Queen’s Speech

Lord Mawson Excerpts

Wednesday 3rd June 2015 Lords Chamber

[Lord Mawson (CB)]

My Lords, not for the first time, I find myself in full agreement with the good intentions in the gracious Speech and the sound purpose of a Government’s health policy. It seems to me that the desire to improve health outcomes for patients and to do that more efficiently and effectively are laudable twin goals and ones with which few could argue. However, I want to reflect on matters beyond these good intentions. In my case, it is not to question Her Majesty’s Government’s underlying purposes with their health policy but to challenge their narrow definitions of health and social care and, indeed, to suggest that they are simply not being radical enough.

Professor Sir Michael Marmot published his seminal report Fair Society, Healthy Lives in 2010. It was a comprehensive review of the causes of health outcomes and contained a damning indictment of health inequalities prevalent in many of our most deprived communities in the UK. One of Sir Michael’s key contentions—one that has not been seriously challenged—is that positive health outcomes are significantly more influenced by social determinants than clinical determinants; indeed, that our health is 70% driven by social determinants and only 30% by clinical factors.

Over the past few years I have been astonished by how little mainstream health policy takes the findings of the Marmot review and seeks to turn them into a new and radical approach to how we define health and deliver better services. Indeed, it feels like our attention has been deliberately drawn into an important but none the less constrained conversation about the merging of health and social care. It seems to me that this narrowly defined health and social care debate has had two consequences.

First, it has enabled the principal focus to remain—not exclusively but largely—on how the public and statutory systems talk to each other. I am constantly hearing about earnest initiatives that will pool health and social care budgets and force a new way of working. To my mind, this focus keeps us away from a more radical debate. Secondly, the health and social care debate has kept us away from the conclusions of the Marmot review. It has kept us away from the fundamental questions that inextricably link health outcomes with their social determinants. It keeps us from asking the awkward questions about how we unshackle the central control of health and unleash it into communities.

I am frequently reminded that the vast majority of health interventions happen in communities, not hospitals. They happen in primary care. Some 20 years ago, a young East End mother died of cancer in tragic circumstances. Her name was Jean and her death has had profound consequences for both my life and my work. There were two sides to Jean’s story. The first was that she fell through all the nets of statutory provision that we reasonably expect to be there for us. The health system did not work for Jean. The social care system did not work for Jean or her family. In short, everything that could go wrong went wrong. Jean was badly let down by the state.

However, the other side of Jean’s story was more life-affirming. Just as the state was busy letting Jean down, something very interesting—and very normal and human—happened. Suddenly there was a rota for going down the launderette and doing her washing, and people were going off to Tesco to get her shopping. Jean was inundated with offers of help. Jean was being cared for, not by professionals but by young mums like herself. She was being cared for by the community in the community. She was having the social determinants of her health addressed.

Some months later, there was an inquiry at the Royal London Hospital into the circumstances of Jean’s death. That in turn led to the building of the first healthy living centre in Britain in Bromley-by-Bow—the first health centre in Britain to be owned by the patients and rented to the doctors. Something had shifted in who owned health in that community. Critically, the initiative was supported by the noble Lord, Lord Mawhinney, who helped to navigate the tricky waters of an NHS for which this approach was radical and difficult.

My belief is that we need a different approach to health, creating centres of heath in our communities that address the full range of health determinants. We need a big purpose in our pursuit of a healthy community. Today the Bromley by Bow Centre—I declare an interest as founder—offers a vast array of services to its local community. These stretch from conventional healthcare for local residents to opportunities to set up your own business; from support with tackling your credit card debts to becoming a stained glass artist; from learning to read and write to getting a job for the first time or a helping hand up the career ladder. The centre hosts visits from thousands of visitors and health leaders every year from across the world who come to learn from its experience and who want to see the model in action first-hand. One health leader recently asked, “What do you think we learn from the Bromley by Bow Centre’s experience about how we should build health centres in the future?”. Our CEO Rob Trimble’s answer was very simple: “Do not build health centres”.

This is not an argument that denigrates clinical health. On the contrary, it positions it within a broad range of services that drive well-being in communities by creating a locally blended offer, where doctors sit alongside others, including patients and local residents, in high-quality buildings to provide what people need. Creating buildings which act as centres of the community, not just health centres, makes sense for so many other reasons, not least financial ones. Our friends who run successful businesses such as John Lewis will tell you that the idea of a well-run department store where you can offer a whole range of products makes complete sense for the customer and complete financial sense for the business. You can capture the customer and have the opportunity, in the convenience of one place, to offer myriad products and services. This is the same principle in integrated holistic centres, where health is about life and living, not just disease and illness. It is about sweating our community assets and ensuring that one investment in a new set of buildings creates benefits and savings across a whole range of Whitehall departments, not just the Department of Health.

I am led to believe that there are few avowed disciples of the silo approach left, yet in many parts of Whitehall it seems to remain the prevailing culture. We need more of the department store approach and less of the citadels of health and social care approach. I urge Her Majesty’s Government to be brave and back dynamic and radical local solutions—more human solutions—and to move on from old-fashioned silo thinking in Whitehall.