The urgency of the vulnerability challenge

18 December 2020

This edition of Innovate has been written in the time of COVID-19, when people have suffered physical, mental and social health consequences, or been left behind, by the changes imposed centrally to deliver two aims: stop the NHS being overwhelmed and save lives. COVID-19 and the changes made to deliver these aims are the insult which has framed this thinking but the people affected are vulnerable to many local or national insults and the learning is not specific to a viral pandemic.

These are the people who mostly were not shielded, who don’t have multiple physical co-morbidities and who aren’t particularly at risk should they catch the virus.

However, they might have been the people who have not been saved, or the lives that have seen significant morbidity as a consequence of re-prioritisation of funding, or human resources; the furloughing of charity workers, or the re-deployment of mental health or domiciliary workers, or even the closing of schools.

The mortality and morbidity is real and the numbers will presumably emerge one day – the increase in suicide in all ages, the increase in child and domestic abuse, the increase in homelessness and street sleeping, offset by specific initiatives. 

Our imperfect picture

Some of these effects are hard to count. Will we be able to see the upturn in people admitted to residential care as a consequence of carer fatigue and burn out because carer respite was unavailable? Will we be able to measure the effect of unaddressed anxiety and depression in young people whose scaffolding, from school or charity, was removed?

Will there be an appetite to look for outcomes from economic impact within a family, or within a community, when many people believe they understand the effects intuitively, or energy needs to be devoted to new challenges and catch up?

Against this mass of unmet need that may swamp services at an unspecified time in the future, there have been pockets of success where people have continued to be supported despite the national challenge.

Successful recipes need ingredients not models

It is worth understanding why these initiatives have worked in the face of the national challenge, and what the similarities and differences between them are – not to lift a model lock-stock into another place and impose it, but to determine key ingredients and help locations or communities with similar ambition to understand what might work for them. 

Our first case study presented in detail is the social prescribing community response that now is 1 Northern Devon. This project started as 1 Ilfracombe in 2014, was well thought of locally and this enabled neighbouring geographies to value the initiative and attract funding to extend the geographical coverage. In the context of COVID-19, relationships between providers and the people of North Devon were already strong and already trusted.

The challenge of keeping something effective going is different to setting something up from scratch, and a well-run programme was able to take advantage of the upswelling in national civic responsibility, manifest in part through the NHS Good Sam response. 1 Ilfracombe is structured around six community providers focussing work under three related but discrete headings with health, as shown through successive Marmot reviews, recognised as only one aspect that helps people to thrive. More co-ordinating time was supplied within the 1 Northern Devon project to maximise ability to meet an upturn in need.

Sense and definition of place is also interesting. These projects are named for their geographies, and can be thought of as geographical or service commissioning footprints by service providers.

However, this isn’t necessarily the way they are thought of by people who receive a contact, or have a need addressed. For them the geographical or service offer breadth may not be appreciated or need to be appreciated if their need within their street, or their place of residence, is resolved. This is apparent from the NHSE Good Sam volunteers project as well, where services such as phone calls for social contact can link need in Chichester with resource in Yorkshire.

One Northern Devon tries to help people with a variety of challenges flourish, with an ambition to address as much need as possible. In common with other offerings, the challenges are sustainability and identifying the newly vulnerable.

How to measure success?

Programmes that seek to build sustainable improvement, rather than ‘just’ getting through a crisis, need to work over long periods of time. Their success can be measured in a number of ways and may differ from the data and metrics health services are used to considering. The metrics of (healthy) life expectancy, number of chronic conditions, smoking and exercise rates are well understood, but some of these programmes are more likely to see contacts as a positive outcome and number of relationships formed as valuable in improving lives.

The data currency of people flourishing at a place level in response to an acute insult such as COVID-19, or more chronic factors, is less likely to be collected, or available in one place.

Qualitative data on how people perceive service availability and intervention is valuable, as is quantitative data suggesting changes in GP attendance, or school absenteeism, but often output data is process related, or inferred.

Are we starting from scratch or building on existing relationships?

The second case study, from Sussex, focused on young peoples’ mental health. The immediate difference from One Northern Devon is that this work used a medical health risk to define its in-scope population of interest. However, like One Northern Devon the work was up and running and trust round the table between commissioners, providers, third sector and user representatives was in place. This allowed ideas to be discussed and decisions to be taken quickly, as they were taken for the more mainstream COVID-19 response. The YMCA got quick and comprehensive responses from more than 40 charities and could highlight concerns arising from young people and also from the voluntary sector providing support.

As with many system responses during the first wave of COVID-19, decisions could be taken quickly and priorities of facilitating provision of information and peer support could not just be put in place because of relationships and trust, but also be studied for effectiveness and wider learning. This latter was facilitated by the strong relationships with the ARC KSS, and its Starting Life Well mental health theme.

The first common factor in our case studies from different AHSNs is success was associated with pre-existing, well-regarded initiatives where the challenge was to sustain and accelerate. 

The charismatic champion

The next common factor is visible and charismatic champions and advocacy. This doesn’t have to come from the individual status of an organisational member as the One Northern Devon case study shows, but more from the way in which subject matter experts who live their beliefs and their priorities can be enabled by a system or place to make a difference.

The third common factor stems from the first and is underpinned by the second; relationships and trust. This is particularly apparent in the change of attitude and permissions which are applying this winter in Manchester’s A Bed Every Night initiative, where separate projects predicated on different but related needs have been able to come together this winter when they couldn’t previously, to the presumed advantage of the recipients of services and support.

These are the main and common ingredients these case studies have shown. In conversation with some of the key people who are responsible for the success of the studies presented here we asked what role if any might the local AHSN offer. The answers we received included helping with project or programme management, analytics and spread (through methodologies of education and telling stories). These are capabilities all AHSNs have, and all have a track record of successfully bringing partners from a variety of backgrounds round a table to deliver innovation and improvement for ordinary people.

Support to flourish

I hope this edition of Innovate and the compelling stories and comments from subject matter experts from a variety of backgrounds will help AHSNs be catalysts.

I hope AHSNs will look for the people and partnerships that have come together to support individuals living precarious lives within their regions and support effective interventions to sustain, broaden and deepen the difference these coalitions can make to people and communities who struggle to navigate systems, and struggle to flourish. 

Most of all I hope those who have led such powerful and valuable local initiatives will keep going and keep making a difference and support and inspire others to do the same.

Des Holden

Des is Medical Director of KSS AHSN, Implementation Director for ARC KSS, and Chief of Innovation at SASH. In addition to these roles he is a non- executive director of the South East Health Technology Alliance (SEHTA).

More from this issue of Innovate

Taking a place based

Pockets of success