked about what we lost. When we went into local government, we gained more than we lost; I want to make that point really clearly. I about believe directors of public health are in the right place to influence social determinants, and I am really pleased to be working there. What we did lose was some of the responsibilities and authority to act on some issues, such as screening, immunisation, dental public health, and health protection issues. We regained that over time. We worked through the process, but it is certainly not a loss to move into public health. I do not want this committee to think that is what I said.
Baroness Barker: Did you lose that because of access to data?
Julia Weldon: Yes, but also because when things are fragmented, it is often more difficult for people to understand what their responsibility and accountabilities are. As a director of public health, it is my job to be assured of those things. I had to work with a number of organisations.
In answer to your second question, we have always understood the importance of the voluntary and community sector, but I do not think we have truly entered into an equal and reciprocal relationship in the way we should have done. It is something I have wanted to happen for such a long time. The voluntary and community sector is not who we go to when we have a problem to fix, they are partners around our table who know and understand our communities. Earlier, a speaker talked about the enormous amount of funding that the voluntary and community sector brings us and also the enormous amount of impact it has. It was an opportunity to demonstrate what could happen if we worked together in that way and it has made a fundamental difference.
Q138 Baroness Wyld: You have started to touch on my question—and tobacco is probably a very good example—but we were interested in the role of health promotion strategies in easing pressure on wider health services. If you could each give a personal perspective on that and, if possible, some examples. Let us start with Tanya because I am sure that nutrition is a key part of this.
Tanya Rumney: Absolutely, I mentioned earlier the introduction of dietitians into primary care and that has given us a good opportunity to work more closely with our communities. Historically, we have a workforce that is based mainly in acute and community sectors, whereas moving into primary care has allowed us to work much more closely with nurseries, schools and the criminal justice sector. It has also allowed us to integrate a lot more with our community leaders and that really has demonstrated some good benefits.
As an example, working with groups of refugees has been really beneficial and this has historically been quite difficult, as someone said, where we already have complex health issues with our patients. Bringing dietitians into primary care really gets them involved much earlier in the patient’s journey.
One thing I would add, and one of the significant challenges that we face, is dietitians are allowed only to be supplementary prescribers at the moment. A key benefit for the profession would be to gain independent prescribing rights, which would allow us to support our communities much more. At the moment, that adds quite a lot of red tape and quite a lot of burden into the system. Ultimately, that means that individuals wait longer for their medications and their treatments.
Baroness Wyld: If you had prescribing rights, what main intervention would you be able to make?
Tanya Rumney: It would allow us to support individuals who have conditions that are quite significantly impacted by diet and lifestyle, such as type 2 diabetes or weight issues. At the moment, supplementary prescribing rights mean that you always have to have a GP or a consultant involved in that patient’s care, whereas there are a huge number of people who we could support better by having independent prescribing rights.
David Buck: It is a very good question. I am a health economist by background, many years ago. There are some examples where specific and successful health promotion and health behaviour interventions make a big difference; that is a given. One clear example is tackling smoking during pregnancy, because that feeds back very quickly into less likelihood of lower birth weight babies and all the care that they receive. However, sometimes we expect too much of prevention.
If you look at periodical summaries of NICE’s health promotion and health behavioural interventions, about 70% to 75% of the ones they have looked at are conventionally cost-effective, meaning that we have to pay something to get something of value back in terms of health improvement. About 10% to 15% of those interventions are cost-saving. The danger is that we set ourselves up to fail if we say that prevention’s job is to reduce demand on the NHS. Prevention’s job is to provide cost-effective, value-for-money intervention, just as treatment’s job is.
In the NHS, I sometimes see that prevention is held to an artificially high barrier compared with other interventions. It is something the NHS will do only if you can show it will save money in 12 or 18 months. We do not do that for treatment interventions.
In my view, some prevention interventions are cost-saving, and we should do them. Many prevention and behaviour interventions are cost-effective, but we are not doing them because we hold prevention to a different standard. We need to set prevention the same challenge as we do treatment interventions but we do not and, worryingly, I see that prevention is being held to this artificially high standard.
Julia Weldon: I absolutely agree. We have to get much smarter about understanding return on investment for prevention activity. I have talked a lot about policy, which we call primary prevention. Secondary prevention is, for cardiovascular disease, preventing the harm from strokes and heart attacks, and reducing the impact of dementia. The return of investment is about £2.30 for every £1 spent over a 10-year period on those strategies to reduce harm. This model really depends on integration, early detection, early treatment, the right clinician at the right time, continued support for individuals within the community, and a narrative that helps people access services within the environment in which they live.
In West Yorkshire, and Yorkshire more widely, there are some really good examples of clinicians and wider primary care community teams coming together in community hubs to support people with long-term conditions and help people live longer and healthier lives.
Baroness Finlay of Llandaff: I was listening to Mr Buck’s comments about the Royal Free and wondered whether we are collecting the right data to be able to evaluate interventions, or whether not collecting the right data to show efficacy is part of the problem?
David Buck: It partly goes back to the point about the spillover of some of these outcomes into different sectors. We need to make sure that the data is collected together, and public health colleagues are critical in that. NHS England has pursued population health management for some time and increasingly started trying to connect the NHS data together: if we do something in acute care, what happens in primary care, and vice versa?
With good connections with local government, we can increasingly pick up indications from local government data. These patients go through our system, we have lots of clinical data about them, but we do not have social data, so can we actually look at to what extent their housing background is the reason they do not come for appointments, or the fact that they have no public transport, et cetera? Increasingly, this is where the system is going, and this is where the value of integration is.
We talked earlier about “integration of what?”. There is integration of care and the delivery of care, integration of organisations, integration of data and information, and, for me, integration of accountability, too. We can look at all those different levels, and if one of those—including the data—is out of skew, you do not get the full impact or see the full picture.
Again, I am an optimist here. I think that data does exist, and in some cases, it is connected together. In Kent, they were doing this way before integration was heard of; they have lots of expertise, and some other parts of the UK do too. But the critical thing is getting it in front of the right people. It has to be in front of the key decision-makers, not just stuck with the analysts. In a way, there is an education job in making sure that this data gets in front of the key decision makers at the right time, as well as knitting all the data together.
The Chair: The right data at the right time. Thank you very much.
Q139 Lord Altrincham: I have a short question for Julia. You have touched on this already, but perhaps you can give us an example to what extent are new integrated care systems and primary care networks facilitating the involvement and leadership of directors of public health?
Julia Weldon: It is variable across the country, but most are doing really well. It is the responsibility of the ICSs and the DPH to ensure that we are involved and playing our part in integrated care systems, and we are taking that very seriously. In Humber and North Yorkshire, which is a system I work in, there is a director of public health on the board. That was something that we asked for as part of the work that we have done with the chief officer and his team in ensuring that we play our part. We needed that place on the board.
The director of public health and I co-chair the population health and prevention group, which is what enabled us to get those inequalities funds into the system and additional funds into place. I am feeling optimistic. I am worried about the impact of the current budget cuts to the NHS and what will happen as a result of that. Other people have mentioned the budget cut to the public health grant, which is important, but it is not the only public health money we have. We have to use every single penny of allocation to improve the public’s health, and that is where directors of public health can influence.
It is positive, Lord Altrincham, but we need to work really hard to make sure that it continues that way.
Q140 Baroness Armstrong of Hill Top: My question is meant to be specifically for Tanya, but I want to ask another supplementary, which others may like to come in on, replicating what Lord Altrincham just asked Julia in terms of public health. How far has the integration between different stakeholders within the ICSs improved diet-related health? What are the barriers to this, how do you think they can be overcome, and how far are the new systems listening to people like you?
Tanya Rumney: That is a really key point because, as I mentioned previously, one of the main challenges we face is that we are not always at the table. Dietitians are not always involved in those conversations, and therefore it really does make it difficult to influence directors of public health. That comes with good leadership. There is a lot of evidence to show that within organisations and systems, lead allied health professions can produce good outcomes for our population. It is about making sure that we are embedded in those conversations. We know that good nutrition will improve pretty much every health condition, and therefore a clear and co-ordinated dietetic-led strategy on embedding good nutrition into every workstream would be of benefit.
Baroness Armstrong of Hill Top: It does seem to me that there are very key things that folk such as me, who are not experts, understand, for example, the importance of nutrition and diet in diabetes, and there are others.
David mentioned the north-east and Cumbria, which is my bit of the world. Our child poverty has risen very significantly in the last decade. Are dietitians working with other public health people to identify ways in which not just individuals can be advised, but where there is a much stronger push to change the way we do things so that we are able to support families who have no money more effectively so that down the road they do not get the issues that we know happen because of a very poor diet and very poor understanding of what a good diet will be?
I think particularly of Finland, where they introduced universal free school meals. They realised that so many of their population were getting strokes and heart conditions because of what they ate—because it is pretty cold in Finland in the winter, and they were eating particular things—so they introduced free school meals. Not only that, they then introduced very good nutrition and cooking programmes in all schools.
I have seen one primary school in this country do that, and it had a fantastic outcome. Are dietitians arguing for that, locally and nationally? Are you making sure that the people making decisions at both local and national level are aware of interventions that really make a difference?
Tanya Rumney: Absolutely, and there will be pockets of really good work where that is happening. We have lots of evidence within the Allied Health Profession (AHPs) Strategy for England published in 2022, with lots of good resources where dietitians and other allied health professions are doing this work. However, it is in small pockets, and we need it to be more widespread. That comes with trying to grow the workforce and ensuring that we are in the right place of the system. At the moment, there is an imbalance, with more dietitians working in acute and community care rather than primary care, where we could potentially have the benefits that you are talking about.
Baroness Armstrong of Hill Top: Do the public health people have any feeling about those really big issues?
Julia Weldon: Yes. Child poverty is a direct result of social inequalities, and the way we address good health and well-being in children from the prenatal period right through their lives is to reduce child poverty. A lot of our children who are living in poverty are in families who are working, so it goes right back to what we were saying about the social inequalities.
It is as important that we address the causes of these issues as is supporting families to access healthier foods more cheaply. There are lots of community examples that are happening across the country that I am happy to share with you outside of the committee, but they are not enough on their own. We need to tackle the underlying causes.
David Buck: I have two brief points. First, and it may be worth you following this up, around allied health professionals more broadly, we did some work with Linda Hindle, the deputy allied health professional officer, about AHPs’ roles in tackling health inequalities. There is an interest about allied health professionals as a whole, and there were lots of case studies about what that meant, from the clinical encounter all the way up to that much more strategic role among allied health professionals. The allied health professionals’ community is interested in this, and ready, so it may be worth following up directly with Linda Hindle and see where that goes. Free school meals are very interesting, too. We know that the Mayor of London has pushed for that, and this gets into the role of mayors and devolution, et cetera.
In the North East and North Cumbria ICS, the chief executive advocated around fuel poverty, which you would not have expected five or 10 years ago. It is really powerful that the ICS leaders start to speak up and advocate around these issues, moving beyond just care provision. That maturity, talking about these big issues and using their leverage and their power and their influence, is a positive sign that we are moving in the right direction.
The Chair: The committee would be very pleased to receive any examples that you have mentioned that would speak to this.
Q141 Baroness Barker: What one change should be made through integration to address health inequalities and facilitate health promotion, and who should be accountable for that?
Julia Weldon: Speaking on behalf of directors of public health, who released their manifesto just a few days ago, our one change would be consistent cross-government policy, with all of us being really determined to tackle the underlying causes of ill health. That gives people better opportunity to make the choices to lead healthier, happier, longer lives, and, underpinning that, consistency in resources and funding.
We really do welcome the significant resources that come to local communities for family hubs, housing and combating drugs, but they are short term funds for just up to three years. They often have additional asks in terms of data returns, and they do not give us the local decision-making we need. We need to look together at how to resource the public’s health going forward.
Tanya Rumney: I would add using all the data we have and trying to make sure that we commission services that specifically address health inequalities with long-term funding, while recognising that that takes resources and time.
My final point is about our IT systems. They really are not integrated at all, which can make it very challenging for us to work together effectively. As a clinician, I might have to log into eight systems to review one person, and that is within one organisation. We are not integrated in organisations, let alone within systems.
Baroness Finlay of Llandaff: How do you get people to change their behaviour? This is all about the big picture and external, but in the short term, people have to see an incentive to change.
In managing alcohol misuse, one of the things is the unique teachable moment where they suddenly realise that their alcohol abuse is linked to their problems. I am not quite sure how you are going to get that behaviour change in the population—particularly the deprived population—in order for them to have better health outcome.
Julia Weldon: In giving my evidence, I have set out that too much focus on individual choice often blames the individual who finds those choices harder to make. I know this committee knows and understands that.
There are some really good examples of how we support people, even in those really difficult circumstances, to make decisions that will help improve their health and well-being. Some of the targeted tobacco stop-smoking services are an example; incentives on smoking in pregnancy also help. In every hospital in the Humber and North Yorkshire system, we see that the one teachable moment in treating tobacco addiction is when people are admitted to hospital or come as out-patients as a result of tobacco use. That really makes a difference.
It is using those opportunities but never just expecting, when people are being given information about changing behaviour, that they can do that in the context of some of the difficult circumstances they find themselves in. We have to tackle commercial determinants, we have to tackle social determinants, and we will see people able to make better choices about health and well-being.
David Buck: It is very good that you mentioned accountability because that is the question. That is exactly what I have put down here. It is a difficult question. My one change would be a performance framework for ICSs that really takes into account what drives population health, which is what we have been talking about—the wider socioeconomic determinants, health behaviours and the role of communities themselves.
In this session, we have not talked much about the strength in communities and what we know about how community networks being weaker or less broad directly and indirectly affects people's health, and also, obviously, part of that role of the integrated care system.
We are expecting to see shared outcomes frameworks for ICSs, either from the centre, the ICSs or a combination of the two, and the single change I would like is that outcomes framework having the right balance of metrics in it so that we do not get skewed into understandable focus on waiting times, et cetera, and that there is accountability in the local system.
There is accountability in NHSE, so this requires NHSE to walk the walk of integrated care systems and its four key principles to actually get that written into shared accountability frameworks. Let us be honest, accountability is very complicated. We have electoral accountability, quite rightly, in local government; we have central accountability to NHSE all the way up to DHSC, et cetera. We have very complex accountabilities. We need a clear outcomes framework that draws that together and makes clear that some of these things can only be delivered by one sector. However, most of the things we have been talking about have to be delivered jointly, and therefore people are jointly accountable for the money, outcomes, reporting, data, and transparency to all the individual bits of accountability. That alignment is critical if we are going to sustain this push over time and embed it within integrated care systems.
The Chair: My accountability is to keep this committee to time, and that is what I must do. Reluctantly, I bring this session to a close. Your evidence has been both interesting and interestingly put. I am very glad that at least two of you are optimistic because optimism is what we need in the committee.
There will be a transcript of your evidence, which you will be able to correct for any errors. If there is anything else that you feel you have not had the opportunity to say or would like the committee to know, please feel free to get in touch with us. In the meantime, I thank you very much on behalf of my fellow members for your evidence this afternoon.
