(Photo credit: Eric Fischer)

Health devolution is coming to London. The idea is to give City Hall greater powers to make decisions in the field of health. In theory, this should create opportunities for the Mayor to get a grip on the way health services are delivered, including moves which help realise the potential of digital technology in health.

In practice, the situation is more complicated. Related challenges from the health and digital policy worlds make it very difficult to develop actionable digital health measures at the London level. Health data is a touchy subject for politicians for all sorts of reasons. Given the state of the National Health Service (NHS), the Mayor is having trouble getting beyond a reactive, system-oriented health policy.

Our work with the London Ambulance Service over the last few months suggests concrete opportunities for the Mayor to try something more imaginative and progressive to help patients, by improving the data available to London’s ambulances in the devolution context. Specifically, improved access to transport data is achievable and can help ambulances respond faster and more effectively. More generally, initiative over better connections with ambulance data can help advance a more constructive digital health agenda for London.

In this three-part blog series, DASH Research Associate Archie Drake sets out why we think it is a good idea to improve the way transport data is used to support London’s ambulances. THIS TIME (PART 1):

THREE REASONS WHY DIGITAL INNOVATION IS NOT A MAJOR FEATURE OF HEALTH DEVOLUTION IN LONDON

In December 2015, a London Health and Care Collaboration Agreement set a group of ‘London Partners’ (the Greater London Authority plus London’s Clinical Commissioning Groups, Local Authorities and various London-oriented NHS bodies) on a ‘journey’ towards controlling how health and care services are delivered in London. Now we’ve reached a major milestone on that journey, with a ‘ground-breaking devolution deal’ announced on 16 November 2017. The focus is on continuing the integration between health and social care and on NHS land and buildings.

One of the ways we might expect the city level of government to make a distinct contribution to how the health service works is to find ways to exploit advances in the digital domain. The idea of ‘smart cities’ is fashionable. A collection of technological developments (such as ‘internet of things’ and ‘big data’) are accelerating towards wide-scale deployment. For health purposes, people are most excited about the potential for applications and devices to support preventative or self-management approaches to health services, aimed especially at older people and patients with complex long-term conditions.

So why aren’t we seeing the Mayor and the GLA putting forward impressive, futuristic digital initiatives as part of health devolution? Because in practice it’s much harder than people think to combine health and digital policy effectively, especially in a city as large and diverse as London.

Reason 1: the Mayor lacks clear means to organise digital health initiatives in London

Firstly, the Mayor lacks a coherent London-level health organisation through which to pursue digital health initiatives in the short term.

One of the reasons that devolution is needed in the first place is that the set of organisational arrangements for health governance in London has become confusing through recent reforms. Each region in England used to be administered by a Strategic Health Authority (SHA) on behalf of the Department of Health. But London’s SHA was dismantled along with the rest in 2013. That same year, the Mayor formed the London Health Board (LHB), which comprises national and local representatives as well as the Mayor and aims primarily to ‘drive improvements in London’s health and care and reduce health inequalities’. The LHB was ‘refocused’ in 2015, the year in which the Healthy London Partnership (HLP) was formed. The LHB and HLP now operate in parallel. Although they have much the same membership, HLP presents itself as a more bureaucratic layer with a focus on the ‘aim [of making] prevention of ill health and care more consistent across the city’.

With the recent devolution deal, we will now have a London Estates Board and it turns out that a London Health and Care Strategic Partnership Board (SPB) has been operating ‘in shadow form’ and is now ready to join the party. The final health governance structure for London as it is now envisaged is set out below.

The latest governance arrangements for health and care transformation in London (London Devolution MoU, November 2017)

 

Hopefully this new set of arrangements will help the Mayor to improve London’s grip on health. But it looks likely that the struggle to clarify what the London level does (or can do) for health generally will continue, even before getting to specific digital possibilities, because the wider system is so completely confused. Looking upwards at the national level, even those working inside the system are now confused by the endless cycle of management innovations:

‘In England, the array of different organisations that make up the health service and the way they do (or don’t) work together can be baffling, even for those who work in the NHS. Once you’ve got your head around which organisation does what, you need to get to grips with the acronyms that pop up, mushroom-like, to describe the array of initiatives around new ways of working, new ways of containing spending and new ways of delivering care.’

Looking downwards at the local level, there is an ongoing struggle to relate NHS accountability arrangements to wider local government. Here things get truly bewildering. Clinical Commissioning Groups (CCGs) are working more closely with Local Authorities (councils) on health issues through ‘integration’ initiatives, including joint responsibility for the Better Care Fund (BCF) and local Health and Wellbeing Boards (HWB). So there is some hope of working out who the Mayor should liaise with at the London level, for example the Office of London CCGs or London Councils (or some combination of the two). But now CCGs are also forming into groups as Sustainability and Transformation Partnerships (STPs). And in a related but separate line of thought, there is growing excitement about Accountable Care Organisations (ACOs).

Reason 2: the state of NHS governance makes it difficult to engage people on digital health

The second factor making it tough to combine health and digital policy effectively at the London level is the current state of the NHS, which makes it very difficult to foster the public engagement that digital initiatives need to be successful.

Over the period of years that it will take to develop coherent London-level structures, the sheer scale of the health system makes it difficult to know where to start on digital initiatives. Health in London operates at a larger scale than most public functions in the city. The budgets involved gives some idea of the magnitude of the health devolution process. The Mayor’s current direct operation is the Greater London Authority (GLA) which had a total budget of around £11.5 billion in 2016-17 (mostly devoted to policing and transport). NHS England London’s current overall budget of over £15 billion is bigger.

In the absence of any distinct London-level conversation to engage Londoners on the potential of digital health, the Mayor will be obliged to participate in the toxic national conversation which has arisen over time based on concerns about the privacy and security of patient-level data (most recently following the ‘ransomware’ attack and DeepMind patient data breach, for example).

The NHS’ disintegrated governance makes it virtually impossible to foster more constructive public engagement because things have gotten so bad that even specialists find it hard to understand what’s really going on. The King’s Fund is doing an especially good job of explaining this. The NHS has become ‘complex and fragmented’, especially under the simultaneous localisation and marketisation reforms of the Health and Social Care Act 2012.

One of the central aims of health devolution must be to clarify how the system works at the London level. As Dr. Kailash Chand has pointed out, in relation to health devolution in Manchester, the health devolution process in England has made the worst possible start in terms of communicating why devolution to the city level is valuable:

‘Some [people] don’t know what it is, others see it as just another layer of bureaucracy – another politician and less power for the people. These new deals have been done with no public awareness, no public consultation, no democratic engagement, no scrutiny and no impact assessment.’

The best measure apparently available for how engaged Londoners are in health devolution is the number of views on the YouTube videos the ‘London Partners’ have put out. At the time of writing this one, for example, had 235 views after being online for more than a year. It would be reasonable to expect more given London’s population is estimated at 8.8 million. More recently, announcement of the 16 November 2017 devolution deal affecting how the NHS (our most treasured public system) works in London (our national capital) has been released with minimal press attention or comment.

In the meantime, the momentum is with others. For smart city approaches, the big tech players who are relatively uninterested in public health goals are leading the way. Some, like Google in Toronto, are pursuing a technology-centred revolution in urban planning. Others, like Microsoft, are tracking how technology is transforming civic engagement generally. For assistive technology in care, that means councils continue to procure telecare solutions in a way that is cost-driven rather than outcomes-oriented. All of this, by the way, looking at the ‘stream’ of public health perspectives, as distinct from the wider ‘smart health’ landscape in which a dizzying array of private businesses are busying themselves putting forward apps, devices and other technological innovations to support health.

Reason 3: the Mayor has been forced into a reactive stance on health

Thirdly, the Mayor has been forced onto the back foot when it comes to health policy – in particular because of the trend away from preventative and population health approaches since 2012. Health devolution in London is so far mainly focused on addressing this institutional recession.

Recent health service reforms in London have not configured it to handle demand sensibly. Under resource pressure, the national government has undermined the main preventative health structures in the city and focused on hand-to-mouth funding of the more reactive elements. Work on Lord Darzi’s demand-oriented and prevention-promoting Framework for Action was discontinued in 2010, and the public health responsibilities that sat with the SHA were split up and moved simultaneously down to Local Authority level and up to Public Health England. Meanwhile changes to local government funding have hit social care funding in London hard, with some of the deepest cuts in the country (with adult social care, for example, decreasing 18% in the city from 2009-10 to 2015-16).

This is focusing attention at the London level on an initiative to support primary care, especially general practice. Politically speaking, general practice seems to be the right point at which to address people’s day-to-day engagement with the NHS in London. The King’s Fund think tank builds on prior thinking about the crucial role of general practice in driving perceptions of the NHS overall when it reflects on:

‘The public’s familiarity with this service, and the ongoing and (often) more personal nature of their relationship with their GP…’

The Care Quality Commission has just published a report on the state of care in general practice 2014-2017 which highlighted the fast growth of London GPs’ workload (+10% between 2013 and 2016) and practices struggling to maintain standards as a result (especially in outer North and East London). A recent study from colleagues at King’s suggests that anything the Mayor can do to shore up general practice is likely to reduce funding pressure on secondary care and emergency departments. In 2016, the Healthy London Partnership promised a 14% real terms spending increase to support general practice in London by 2021.

The Mayor is working to stimulate a more thoughtful conversation ahead of devolution by concentrating attention on health inequalities, which are disgracefully high. The draft strategy, ‘Better Health for All Londoners’, represents a start towards a more constructive city-level approach to preventative population health (especially by promoting a ‘health in all policies’ approach which looks to harness strengths in other policy areas like air quality to health-oriented objectives). But as things stand there is limited content on digital initiatives, with the only mention being a new Child Health Digital Hub which will include an online version of the ‘Red Book’ given to new parents to support them in keeping track of screenings, vaccinations and physical development.

So… are there other things that the Mayor might do to exploit technological advances for London’s health? We think that there are. The Mayor of London already controls various other areas of policy which might contribute further to Londoners’ health, including transport through leadership of Transport for London (TfL). In 2014 London became the first city in the world to publish a transport health action plan. TfL’s plan observed that:

‘It is important that people can conveniently access healthcare so transport implications need to be considered at the earliest stages of proposals to change healthcare provision.’

Building on the ‘health in all policies’ idea that non-health matters should contribute more to Londoners’ wellbeing, one thing to consider is whether the Mayor’s control over transport policy provides an opportunity to go further.

NEXT TIME (PART 2):

HOW TRANSPORT DATA MATTERS FOR THE LONDON AMBULANCE SERVICE