1. Question 1: What does your organisation want to see included in the 10-Year Health Plan and why?
1.1. As there is now a clear understanding of the wider determinants of health and the impact that this has on the NHS, it should be reflected in the 10-Year Health Plan. These include social determinants such as housing, education, economic status through to physical access issues such as residents not being able to register at a doctor due to living circumstances, or not being able to find an NHS dentist within travelling distance.
1.2. In the 10 year health plan, we would like to see the fundamental issues of funding and workforce addressed. Without funding to the NHS and local authorities, services cannot run effectively and we would be putting our residents at a disadvantage.
1.3. We are seeing worsening access to NHS doctors and dentists. People are having to travel further and wait longer for appointments. For some this is a complete barrier as they are unable to travel due to health or economic reasons. For others it impedes their health as they wait longer for diagnoses and the support needed.
1.4. Dentistry is often overlooked, but oral health impacts wider health and self-esteem. The longer dental issues go without treatment, the worse they become and the more costly the treatment is. This disproportionately impacts those from disadvantaged backgrounds.
1.5. For Maidstone Borough Council, addressing the wider determinants of health and health inequalities requires true integration between health and social care. For example, the NHS spends almost £4 million per year on treating conditions caused by cold living environments[1]. This could be mitigated by joining up services to change the living environment and improve the health conditions caused by those conditions.
1.6. The link between health and social care has been made multiple times[2]. They form part of a complex, open system and need addressing as such. There is a tendency to discuss health and care as though they work seamlessly together, which is not the case. Services are becoming increasingly fragmented and difficult to navigate.
1.7. There needs to be adequate funding to tackle inequalities through better housing, education, food provision and access to services. There are certain wards in Maidstone that are amongst the most deprived in the country[3]. These are often hidden by more affluent areas of the borough so it is essential that the importance and funding for tackling health inequalities is included in the 10-Year plan.
1.8. Local government is the ideal place for health and social care to be integrated because of expertise of the residents needs and cultural sensitivities[4]. It provides an opportunity, if data is being shared effectively and safely, to tackle problems that exasperate one another, such as: homelessness and mental health, air quality and respiratory illness, living environments and health conditions and associated conditions like education, employment and chronic disease. Neither the NHS or Local Authorities have the power, the funding or the expertise to do this in silo, but working in integration then these issues could be tackled for the benefit of all parties.
1.9. To illustrate, one of the main causes of hospital readmission in West Kent is falls and fractures in the elderly. In Maidstone we have a scheme in place to triage, signpost and support those that need it with living conditions, preventative health measures and sharing knowledge between healthcare and welfare workers. This reduces the number of and severity of falls, and reducing the burden on hospital beds and quality of life. This scheme could be duplicated in other areas of health, such as respiratory illnesses, which may be caused or exasperated by air quality or damp living conditions. This would need better data sharing, access for non-NHS workers to multi-disciplinary teams and integration of services.
1.10. As well as funding, the importance of a ‘Health in all Policies’ approach should be included[5]. ‘Health in all Policies’ is recommended by the World Health Organisation to explicitly takes health into consideration in every policy that is made[6]. It is a form of policy coherence that ensures that decision-makers know how their policies impact health and why that is important[7].
1.11. For councils to successfully implement a ‘Health in all Policies’ scheme, stakeholders should be able to see successful modelling across other areas of government. A successful ‘Health in all Policies’ scheme could have short term wins for health such as residents being successfully signposted from one existing service to another with ease, to long term solutions of physical health conditions improving with different planning regulations around healthy cycle paths and walkways being commissioned.
2. Question 2: What does your organisation see as the biggest challenges and enablers to move more care from hospitals to communities?
Table 2.1. Challengers and enablers to move more care from hospitals to communities
Challenges |
Enablers |
Non-integrated systems and services working in silos |
Publicly funded community care |
Lack of awareness and understanding of different services available |
Investment in GP services and Workforce |
Digital Exclusion |
Health Alliance Partnerships |
NHS Estates |
NHS Estate/Assets |
Overwhelmed Community Services |
Respite Care |
Vulnerable populations |
Data sharing |
2.1. One of the biggest challenges for moving more care from hospitals to communities comes from services working in silos. In a non-integrated system, service users have to access different services by a range of providers. This could lead to breaks in care, health issues being miscommunicated and a lack of clarity between service providers. At best this is a nuisance for a service user, at worst this could be a danger. An example of this is in Maidstone housing services, vulnerable people often do not have knowledge or access to the support that they are entitled to because of siloed working of departments. This leads to further deprivation if they do not access credit entitlements, and live poorer housing conditions that exasperate vulnerabilities and worse quality of life.
2.2. In addition to this, the range of services that are available and needed vary, with expertise in different areas not well mapped and the touchpoints between them are being eroded. Training, expertise mapping, best practice and data sharing would need to be considered to integrate services. Fragmented systems and difficulty of navigating them puts further pressure on users and can lead to lower quality of care. Person and professional led systems have been shown to improve system navigation and standard of care[8]. Systems would need to be designed and in place to ease the administrative burden on service providers and service users.
2.3. Digital exclusion is a pertinent challenge in Maidstone which has a significant and growing older population, as well as vulnerable communities that are affected by digital exclusion[9]. The increased use of technology in the NHS is positive in many ways. However, video appointments or health monitoring technology may not be appropriate for some residents and could lead to them being at a disadvantage when accessing health care in the community[10]. Maidstone scores lower than the national average on physical and personal wellbeing[11], part of this is caused by isolation and inappropriate accommodation for individual needs.
2.4. There is a significant population of vulnerable communities in Maidstone, such as Gypsies and Travellers, incarcerated people and other vulnerable groups that may be hesitant to engage with services, or are unable to engage due to their situations. Some of these will have difficulties with literacy, meaning that the common ways that the NHS communicates services, such as sending letters and leaflets may not be appropriate. In some vulnerable communities, such as those experiencing homelessness, they are not known to council services until they are admitted to hospital.
2.5. Community services are currently overwhelmed, for instance, the type two weight management programme in Maidstone is receiving more referrals than space on programmes allow. If people cannot access the required care at the time they seek it, health issues will persist and their conditions could become chronic and lead to economic inactivity if they are unable to work, or have the need for secondary care, increasing the burden on hospitals.
2.6. To bridge the gap between hospital care and care in the community, the NHS should not ignore the importance of respite care. In Maidstone, the Dorothy Lucy centre is an example of excellent practice that supported those with high level needs in Maidstone. Those that benefitted from the support have said in the past, that the respite care meant that they were able to continue as carers. This eases the pressure on the NHS, however respite care has reduced and the Dorothy Lucy centre closed with the services being split between multiple other centres that were not always appropriate for users. There are other respite care providers, such as Garden of England and Invicta care homes, that could benefit from further funding to continue their valuable and experienced services.
2.7. Another enabler would be well resourced GP services that have the capacity to work with service users. This includes supporting them with health and social prescribing before they enter secondary care, as well as supporting them returning from secondary care settings into the community[12]. In Maidstone, we are privileged to work with Involve Kent who carry out much of the social prescribing. This is a good practice example of collaboration, and with funding and effective data sharing in place could be used as a template to for other collaborations with third sector and charitable organisations. Social prescribing was once lauded as a way to improve the nation’s health, more emphasis, funding and support for providers are needed to make this a success.
2.8. For services to move to the community, there needs to be a workforce in place to provide them. This includes GPs, nurses, midwives and other allied health professionals. There is a concern that the removal of bursaries for those training could impact the already growing number of vacancies in health and social care. Kent is home to two universities that offer courses for health care professionals and have worked hard to widen participation to those that are less likely to go to university. Removal of funding could reverse these steps forward and deter people from the local area to train. Recently Canterbury Christchurch University had accreditation removed for the midwifery course, leaving over 100 students without access to the profession they were training for. This has ramifications for students, the university, the NHS and the local area.
2.9. Even with proper funding in places to train the workforce of the future, there is an immediate problem of the current gaps in the workforce. In the 10 year plan, we would like to see how this will be addressed, whether through plans for more visas, incentives for people to return to the NHS, or plans to quell the exodus of NHS staff to countries that offer more benefits.
2.10. As well as a bigger workforce, to enable this shift there needs to be publicly funding community care to ensure that services have capacity when people need to access them[13]. Effective partnerships and data sharing between services in the NHS, the council and third sector organisations, such as has been seen in successful health alliance partnerships would improve signposting, training opportunities and ‘making every contact count’[14]. This could go even further to take the ‘tell us once’ approach that the NHS and council use for a bereavement, and incorporate it into situations where people disclose health conditions.
2.11. An example of good practice is the involvement of non-NHS employees in the multi-disciplinary team. Maidstone Borough Council used to have a representative on the frailty team in the local NHS trust. This meant that services could work seamlessly together on multiple issues that service users faced. As data protection legislation became more robust, this became more difficult to do. With effective partnerships and integration of health and social care, this could lead to a truly effective form of ‘Making every contact count’.
2.12. Finally, services need space to operate from. All sectors have finite resources and assets, however being able to share these and mobilise the assets of the individual parties would be beneficial to all. The current business case system that the NHS operates is complex and exclusionary. This makes partnership working difficult and timescales for project delivery long.
2.13. A system that would allow mapping and easy use of NHS assets for community health and social care services would mean that there are less costs for service providers and more opportunities for service users to engage with services. For instance, currently the in-person type 2 weight management programme offering only occurs at Maidstone Leisure Centre which is a barrier to people accessing the service. If there is a cost-effective and appropriate place that this service could be provided in other areas, then the service could reach more people.
3. Question 3: What does your organisation see as the biggest challenges and enablers to making better use of technology in health and care?
Table 3.1: Challenges and enablers to better use of technology in health and care
Challenges |
Enablers |
Digital Exclusion in elderly, vulnerable, deprived and rural populations |
Integrated service provision |
Inequality of digital service provision |
Education of service users |
Erosion of patient-provider relationships |
|
3.1. Although the use of technology in the NHS has led to positive outcomes for many service users, this shift has challenges especially for older or vulnerable service users[15]. Digital exclusion rates increase with more vulnerable populations. For instance, Gypsy, Roma and Traveller populations, of which there is a significant population in Maidstone, experience digital exclusion at over double the rate of the general population[16]. They also have worse health outcomes and are more likely to have multi-morbidities.
3.2. Maidstone borough is large and includes both urban and rural areas. Those that are in rural locations may not have the Wi-Fi or network infrastructure to allow for digital services to be deployed. People in these areas also have less access to physical services. Even where the infrastructure is in place, either in developed or rural areas, deprived communities may not have data plans, internet access or devices that digital platforms rely on.
3.3. Although Maidstone has a lower number of households that are digitally excluded overall in comparison to other areas of Kent, some areas are within the top 10% of those likely to be digitally excluded. Maidstone also has lower broadband speeds (mostly in rural areas) than the average of the county[17].
3.4. By making more services only bookable online (such as GP appointments), inequalities could be exasperated. For those that cannot or do not want to access services digitally there should be an alternative that does not shame or exclude people.
3.5. Where technology is deployed, there is a challenge that the service is only available for providers that can afford to invest in it. In areas of poverty, NHS services are already stretched, and those that need it the most lack access[18]. This inequality of service provision and access could then be exasperated by life-changing technology not being available in some areas or by some providers.
3.6. There is a risk that the use and reliance on technology could erode patient-provider relationships and trust[19]. These two elements are integral to successful care. Ways that this trust could be eroded include technology failing, technology not being available when it was meant to be, loss of human contact and fear due to lack of understanding from a patient (or practitioner) perspective. There is also the risk that the reliance on digital services and technology could increase loneliness and isolation, especially in those that are digitally excluded.
3.7. Technology does offer many positive outcomes and a great enabler to this shift would be showing service users what can be achieved by an integrated service[20]. For instance, if primary, secondary, and social care providers were able to access a single system and service users did not have to repeat their situation to multiple providers, this could save time and reduce the likelihood of health issues being missed or miscommunicated.
3.8. Another enabler would be the benefits to service users if they could have education about digital services and be able to have more autonomy over their care, and other areas of their digital life[21]. There is ample evidence that ‘helping people to help themselves’ improves wellbeing, motivation, and confidence[22]. This could take the form of a blended model of digital and human contact, training programmes and support from different service providers in an integrated health system. This could also support other policy areas such as digital and financial literacy and reduce the risk of being victims of fraud.
4. Question 4: What does your organisation see as the biggest challenges and enablers to spotting illnesses earlier and tackling the causes of ill health?
Table 4.1: Challenges and enablers to spotting illnesses earlier and tackling the causes of ill health
Challenges |
Enablers |
Non-integrated health and social care system |
Health in all policies approach |
Ineffective signposting and silo-ed working |
Health alliance partnerships |
Data sharing legislation |
Data sharing Agreements |
Erosion of early years services |
Economy and Health |
Mental Health provision |
|
Special Education Needs provision |
|
4.1. One of the main challenges for tackling the causes of ill health is a non-integrated health and social care system. The social determinants of health and health inequalities are one of the main drivers of ill health and illnesses, yet are controlled by different departments, policies and systems[23]. For instance, air quality is linked to respiratory illnesses and hospital admissions[24]. Air quality is lower in urban areas of deprivation. Maidstone is committed to improving air quality and reducing pollution for residents. If this was connected to a health agenda then it would have an even greater impact.
4.2. A further challenge to spotting illnesses early comes from siloed working and fragmented systems[25]. If services do not communicate effectively, they may not see the whole picture of a service user’s life. If services and systems were integrated, and providers trained, then a holistic picture can be drawn and health issues possibly mitigated or caught at a stage before they become chronic.
4.3. Fragmented systems are also impacted by data protection legislation, and barriers to sharing health data. There are opportunities for Maidstone to work with the Department of Health and Social Care and Kent County Council. These opportunities would be easier to navigate if data could be more easily shared across the services. Trends could be analysed and local expertise could map where and when the illnesses are occurring and identify preventative actions and mitigating services could be put in place.
4.4. At the very least, if a high number of admissions to a respiratory service were coming from areas of privately rented homes of multiple occupation, then an inspector could investigate if there was a mould or ventilation issue. For those living in privately rented accommodation, a growing number in some of Maidstone’s more deprived wards, may not have the knowledge to identify what is causing their ill-health until it reaches the hospitalisation stage. Tenants may also fear of being evicted if they complain about living conditions[26].
4.5. There is the potential for even earlier prevention work. Maidstone Council has experience in this with other services using predictive analytics to identify those at risk of homelessness. Predictive analytics enables the service to take early action to intervene with support and enable residents to stay in their homes. This pre-emptive action reduces the burden on the Council providing high-cost temporary accommodation services and reduces the impact on the resident. If the same approach was applied in health, there is the opportunity to predict who is at risk of certain illnesses and act before those illnesses occur. It could take the form of lifestyle, social, education interventions or a combination that supports the individual to stay healthy.
4.6. A further challenge to early intervention and prevention is the erosion of early years services such as sure start centres and family hubs. These services have been eroded in Maidstone. Those that remain are not equipped to cope with the number of families that need support and may be out of reach for many to access.
4.7. The erosion of support services is mirrored in waiting lists for mental health and special education needs (SEN) support. The situations compound each other, as people feel more isolated, their mental health can worsen, and without specialist support for needs it can put a further pressure on already stretched services.
4.8. Mental health is an epidemic across the country, and Maidstone is not immune. There is a higher rate of mental ill health in Kent than the average for the country, and this is rising. Kent has a higher suicide rate than the national average, although a suicide prevention plan is in place and the rate is reducing slightly.
4.9. Long waiting times and lack of support will deepen the mental health crisis. With the correct support at the earliest available opportunity, we can reduce the burden on the NHS by reducing the amount of people needing hospitalisation due to mental health crises, and support people to live happier, healthier lives.
4.10. Similarly to mental health, if people receive appropriate diagnosis and support for SEN they are able to reach their potential. However, the current waiting lists for assessments, the shortage of medication available and the overwhelmed support services in place, especially in education settings, means that SEN support is often not in place adequately. There is an expected waiting time of seven years for an ADHD assessment, and three years for an Autism assessment[27]. This could exasperate mental and physical health issues and detrimentally impact their life, and the burden on NHS services, in the long term. The earlier that someone with neurodivergence is supported, the higher the likelihood of them living a prosperous and healthy life. Those with neurodivergence are more likely to experience mental ill health due to many factors, including lack of understanding and lack of support[28].
4.11. An enabler to this shift would be a ‘Health in all Policies’ approach to ensure that policies were not incoherent between departments[29]. Going further than policy coherence, an enabler would be for health alliance partnerships and integrated systems to support the local community by sharing information and signposting effectively[30]. For this approach to work then more coherence and sharing of funding between the different levels of authorities (local, county, national and health bodies) would be needed.
4.12. In some areas, Maidstone is already taking a ‘Health in all Policies’ approach. An example of good practice is Maidstone museum, before COVID19 they partnered with the Council to improve the visiting conditions of the museum for residents with special educational needs. Actions included offering headphones, activity packs and quiet spaces. They also provided community activities and keep warm hubs that supported a holistic view on wellbeing as well as increased their footfall in the museum. This example shows that ‘Health in all Policies’ can be implemented at many different levels successfully. Maidstone museum is now a highly sought out space for families and those with special educational needs. Some community groups that started in the space have now expanded and become Community Interest Companies.
4.13. Preventative health and wellbeing measures have a positive economic impact[31]. Those that are healthier are economically active for longer. Almost 25% of people in Maidstone are economically inactive, this is higher than the average for the Southeast and England[32]. Sickness and chronic disease plays a large role in economic activity, as well as people caring for those that sick. In addition to this, as seen by the museum example above, wellbeing initiative increase footfall to local businesses. If there are more funding and incentives to offer support in the community, it increases the value and economy for local businesses.
4.14. These enablers are all part of a holistic approach to health and wellbeing for both the system and the individual. Local partnerships between NHS, the local authority, and other stakeholders are best placed to meet the needs of the local population, and can work across employment, education, health and social service provision to support good health and wellbeing. Together we can tackle ill-health with the service user as an active participant.
5. Question 5: Please use this box to share specific policy ideas for change. Please include how you would prioritise these and what timeframe you would expect to see this delivered in, for example:
5.1. A short-term policy for change is to support and incentivise health alliance partnerships, by making them attractive to participate in. This could be in the form of relief, accreditation, training opportunities or access to funding for those that are part of one. This could be delivered within the next year and could immediately improve users accessing different services and support a joined-up system, as has been shown in areas with successful health alliance partnerships in place[33].
5.2. Health alliance partnerships, as outlined elsewhere, include working with stakeholders interests to achieve a common goal. In a successful alliance in Southeast Essex, the partnership between police, the NHS and the council aims to address the wider determinants of health by jointly deciding what initiatives should be funded, so that all parties are invested in their success[34].
5.3. Introducing ‘Health in all Policies’ as a mandate would be a mid to longer term policy change, however once implemented it could have wide reaching outcomes in all areas of housing, environment, education, health and justice. By making it a requirement of policy development, it could ensure that it is prioritised and considered at all levels, without falling of the agenda or losing momentum if a key driver of the approach is removed.
5.4. In some areas, Maidstone council already considers health in all policies. The work of the housing team to support residents to get access to white goods, cooking utensils, carpets and amenities means that they can operate basic self-care. Maidstone operates community larders to help people access food and be signposted to other services. However, this could be taken further to embed health in all policies from the beginning of any policy decision. It would make sure that there is a set of questions that are being asked at the beginning of strategic and planning services. This can only be fully embodied if it is initiated and mandated to all council services.
5.5. There is a clear link between educational outcomes, social inequalities, and ill-health[35]. The causes are multi-factorial supporting young people at a pivotal time that can set health behaviours that maintain well into adulthood would improve health and social outcomes in future generations. To maximise on this opportunity, there should be fairer education for all to improve their life opportunities, and increase health and social education in the curriculum to improve specific health related knowledge.
5.6. The evidence for interventions in early years and education is clear, however the reduction in services such as Sure Start means that there is a lottery on the services for young families. Over 15% of Maidstone’s children are living in poverty, which is over 4000 children[36], this figure is rising each year and each year support services and centres are closing. Those that are still in operation are not reachable by all those that would benefit from them. This can exasperate isolation and loneliness, especially amongst mothers. The leading cause of death in mothers in the first year of their child’s life is suicide[37]. The link between support services, mental health and wellbeing cannot be overstated, and needs to have due seriousness attached to it.
5.7. Attention and respect for early years is paramount to reducing health inequalities for future generations. By providing extra funding to family hubs and support services, an integrated system could also support the health and welfare of mothers and families. This would also improve loneliness, isolation, and lead to improvements in economic activity, literacy and social welfare.
[8] Effectiveness of system navigation programs linking primary care with community-based health and social services: a systematic review | BMC Health Services Research | Full Text
[26] https://england.shelter.org.uk/media/press_release/private_renters_who_complain_about_disrepair_more_than_twice_as_likely_to_be_slapped_with_an_eviction_notice
[27] https://www.kentcht.nhs.uk/service/asd-adhd/
[31] https://institute.global/insights/economic-prosperity/the-macroeconomic-case-for-investing-in-preventative-health-care-UK
[34] https://www.local.gov.uk/case-studies/creating-robust-health-inequity-strategy-south-east-essex-evidence-based-scoring-tool