Duncan Selbie: A step on the journey to population health

Source: NHE Jan/Feb 18

The NHS plays a part in the country’s wellness – but it’s far from being all that matters. Duncan Selbie, chief executive of Public Health England (PHE), lays bare to NHE’s Luana Salles his views on what truly matters to keeping England healthy.

Duncan Selbie’s track record in the NHS is impressive. He has worked in the health system from the remarkably young age of 17, first joining in early 1980 and eventually working his way up to chief executive of South West London & St George’s Mental Health NHS Trust and, later in 2007, of Brighton & Sussex University Hospitals NHS Trust. In 2013, he solidified his career in the sector by becoming the founding boss of PHE, the Department of Health’s arm’s-length body fashioned from the consolidation of a number of health agencies.

It is refreshing, then, to see that he has such a realistic perspective on the functions of the NHS: rather than a one-stop shop for improving the public’s health controlled by catch-all policies and siloed organisations, Selbie is adamant to stress that the UK’s most prized possession is not a panacea and actually needs to learn to take a step back – or, to put it bluntly, we must cut the cord of overreliance between the system and the British people.

Staying well for longer

Speaking to me before his keynote speech at last year’s New NHS Alliance (NNHSA) action summit (more on page 26), the PHE boss pointed out the importance of the event’s core message: the value of health creation to building happy communities. In other words: helping people stay well for longer, stay at home for longer, and – when they become unwell – stay out of hospital for longer.

“The whole thing is about how to help people in their home and in their community. And the best way to help the NHS is to use it smartly, and not to be using it when there are genuine alternatives. That is at the heart of a health-creating community,” he explained.

“Prevention, in the sense of the days gone by, would’ve meant how to help people quit smoking or drinking, focus on what they’re eating, that sort of thing – or it might’ve been thought of as how to help people get out of hospital faster or avoid admissions. But it’s much more than that.

“It’s about how to help people stay well for longer. The way I frame it is, it’s not so much about what the matter is with people, but what matters to them.”

This could be anything from staying in work and having money in your pocket to simply having a meaningful reason to get out of bed every day or a friend to turn to – someone to care for and about. “We know that there’s as much or more science underpinning people remaining well by having a job or a friend than there is anything we do in healthcare,” continued Selbie.

“That isn’t to say healthcare doesn’t matter; it’s just not all that matters. There’s a whole range of other things that matter, and they fall into two themes: the choices people make about the risks that we know matter – whether it’s heart disease or dementia or cancer; smoking, drinking or exercising – and then the economic, environmental and the social. Enough money to live on, somewhere to live, friendship and social contact in your life.

“The NNHSA is about speaking truth to that. It’s saying that for years, politicians, the media and the public have conflated good health with what the NHS can do. The NHS can do a lot, but it can’t help people to stay well. That’s not what its function is.

“The NHS is there to help people when they need help that only the NHS can give – which is obviously more than A&E and hip fractures, but that’s not what good health is about. Good health is about these wider issues.”

Of course, the NHS – in particular the preventive services that aim to be proactive rather than reactive to crises – plays a key part in keeping the country healthy. But the backbone of a place’s health should be its community values rather than the walk-in clinic down the road.

NHS drip c. JoKP© JoKP

A drop in the ocean

This notion was, in part, the reasoning behind creating sustainability and transformation partnerships (STPs). As Selbie put it, rather than these being about how the healthcare system comes together, they are about the NHS recognising it needs to speak to others and about how it sees itself in a wider context.

“It’s not body parts or conditions or diagnoses that matter – it’s people living in places. And STPs, ACSs (accountable care systems) and ACOs (accountable care organisations), all these different acronyms, are about the NHS getting out a bit more and recognising that in order for it to thrive, it needs to be more engaged in the community,” he stated.

“It goes back to the [Derek] Wanless Report in 2004: if we want a sustainable NHS, then we need to invest in the public’s health and be concerned with these wider issues: housing, economic growth, jobs, how to help the education system to support young people getting into work. And the NHS depends on that.

“STPs are, if you’d like, an advanced form of planning for the NHS, but it’s only a step on the journey to recognising that it’s people and place, rather than treatment and diagnosis and illness and conditions, that matter.”

Public health is also a crucial piece of the jigsaw, of course, but it does not tell the full story. “It’s about what matters: economic growth, inclusive growth, inward investment, creating jobs that local people can get. It’s a very local thing,” he noted.

Because of his perspective on what drives good health, Selbie’s view on the much-anticipated Industrial Strategy, released late last year, is also unique: with its relentless emphasis on equal growth – across the Midlands and the north as well as in the southeast and London – it is as much a public health strategy as anything else.

The energy of devolution

Despite his health-driven background, the PHE boss is also a big advocate for local government, which he claims has a fundamental role to play in shifting the focus to place-based health because of its inherent ability to speak to the public. Naturally, then, Selbie is also a strong proponent of devolution and all that comes with it: elected mayors, combined authorities and localised powers.

“It’s about a place budget – it’s not an NHS budget or a council budget or a police budget. It’s about a Birmingham budget or a Newcastle budget or a Suffolk budget or a Cornwall budget – new forms of localism at scale. The NHS has further to travel in knowing that it can’t do this on its own,” he said.

This is, in effect, what STPs are seeking to do, but they lack the same democratic powers and accountability that already exist on a local political landscape. “It becomes magical when they get it, but they need each other. STPs are a necessary but early step; devolution, combined authorities, elected mayors, that’s where the most energy is, and that’s what we should be focusing on.”

Of course, not every part of the country has been blessed with the powers to pool budgets, with a recent review into devolution deals even finding that no new agreements were reached between April 2016 and March last year. But Selbie doesn’t believe that should stop areas from thinking locally, and is quick to refute the claim that their hands are tied by Whitehall.

“There is a deal to be had for parts of the country that are willing to rise above their own particular area, join with others and be more in control. But it’s not so much about a bigger share of the budget; it’s more about saying ‘we just think we can do it better.’ And I think they’re right – but they have to take that responsibility at a local level. The whole point of devolution is about doing what matters at scale,” he argued.

“And although places like Cambridgeshire and Peterborough, North of Tyne, Greater Manchester and so on are finding their own way to achieve that, every single part of England is on this journey.”

For the soft-spoken Scot, the message to the NHS is clear: we need others engaged in the collective effort to keep the nation well. Every local authority, every local enterprise partnership, every elected mayor, and every part of government.

“My role in this is to tell that story – that health is about more than healthcare,” Selbie concluded. “It’s not to say healthcare doesn’t matter, but it’s definitely not enough.”


(Top image c. Joe Giddens/PA Images)

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