On November 2nd I attended a meeting of LINk members to discuss Gloucestershire’s consultation on strategies for health and wellbeing, which they (the Council and NHS Gloucestershire) are calling Fit for the Future. The meeting was addressed by Cllr. Mark Hawthorne, Leader of Gloucestershire County Council and Chair of its Shadow Health and Wellbeing Board. About two dozen LINk members attended.
The twenty-year strategy is called Fit for the Future and the five-year strategy is called Your Health, Your Care. The consultation has two parts, a public health part called Let’s Talk Health, and an NHS and social care part called Let’s Talk Care, Support and Services.
Cllr. Hawthorne spoke fluently about the strategies, describing what has been nicknamed “The Graph of Doom”, which shows the rising costs of social care absorbing 70–80% of the Council’s budget in ten years’ time if things are allowed to go on as they are:
“If we continue as we are, we will simply go bust.”
The strategy documents don’t actually contain the graph of doom, but they do contain this graph showing NHS Gloucestershire being unable to meet its financial commitments this year, with little improvement in the next four years:
This is what Darrell Huff, in How to Lie with Statistics, called a “gee-whiz graph”. As he put it:
“…suppose you wish to win an argument, shock a reader, move him into action, sell him something. For that, this chart lacks schmaltz. Chop off the bottom.”
The chart, with its bottom chopped off, exaggerates both the shortfall and the year-on-year rise by a factor of about 4. Here’s the same chart with its bottom restored, so you can see things in their correct proportion:
Now, if the published draft strategy contains a deliberately misleading graph, what about the “Graph of Doom” itself? Is it possible that it is equally misleading? Blogger Mr Reasonable has taken Barnet Council’s “graph of doom” to pieces, identifying the faulty assumptions behind it and correcting them. The resulting picture is quite different.
I don’t know whether Gloucestershire really has its own “graph of doom” or whether it’s just that the Barnet one has been circulating. Either way, it seems possible that some faulty assumptions might underlie Gloucestershire’s strategy too.
The presentation, like the consultation, was in two parts, and it was full of persuasive statements. For example, in the public health part:
“Prevention is cheaper than cure. It’s better than cure. It’s a better way of doing things…”
“…the earlier you are able to intervene, the more likely you are to get a better outcome.”
An example from the care services part was:
“The answer is better integration of health and social care delivering better outcomes for individuals.”
His only stumble was over the too-clever-by-half slogan:
“Adding life to years, not years to life.”
Or perhaps it should be:
“Adding years to life, not life to years.”
He couldn’t work out which way round it should be, and I can’t either.
There were quite a few questions from the audience, and I’ll only report a selection of them.
Someone who had been a carer for 26 years asked why carers don’t get a mention in the strategies. Actually, they are mentioned, but Cllr. Hawthorne didn’t admit to knowing this. He gave a good but rather too general reply that is summed up by his statement that:
“We all recognize the vitally important role that carers play.”
The trouble with this reply is that it doesn’t reflect what the strategies actually say. Carers are mentioned as an afterthought in many places, although there’s a more extended section on elderly carers who need support themselves. My overall impression is that the strategies don’t properly recognize carers’ vital role.
Someone asked about whether a psychological approach to changing peoples behaviour had been considered, to make people adopt healthier lifestyles. The reply was that most people do respond to messages about healthy lifestyles, and only a problem minority don’t. As an example, the 5 a day campaign was cited:
“The majority of kids get it…everyone’s heard of the 5 a day.”
The trouble with this reply is that it ignores the unintended consequences of the campaign, such as those revealed by Channel 4’s Dispatches investigation earlier this year. It also ignores the weakness of any evidence for actual improvement in health outcomes, such as is described in this summary by the BMJ Evidence Centre.
Someone asked about the costs of misdiagnosis by GPs, giving HIV as an example of a condition that is widely misdiagnosed. The reply was that Clinical Commissioning Gloucestershire (CCG), when it replaces NHS Gloucestershire in April 2013, will need to get rid of inconsistencies between GPs.
The trouble with this reply is that while NHS Gloucestershire commissions primary care from GPs at present, that function will not transfer to CCG in April. Instead, it will be the NHS Commissioning Board that commissions primary care, even though CCG will have something to do with the overall care pathway for HIV locally.
Significantly, the replies to questions at this meeting didn’t tend to relate well to the strategy. For example, HIV is a long-term condition, and the strategic solution for long term conditions is that people who suffer from them should take more responsibility themselves. That just doesn’t make any sense as a solution to the problem of misdiagnosis.
In my opinion, this kind of mismatch between strategic theory and real-world solutions is pervasive. Cllr. Hawthorne’s replies to the questions in this meeting showed that the strategies don’t provide a realistic framework for solving the problems that LINk members are concerned about. My recollection is that in the question-and-answer part of the meeting not one of his replies was explicitly based on the strategies.
The meeting concluded with a group exercise. The task was to allocate resources, represented by tiddlywinks, to four fictitious people with various health and care needs. (We didn’t have real tiddlywinks, because apparently they’d been nicked, but that was the idea.)
We got four black tiddlywinks representing public services, five red ones representing community support, and seven green ones representing individual responsibility. There seemed to be no particular reason for the numbers 4, 5 and 7. Also, taking the four fictitious people together, more than 16 needs were identified. It would be impossible to allocate tiddlywinks to them all.
I pointed out that in reality everything that’s not taken care of by public services or community support becomes an individual responsibility. Individual responsibility always expands to fill any gap. This suggestion didn’t go down well.
Then I pointed out that as there are four people and four black public services tiddlywinks, each person has to get one of the black tiddlywinks. The alternative is that one or more of the four people loses their entitlement to NHS care. This suggestion didn’t go down well either. The rules were hastily changed so that NHS care was no longer part of the exercise — everybody gets that by right anyway.
When someone said that the woman with depression required public services to support her, I pointed out that treatment for depression is part of standard NHS care that everyone is entitled to. This suggestion didn’t go down well. The feeling was that support in pregnancy and treatment for high cholesterol were legitimate NHS concerns in a way that depression is not. Should I have screamed “Mental health stigma!” at that point? Maybe.
At some stage, thinking of the chap who’d been a carer for 26 years, I pointed out that family support was completely missing from the exercise. There were no tiddlywinks at all for that. This suggestion didn’t go down well.
Finally, in a discussion about the man who worked for a large company, had high cholesterol and didn’t exercise enough, I pointed out that large company’s occupational health department would probably provide him with some support. This went down well!
This kind of exercise, designed and facilitated by people with a vested interest in the outcome, mostly captures the suggestions that the powers-that-be want to hear. Anything else doesn’t go down well. I realized afterwards that the mind-set behind this is that local government thinks it controls all the tiddlywinks.
Local government controls public services, obviously. Local government controls community support because it funds the charities and other local groups that provide community support. Local government thinks it controls individual responsibility through campaigns like 5-a-day. That’s why there’s a limited number of individual responsibility tiddlywinks. The local government mind-set is that where individual responsibility isn’t the result of one of their campaigns it’s not worth considering.
And local government sees families and carers as obstacles. They aren’t under local government control, so they don’t really count for anything. They get in the way by acting as advocates for their loved ones, demanding effective treatment and services. Strategically, the plan is for them to be sidelined.
It was altogether a very revealing meeting.