Co–production addressing health inequalities
Inequalities in health outcomes and health literacy are not often discussed in the context of co–production for long–term conditions. Long–term conditions fall more heavily on the poorest in society: compared to social class I, people in social class V have 60 per cent higher prevalence of long–term conditions and 60 per cent higher severity of conditions. This tallies with the Marmot review which reported that the poorest people die on average seven years earlier, but more importantly, they have on average 17 years of disabled living before they die.
Social determinants, such as poverty and educational failure are responsible for these poor outcomes but the common intermediary is health literacy which has been defined as the ability to make sound health decisions in the context of everyday life – at home, in the community, at the workplace, in the healthcare system, the market place and the political arena. It is a critical empowerment strategy to increase people’s control over their health, their ability to seek out information and their ability to take responsibility.
A variety of studies quoted in the above document have identified that people with low health literacy:
• Are more likely to use emergency services.
• Are more likely to be hospitalised.
• Are less likely to take medication correctly.
• Are less likely to use preventive services.
• Incur higher healthcare costs.
This is an enormous challenge which one study has estimated costs the American economy $73 billion per year. At present we are tinkering at the edges with a lot of rhetoric about transforming health professionals from the default position of viewing patients with long–term conditions as passive and incompetent, to viewing them as active and engaged citizens willing, with support, to take responsibility for their own health. This shift will only be achieved if we move from our current model, where expert health professionals are responsible for health production influenced from the outside by consumer voice and choice, to a model where co–productive engagement between health professionals and health consumers at the point of service delivery becomes the norm. This will mean taking a serious look at current drivers for workforce behaviour and at how we incentivise different ways of working.
Current drivers for workforce behaviour include the following:
• Managerial and time–based approaches looking at productivity and flow through systems e.g. four–hour waiting times.
• Competency based around expert knowledge and hard skills with high value placed on specialist expertise. This has tended to result in a complex hierarchical system with a multiplication of niche roles and responsibilities.
• Reward systems such as QOF and Clinical Excellence Awards which tend to reinforce patterns of behaviour around hard evidence and expert knowledge.
• NICE Guidelines and current professional competence to practice systems which again reinforce expert knowledge at the expense of soft skills
All of these mean that moving from an expert–based system to a co–productive system will be challenging but places to start this change could include the following:
• Professional appraisal and re–validation systems need to pay more attention to the ability of healthcare professionals to engage with and activate patients, particularly those who have low levels of health literacy. This should include service user in–put, video consultations and post consultation questionnaires about whether or not patients feel more confident about managing their own condition.
• Roll out of care planning training for front-line health and social care professionals, using the model developed by the Year of Care Partnership, which is about experiential training and continuing facilitation and support to develop workplace systems that reinforce and embed professional behaviour change9. The RCGP should ensure that care planning training is part of professional registration and accreditation as a general practitioner.
• Focus on ways of supporting and facilitating better connections between general practices in disadvantaged areas and their communities so that they can better
understand the social context of their patients’ lives and identify and help to develop local community assets. The Links Project, with practices in disadvantaged areas, is one such example.
• Work more closely with and learn from the voluntary and community sector in order to better understand the needs of patients, what the sector has to offer and how to build trust and relationships with disadvantaged groups.
• Develop effective systems which provide information about non–traditional services provided by the voluntary and community sector. ALISS developed by NHS Scotland which is an open–source system with curators has enormous potential.
• Further develop the role of local people and people with long–term conditions as peer support workers, health champions, link workers, navigators and health trainers at local and neighbourhood level. This needs to build on local assets by developing what is working locally.
• Ensure that national and local system leaders such as the Commissioning Board and Health and Well–being Boards support this approach.
Professor Chris Drinkwater, Chair Newcastle West CCG