Wednesday, 3 October 2018

Response to Social Prescribing blog by Anya de longh

Community assets?
Great blog Anya! I'm reassured that person-centred care is becoming mainstream and more than a 'policy' word, but I think 'prescribing' carries baggage that makes it a double-edged sword. Firstly, why is social prescribing to join a gym or do gardening likely to work (for people who don't 'normally' do these things) - partly because of the sense of authority of the doctor giving this advice, in a directive way?
Secondly prescribing (and access to resources-whether drugs or gym) is tied up with evidence - the idea that the doctor has the expertise to weigh up the technical evidence and guide your shared decision-making process. Whilst some people might argue that we can 'test' the effectiveness of going to the gym in the same way as a drug (randomised controlled trial) I believe this is the wrong way of looking at 'social interventions' and that a social prescription will never achieve an equal weight of quantitative evidence base as a pharmaceutical prescription. This immediately puts the social on a sloping playing field of evidence (for the doctor practicing 'evidence-based medicine').
An alternative approach, as Michael Marmot might advocate, is as follows: we know people who live in disadvantaged communities have poorer access to greenspace, opportunities to exercise, and hence higher chance of poorer health. The preventative approach (proportionate universalism) would argue for investment in communities - parks, gardens, gyms etc (as chosen and designed by the local community). Social norms, clubs, park runs etc, then encourage people to make use of these resources.
So, I think social prescribing is good - as far as it goes - but a real preventative approach would invest in communities and community assets, rather than the continual focus on the individual.

Tuesday, 29 March 2016

Complaint to BBC about lack of impartiality in reporting AoMRC statement on junior doctors strike

I just complained to BBC about poor reporting of a simple statement by AoMRC - there's no excuse for this.

Your Complaint

First half of UK Postcode
Type of complaint
BBC News (TV, Radio and website)
Which news service is it about
BBC News website
Complaint category
Contacted us before
Complaint title
Failure to report with impartiality Royal Colleges
Complaint description
The headline "A&E strike should be suspended, say medical leaders" is one sided and lacks impartiality, in breach of BBC Guideline: "News in whatever form must be treated with due impartiality, giving due weight to events, opinion and main strands of argument." The Academy of Medical Royal Colleges statement starts with the sentence: "This is a time of unprecedented crisis for the NHS." This indicates an initial accusation of failure of health policy-makers. The third sentence starts with a call on both sides. The second clause mentions suspending imposition. Therefore an unbiased reporter would include both sides in the headline, or even emphasise the need for politicians to take action. The BBC news article fails in 3 ways; 1) the headline mentions only suspension of the strike, 2) the picture is of a clinician, 3) The headline & subheading both refer to action by medical profession, whereas politicians are only mentioned in ordinary text. In these three ways a bias is created which fails to reflect with impartiality the statement of AoMRC, thus misleading the public. No doubt the reporter's defence will be that the story is about patient care and hence the strike action is a priority. This view does not take account for the future deterioration of patient care following imposition of contract, and therefore still fails at impartiality.

Tuesday, 22 September 2015

Seminar discussing First Contact Schemes & community assets

I wrote the following for our health & social care research website. For my blog, I'd like to make a couple of additional points:

Community Assets - really interesting how this plays out. I guess big question is how local agenda is shaped or dominated by larger third sector organisations.

Who should be targeted? Care Act 3 categories defined by Prevent, Reduce, Delay - nice model. But does this gloss over complexity. i.e. for 'single' LTC this may be appropriate, for multi-morbidity, or disability, it may be that a health or social need becomes acute that is not (directly) connected to the main LTC/disability - i.e. just because someone is in receipt of 'reduce' services doesn't mean that they don't also need 'delay' services, but this need might be missed if the person is categorised as a 'reduce' or 'prevent' category - I guess concern is that ppl are being put in boxes. rather than person-centred or comprehensive.

Re-blogged from 'Frail Older People Knowledge Hub'

I attended this seminar on 30th June 2014 organised by Age Action Alliance (AAA) and Elderly Accommodation Council (EAC), hosted by AgeUK in London. It was great to meet with a range of stakeholders including representatives of First Contact schemes across England.
The meeting followed publication of a second edition of a report into progress of First Contact Schemes, by AAA & EAC. First Contact schemes were described as ‘practical ways to ensure older people can lead healthy independent lives’. These often include multi-agency referral (or signposting) pathways, coordinated by a ‘single point of contact’.
Michael Rodden (EAC) and Simon Wilkinson (AAA Department for Work & Pensions) jointly chaired the meeting and did a great job of introducing people and facilitating group discussions – with lots of flipchart capturing of discussion (see pics on twitter!)
During the seminar we discussed the role of the various schemes; differences and similarities. In particular issues such as partnerships involved, evaluation and funding. Many programmes hoped to be part of Better Care Programmes (led by Health and Wellbeing Boards). See flipchart schematic of Dorset SAIL
Coming from a health research perspective, it was great to hear more from the local government perspective. It was fascinating to discuss how these schemes may help to meet the aims and ambitions of the new Care Act. This places a new duty of improving wellbeing within all local government policy and activity. Helping people to stay healthy and independent is discussed within the consultation document (currently open for responses) as:
  • Prevention
  • Reduction of need
  • Delay of need
Groups discussed how various aspects of First Contact schemes could contribute to these 3 approaches.
Of particular interest for our research in CLAHRC-EM was discussion of standardised assessment of needs. This was seen as a benefit to demonstrate reach of programmes, but also was a challenge to deliver within a multi-agency collaboration. Challenges included both strategic agreement and operational delivery (completion rates). Although sharing data was acknowledged, particularly by Evan Morris (Chief Fire Officers’ Association) this was not discussed in terms of commissioning or Joint Strategic Needs Assessments (or Wellbeing Strategies). There was also interest in developing wellbeing indicators, which may be brief but pragmatic, especially for audit purposes.

On the way home I was pondering three questions:

Could data sharing bring more benefit than risk? Does the benefit of reaching people who may otherwise slip through the net, or the benefit of avoiding duplication, outweigh the privacy and security risks of data sharing. This is particularly salient in the context of the (#caredata) debate.
How to demonstrate added value? If much of referral is about one agency increasing their reach to people who happen to be in contact with another agency – can we demonstrate increased referral rate, increased reach – and hence helping agencies to meet their mission aims? Maybe these are sufficient outputs of First Contact, rather the ambitious aims of showing health or social outcomes for individuals?
How do First Contact schemes relate and interact with Integrated Care programmes, locally? This was briefly mentioned, but it would be interesting to explore how First Contact may identify people with needs that are not identified by risk stratification tools, for example.

See some of the debate from the day by searching on twitter for @ageactalliance @age_uk @endloneliness

A week after the seminar, it was great to see Sue Warr from Dorset SAIL programme featured on the BBC national news!

Support for older people in the community: Part 2 Assessments, signposting and outcomes

In part 1 I described some of the broader or policy changes which will impact how health and social care sector interacts with and funds the voluntary and community sector. The following is a brief overview of some of the ‘mechanisms’ which may have a new role in this ‘new world’.


Preparations for the Care Act has stimulated a lot of activity around assessments – whether these are carer’s assessments or assessing people’s needs for social care before they are eligible. There are assessments for personal budgets and joint health and social care assessments which will be important for integrated care. We have been studying assessments for ‘low level’ needs; which may be addressed by voluntary or community services. There is widespread use of checklists such as ‘First Contact’ which offer a brief assessment to highlight where a range of organisations could help, including housing and fire safety. There are benefits in assessing people’s comprehensive needs, across health, social inclusion, housing etc. This approach may highlight an issue and enable access to other forms of support, which may not have been considered previously. It could also be an opportunity for outreach to isolated individuals. A key issue is how various assessment relate or overlap with each other and also whether core information from such assessments can be shared, with consent, with other services. Collating information could build up a picture of needs within neighbourhoods.


Some people may find it difficult to know who to turn to for help. It can seem that there are a confusing number of similar services. If community and voluntary services can work together this may help to meet older people’s personal needs in ways that are appropriate to their preferences and culture. There are a range of approaches here, which may work in different settings, and they may all benefit from sharing information from needs assessments. Within ‘signposting’ I would include; social prescribing, care navigators, single point of access and home from hospital.


Increasingly, funding is dependent on showing outcomes for individuals who have accessed services. This can be referred to as ‘outcomes-based commissioning’ and it is also an important aspect of personal budgets. Outcomes should relate to the actual health or social benefit that an individual experiences, this contrasts with ‘process’ or ‘output’ measures which might be number of people attending an event. Outcomes may be specified by the commissioner (funder) and there is also a whole series of national outcome indicators. Just to be confusing there are separate indicators for health (NHS Outcomes Framework), public health (Public Health Outcomes Framework) and social care (Adult Social Care Outcomes Framework).
The idea is that commissioners (NHS Clinical Commissioning Group or Local Authority) specify the outcomes they expect and the community and voluntary sector organisation writes a programme bid to explain how they will deliver services to enable people to achieve these outcomes. The hope is that this gives freedom for innovation and flexibility for organisations to design services which will meet the preferences and be culturally appropriate to their community members. There is also an aspect of sharing risk between funder and provider; in theory money isn’t wasted on services that aren’t attended, whereas popular services can receive more funding. Whilst this sounds good on paper, in reality both commissioners and providers may need time to get used to this new way of working. Furthermore some people feel that the policy direction is tending to favour a corporate-style managerialism within the voluntary sector, which may ignore or stifle the very strength of the sector – that is; the voluntary and community sector offers a distinct way of representing the needs of a neighbourhood and outreach to people who, for various reasons, may not access public or private sector services.

These are big issues for older people and organisations who offer support. Within our research study, we hope to explore some of these issues, and to feedback to organisations across East Midlands to enable better communication between the voluntary sector and the health and social sector. We welcome any views or input. Please tweet @nchadborn

Support for older people in the community: Part 1 Care Act

For my research at CLAHRC-EM, we’re in the middle of analysing our survey of health and social care commissioners across East Midlands (UK). We asked them about community services to help older people maintain their wellbeing and independence. In particular we’re interested in how services are funded and whether services are provided by voluntary, private organisations or social enterprises.

Screen grab from My Maps, Google
I presented an update to East Midlands Later Life Forum a short while ago and then read an article where Campaign to End Loneliness highlighted need for ‘range of support’ for older people in the community. This prompted me to summarise a few thoughts on these areas:

Care Act

The postponement of the cap on care costs has meant that much of the Care Act is not being implemented. I’d like to find out from local authorities which aspects are being implemented (answers on a postcard please…?) but I’m sure the broader agenda of addressing wellbeing will still be followed. There were questions as to whether the work on carer’s assessment and support will still be implemented?

Changing context

Alongside the Care Act, there are many other changes affecting community and voluntary sector services. There are concerns from all sectors that austerity and ‘efficiency’ measures are threatening what services and support is available to older people in the community. On top of this there is an awareness of needs of greater numbers of older people with dementia and other long-term conditions. I heard from older people’s forums that, whilst these groups are important to highlight local needs and to inform councils about prioritising their services, they are reaching a critical point of lack of funding. Similarly, several local Community and Voluntary Services (CVS) which provide infrastructure support, are also having to restructure in the face of lack of funding.

Resilience, community assets and wellbeing

There is much talk of ‘resilience’ and this word can be used in many different ways. It can be used to describe an aspect of mental wellbeing of an individual but it is also used to describe a community more generally. A recent publication from The Health Foundation gives a good introduction to these various interlinked topics. It also touches on one criticism of this approach, that is may be used as a cover for a neo-liberal agenda of individualisation and privatisation. When working to improve local services, we should consider whether this may gradually erode the strengths within communities and the impacts on inequality (health and social inequalities). For example, a service that responds to the demand of an individual, may lead to withdrawal of funding from forums which are designed to represent the broader needs of the community?
If you have any thoughts - please comment below or tweet including: @nchadborn

In part 2 I will discuss some of the mechanisms of support in the community; Assessments, signposting and outcomes.

Monday, 15 September 2014

Sustainable Chemistry - reflecting on ambitions for #healthandclimate

Of course, it was on twitter that I first heard that the Sustainable Chemistry building was burning down. Late Friday night (12th Sept 2014), I watched the live webcam set on the building next door, where we've often had meetings, and was filled with surreal shock to see the whole building site engulfed in flames. I had watched construction progress everyday, cycling to work at Institute of Mental Health on Jubilee campus, University of Nottingham.

As this disaster has made national news, I thought it might be an opportunity to reflect on what I felt the building project was trying to achieve (from a partially independent viewpoint!).  In doing so, I will try to link the corporate idea of sustainability and health with the community approaches which I've been involved with in the Transition Towns movement and others.

I have to admit, when I first saw the hoardings go up, proclaiming a carbon neutral medicinal chemistry research building, I was skeptical. I have conflicted views on this - my PhD was studying biochemistry, sponsored by biotech company, yet more recently I've become committed to the idea that communities can do much to improve their health. Furthermore that a community-based approach can bring added social benefits and avoid the environmental detrimental impact that seems inherent with the pharmaceutical industry.

However despite my assumptions I was sold on the idea of sustainable chemisty, following a talk by the man who has been the driving force behind the development of the GSK sponsored wooden building.
Prof Pete Licence told us about the work that they had been doing in improving efficiency of catalysis in the reactions involved in creating pharmaceutical compounds. Through carefully adjusting conditions such as high pressure and uv light, the energy required for reactions within chemical processes can be significantly reduced (I don't remember the details - please don't quote me on this!). This is good news in terms of the 'carbon-footprint' of drugs in the future, potentially reducing the carbon-footprint of our healthcare.

Secondly Pete presented research on using non-conventional feedstocks for creating pharmaceutical compounds. Traditionally the large majority of 'ingredients' in chemical production are based on oil and gas, meaning that our pharma is inextricably linked to the 'fossil fuel' industry, with inherent implications for climate change and peak oil. Within transition towns movement we have discussed the potential of using plant-based compounds for the starting materials for drug production, but I had not realised that 'serious' academics and pharma companies were working on this - so this was great news.

Thirdly the point of Pete's talk was that all this work was going to continue in a carbon-neutral building. This was being built out of sustainable forestry (European I think), and would include the latest technology in insulation, laboratory design, even including solar panels and green roofing. The aim was for carbon-neutrality in 5years, followed by carbon embedding - it was hugely ambitious and expensive. Pete commented that the cost was way above 'normal' and was only possible with the generous and deep commitment of Sir Andrew Witty, the chancellor of the university and also (non-coincidentally!) chief exec of GlaxoSmithKline pharmaceutical giant.
So great ambition for sustainability and health - all good?

While I do support the above ambitions I do have critiques or concerns on each point. My over-arching concern is the creeping medicalisation and industrialisation/corporatisation of health and healthcare. The concern is that the marketing-corporate side of pharma means that people are viewed as customers to whom healthcare is sold, therefore care becomes treatment-focused rather than centred on a person's individual needs (patient-centred). My preferred approach is for community-based prevention and health improvement, i.e. let's invest in how communities can support people to be fit and healthy, rather than prioritising investment in drugs and treatments (of course we need both). Thus the criticism of the first point, is that investment in efficiency of processes may lead to increased production (more people consuming more pharma products) and increased profits, with little reduction in environmental impacts.

The second point that I mentioned from Prof Pete's talk was the most significant - the use of plant-based feedstocks. The main concern with this approach is that, similar to biofuel, in time it could pose similar threats to global food production as biofuel. That is, farmers may convert from food production to 'drugs' production due to it's higher returns. The potential impact on prices and availability of food would exacerbate inequality and malnutrition, having knock-on effects on global health. Thus, if organisations and institutions with interests in global health focused on nutrition and 'low tech' approaches to health, healthcare and prevention, this could be  many times more 'sustainable' (equitable) than advances in 'green-pharma'. At the heart of concerns is the question of whether we can 'trust' pharma corporates to place people and planet first, and profits second. Or whenever we buy into the corporate agenda, we inevitably exacerbate global inequality. This goes back to discussions within Transition Towns and also relates to the new Naomi Klein book (recent review in Guardian)
 - can we achieve the necessary reduction in carbon footprint, and essential improvements in global health and inequality within the current corporate framework, or do these goals inherently run against the grain, thus we should call for a 'new system'. In health terms, this isn't as radical as it sounds, just going back to WHO Alma Ata declaration of Health for All, through primary care and community health.

Thirdly - can chemistry/pharma industry and research ever be 'sustainable' - is this a realistic or useful goal, considering the likely cost and risk (including the fire - which is part of the risk of building with wood). Or could this investment be better placed elsewhere? I don't think I'm giving 'chemists' an excuse to ignore carbon footprint, but would it be just as good to have solar panels on the building next door - or for example the Trent or Portland Buildings? I should note that University of Nottingham has already won awards for the energy efficiency of it's campus.

Maybe sustainable chemistry was aiming to take it a step too far - in terms of cost (including risk) v benefit (including 'leadership')?