REFORM REFORMER THOUGHTS

The biggest health challenges of the 2020s

May 2021 #reformhealth 1 - The biggest health challenges of the 2020s

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www.reform.uk 2 - The biggest health challenges of the 2020s Contents Introduction 3 Sebastian Rees, Researcher, Reform Changing the mantra on infectious disease prevention 4 Professor David Heymann, Professor of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine and Distinguished Fellow, Chatham House Centre for Universal Health

Rising to the challenge of demographic ageing 6 Dr Cham Herath, Medical Director, MSD

Creating a smokefree nation 8 Professor Deborah Arnott, Chief Executive, Action on Smoking & Health and Honorary Associate Professor, University of Nottingham

Tackling obesity in Britain 10 Caroline Cerny, Alliance Lead, Obesity Health Alliance

Lessons from Hepatitis C elimination of HCV in Tayside : 12 building community health in Britain Professor John Dillon, Professor of Hepatology and Gastroenterology, University of Dundee & Ann Eriksen, Executive Lead and Commissioner - Sexual Health and BBV, NHS Tayside Directorate of Public Health

Leading the way in integrating health and social care 14 Rob Webster, Chief Executive, West Yorkshire and Harrogate Partnership & Chief Executive Officer, South West Yorkshire Partnership NHS Foundation Trust

Conclusion 16 Sebastian Rees, Researcher, Reform 3 - The biggest health challenges of the 2020s Introduction As we begin to recover from the greatest health crisis Britain has confronted in a century, we must not lose sight of the other pressures our health system faces. We must look to the future and ask – “what will be the defining health challenges of the next decade?”. This Reformer Thoughts brings together health leaders to answer this question and consider how these challenges can be met head on.

Recent experience shows that bold action is needed for Government responding to infectious diseases to meet its ambition of pushing remains a core health challenge. David smoking rates in England below 5 per Heymann, Professor of Infectious cent by 2030. Disease Epidemiology at the London School of Hygiene and Tropical Alongside tackling the drivers of ill Medicine, argues that we must “shift health, we must consider how our the mantra” on controlling infections health system can be best organised by stopping diseases at their source – to deliver citizen-centred care and the interface at which animal diseases tackle entrenched inequalities in “make the jump” to humans. provision.

While future pandemic threats will Cross-sector collaboration and remain at the forefront of our minds, community understanding are vital to demographic change and the burden improving health outcomes for of lifestyle related illnesses will society’s most vulnerable. John Dillon, Sebastian Rees continue to drive demand for health Professor of Hepatology at the Researcher, Reform services. University of Dundee and Ann Eriksen, Executive Lead for Blood Borne By 2040, one in four people in Viruses at Tayside’s Public Health “Alongside tackling England will be 65 or older and the Directorate show how close number living with dementia is engagement with injecting drug users, the drivers of ill expected to reach 1.6 million. MSD’s a community with a long history of health, we must Medical Director, Cham Herath, argues poor interactions with health services, consider how our that investment in R&D is key to helped Tayside overcome daunting health system can be understanding the biological odds to eliminate the Hepatitis C virus. best organised to mechanisms behind ageing and deliver citizen- developing innovative treatments for Better integration between health and the diseases ageing causes. other care services has been a centred care and long-standing policy ambition. Rob tackle entrenched The obesity epidemic also poses acute Webster, West Yorkshire and inequalities in challenges – the adult obesity rate in Harrogate Partnership’s Chief provision.” England stands at 28 per cent, putting Executive, reflects on what the millions at increased risk of developing partnership can teach other Integrated type-2 diabetes, cancer and heart Care Systems about successful joint disease. Obesity Health Alliance Lead, working. Building a shared vision and Caroline Cerny, argues that developing inclusive governance governments, health providers and structures have been key to West communities will all have to play their Yorkshire’s success in unleashing the part in addressing the structural potential of integrated care. factors that drive obesity. By understanding the drivers of ill Tackling smoking has long been a health and how our health system can health priority and evidence-based be equipped to cope with them, we regulation has been remarkably can better position ourselves to meet successful in combatting the damage the health challenges of the next it causes. However, Deborah Arnott, decade. Chief Executive of ASH, argues that 4 - The biggest health challenges of the 2020s Changing the mantra on infectious disease prevention

Recent infectious disease outbreaks – SARS in 2003, swine flu in 2009, and COVID-19 - have all begun in a similar way – a series of risk factors aligned and allowed an infection in animals to jump to humans. However, the current mantra for controlling emerging infections is to rapidly detect them in humans, respond with public health measures that stop sickness and death, and attempt to prevent infection from spreading further. This model comes with huge costs: strict public health measures – though necessary – affect societal wellbeing, bring large-scale negative economic impacts, and struggle to quickly get on top of fast spreading infections.

As we begin to recover from the When these risk factors lined up in pandemic, this mantra must shift. We the late 1990s, an outbreak of Rift cannot wait for disease to emerge in Valley Fever occurred, causing over humans before acting. We must 450 reported human deaths. address infections at their source – the interface at which diseases in In the UK, an infectious agent from animals “make the jump” to humans. cattle emerged in humans a decade earlier – mad cow disease (Bovine Acting early requires understanding Spongiform Encephalopathy) – the way risk factors line up to cause which causes a fatal human viruses to spread from animals to neurological disease called variant humans. Rift Valley Fever serves as a Creutzfeldt-Jakob Disease. The risk useful case study. It is a disease of factors that aligned to allow the virus Professor David Heymann, cattle, camels, sheep and other to spread from animals to humans, Professor of Infectious ruminant animals, caused by a virus were an unstudied change in the that is endemic in eastern Africa and processing of cattle carcases to bone Disease Epidemiology, spread to these animals by meal, feeding of ruminant animals London School of Hygiene mosquitoes. with bone meal from infected and Medicine animals, and the slaughter of cattle At times the virus spreads to that contaminated meat products humans, either through the bite of an with the infectious agent. Because “We cannot wait for infected mosquito or by contact with the infection only passes between disease to emerge in infected animal blood during cattle and humans, not between humans before acting. slaughter for food or religious humans, culling of cattle was We must address purposes, causing severe illness and required. In addition to the mortality infections at their in some cases death. it caused in humans from the beef source- the interface products they used, the economic at which diseases in The virus tends to make the jump cost was severe. when a number of risk factors line up animals “make the with one another. These include a A better understanding of these risk jump” to humans.” failure to vaccinate animals, but also factors allows prevention to occur excess rainfall and flooding related closer to the source. In the case of to el niño events in the Indian Ocean. Rift Valley Fever, mitigating these risk Flooding forces animals and humans factors would involve short term to live closer together on dry land measures such as ensuring sufficient and deposits excess standing water, vaccination supplies to vaccinate increasing the number of mosquito ruminant animals, and their provision breeding sites. to farmers at a cost they could afford. 5 - The biggest health challenges of the 2020s

In the longer term it would include Animals Infections and Risk international support for better measures such as completing the Surveillance (HAIRS) group, tracking and responding to novel negotiations for the United Nations containing representatives from infectious diseases. Climate Change Framework Public Health England, the Convention to mitigate risk factors Department for Environment, Food To avoid the the catastrophic toll of related to climate change and and Rural Affairs, the Animal and infectious dieases we must ensure flooding. For BSE, prevention closer Plant Health Agency and other that prevention at the to the source would have included expert bodies has met regularly to human-animal interface becomes paying close attention to the identify and discuss infections with a priority for all governments and rendering process of cattle potential for interspecies transfer. global health institutions. The carcasses, adhering to the policy of mantra must continue to include not feeding livestock feed made Yet global problems require global rapid detection and response to from other ruminant animals, and solutions, and the UK must use its tackle disease quickly when it taking better precautionary position as a health leader to make emerges in humans. Yet, all measures at slaughter houses. this kind of monitoring the norm countries must work towards around the world. The recently preventing disease emergence The UK Government has already launched Pandemic Preparedness closer to the source. The UK has put measures in place to monitor Partnership, a key initative of the the expertise and understanding to emerging infectious risks in other UK’s G7 presidency, could play a help them along the way. species. Since 2004, the Human crucial role in helping secure 6 - The biggest health challenges of the 2020s Rising to the challenge of demographic ageing

As the UK looks to take on the next decade of health challenges, it will be essential that industry and the NHS are future-fit and able to come together to face the rising challenge of demographic ageing. At the start of the decade, Britain had the worst healthy life expectancy in Europe. Even prior to the pandemic, UK healthy life expectancy was falling behind most other European countries – and was one of only four countries whose healthy life expectancy declined between 2008 and 2016. As such, it will be critical that the 2020s deliver decisive progress in how we meet the challenges associated with our ageing population.

Government and its partners in the population ageing. This is an area in health sector must take steps to which MSD is investing, building the ensure that, alongside a focus on Discovery Research Centre in ageing healthily, the importance of London which will recruit a team of ageing equitably is stressed. The 150 scientists to collaborate with pandemic has shone a light on leading UK institution, improve our inequalities and made clear that understanding of the underlying levelling up on health is the biggest biological mechanisms of ageing, enabler of healthy population and help develop innovative ageing. The Government’s focus on treatments. The U.K. has many health inequalities is essential to excellent dementia drug discovery ensuring that everyone has the initiatives and partnerships such as opportunity to maintain good health the Alzheimer’s Research U.K. Dr Cham Herath into old age. (ARUK) led Dementia Consortium, of Executive Medical Director which MSD is proud to be a member. UK and Eire, To enable healthy longevity, we Research is inherently collaborative MSD must also shore up a thriving and international and enabling these science base in which early and late dynamics to thrive will secure the stage R&D and inclusive innovation UK’s innovation potential. “The pandemic has are supported. It is important that innovative approaches, treatments To drive forward healthy and shone a light on and services can reach the people equitable ageing, we must ensure inequalities and made that need them throughout the life that innovation reaches a broader clear that levelling up course, and that we have suitable spectrum of the ageing population. on health is the systems in place to allow for this. As we approach the 40th biggest enabler of anniversary of the discovery of the healthy population Investment in R&D is key to first AIDS cases in the UK, we are ageing.” unlocking the UK’s scientific reminded of the significant strides in leadership potential in the field of scientific understanding, medical healthy ageing. Central to this innovation and clinical management GB-NON-04160 ambition will be innovative research of HIV, that have allowed people to April 2021 and the development of new live with the condition into older age. References available upon request treatments to tackle HIV treatment is recognised as one neurodegenerative diseases, which of the great health success stories of continue to grow as a result of recent times, but today people living 76 - -The A new biggest deal health for prevention challenges of the 2020s with HIV continue to face health that are designed to address the populations and ensure the right inequalities, social isolation, evolving needs of the individual. vaccines are matched to the right financial stress and stigma. These population to support individual challenges worsen as they age. Ensuring good health later in life protection. Vaccine R&D must Ageing with HIV is associated with will also require further research meet the unique needs of varied increased incidence and earlier and innovation in vaccines and populations, and innovations in the onset of multimorbidity and frailty immunology. As COVID-19 has system must ensure that vaccines and Public Health England projects shown, vaccination is an get to the people who need them that the prevalence of high indispensable public health tool most. cholesterol, hypertension, diabetes that can be employed across the and ‘heart conditions’ in the ageing life course to protect people of all As a future-focused company, HIV population will double in the ages against vaccine-preventable MSD’s mission is to discover, UK in the forthcoming decade. It is diseases. Immunisation is a key develop and provide innovative important that we continue to component of any healthy ageing medicines and vaccines that save collaborate to drive improvements strategy – older adults suffer from and improve lives globally. that help people with HIV live and vaccine-preventable diseases Understanding and responding to age well. more frequently and with poorer population ageing is crucial to this outcomes. This is due to a number mission and we are committed to These include ongoing research to of factors such as underlying helping develop a future-fit health understand the changing nature of chronic medical conditions and system that can flex and adapt to HIV, sustained access to clinical age‐related reduction in immunity. the needs of an ever-ageing innovations, future-proofed and population and the new and joined-up commissioning and Vaccine innovation must recognise unchartered health challenges funding, and new models of care the complex needs of older which it brings.

Katherine Dunne, Programme Manager, UK Prevention Research Partnership, Medical Research Council 8 - The biggest health challenges of the 2020s Creating a smokefree nation

Smoking is the epidemic which hides in plain sight. It has crept up on us, taking decades to reap its annual toll of death and disease. But make no mistake, smoking is more deadly than COVID-19, killing up to two thirds of long-term smokers, who lose on average ten years of life. In 2020, around 80,000 people in the UK died from COVID-19. Smoking kills on that scale year in year out.

Beyond its obvious harms to promotion by tobacco companies physical health, smoking has much has been banned, the product is in wider impacts. It affects users’ plain packs, taxation has reduced mental health - many wrongly tobacco affordability, and smoking is believe that smoking relieves stress, prohibited in enclosed public places. when in reality quitting is linked to Since 2007, we have led Europe in long-term improvements in taking regulation even further. The wellbeing at least as great as those results are clear to see: in 2007 our derived from taking smoking rates were average for anti-depressants. Europe, by 2020 they were less than half those of the 27 EU member The economic costs of smoking are states. severe, driving over a million people – including over a quarter of a However, there are still nearly six million children – into poverty and million smokers in England – one in Professor Deborah Arnott leaching money out of local seven adults – and we are nowhere Chief Executive, communities, particularly those in near achieving the Smokefree 2030 Action on Smoking and which household income is lowest. ambition. To do so smoking rates Health (ASH) must fall by two thirds in a decade, The harms of smoking are not and by three quarters for smokers in distributed equally. Smoking rates routine and manual occupations. At “The economic remain highest among poorer current rates of decline we will miss impacts of smoking people, in poorer communities. Half the target by seven years, and twice are severe, driving over the difference in life expectancy that for the poorest in society. a million people, between the richest and poorest is including over a due to smoking. If the Government Government understands that achieves its ambition to create a meeting the smokefree target of quarter of a million smokefree nation by 2030, it will rates below 5 per cent by 2030 is children, into poverty have taken the most important extremely challenging and has and leaching money possible step towards delivering on committed to publish a new Tobacco out of local its manifesto commitments to Control Plan, which ASH has long communities, increase healthy life expectancy by called for. To achieve its aims, the particularly those in five years by 2035 while reducing plan must be innovative and which household inequalities and levelling up society. ambitious. income is lowest.”

Fortunately, the smoking epidemic First and foremost, additional is, slowly but surely, being brought funding is needed. The per capita under control. Since the turn of the Public Health Grant has been cut by century, governments have almost a quarter since its peak in ratcheted up smoking regulation. 2014-15, and funding for smoking Advertising and sponsorship prevention has been particularly 9 - The biggest health challenges of the 2020s hard hit. In the 2019 Prevention support must be provided for When the age of sale was Green Paper, government disadvantaged smokers, including increased from 16 to 18 in 2007 committed to consider a ‘polluter the 49 per cent of smokers in smoking prevalence reduced in 16 pays’ approach to funding tobacco routine and manual occupations, and 17 years olds by 30 per cent. control. This happens in the USA, the third of smokers who live in Evidence from the US, where the where the industry pays for its social housing, and the third of age of sale has increased to 21, regulation, without having any say smokers with poor mental health. shows similar reductions in in how the money is spent. smoking among 18 to 20 year olds We also need to further as a result. The impact of enacting Government must follow through denormalise smoking by ratcheting this change in the UK would be on this commitment. Tobacco up regulation. Why not put health immediate: over 100,000 fewer manufacturers are far more warnings on cigarettes and rolling smokers aged 18 to 20 in year one, profitable than any other papers? These are cancer sticks so and 18,000 fewer every year consumer staple businesses, they why not tell it like it is and put the thereafter. can and should be made to pay to warning on the cigarette itself? end the epidemic they caused. Government mandated pack When I started working for ASH in inserts, already shown to be 2003 it was unimaginable that the Once funding is secured, funding effective in Canada, provide advice end of the epidemic would be in for highly cost-effective, on the inside of packs to match the sight while I was still there. Now multi-media behaviour change health warnings on the outside. we have government and public campaigns must be re-instated. appetite to end it within the They are very effective and Although cigarettes are now decade. This is achievable but only economical, but funding has hidden from sight in shops, if the Government delivers the crashed by more than 90 per cent tobacco manufacturers still pay for ‘bold actions’ it committed to in the from £23.38 million in 2008-9 to large gantries highlighting Green Paper in the forthcoming less than £2 million in 2019-20. ‘Tobacco on sale here’ just behind Tobacco Control Plan. the sales counter, making it appear To tackle the stubbornly persistent that smoking is still the norm in our inequalities in smoking, targeted society. 10 - The biggest health challenges of the 2020s Tackling obesity in Britain

As anniversaries go, this is perhaps not one for celebrating. 2021 marks thirty years since the Government first set targets to reduce obesity, after recognising the impact rising levels were having on population health. In 1991, a target was set to reduce obesity prevalence to 7 percent, to reflect 1980 levels.

Three decades later and obesity stigma is rooted in a lack of rates in adults have increased to 28 understanding of the complex per cent. With around two thirds of causes of obesity. The landmark English adults having a weight that 2009 Foresights report mapped is classed as overweight or obese, over 100 factors that influence excess weight is very much the norm energy balance, including a person’s in our society. genetic make-up.

So why is this cause for concern? Yet much of the public and political While at an individual level, having discourse focuses on individual obesity doesn’t automatically mean behaviour. A lack of knowledge or poor health, at a population level it is willpower are commonly cited as clear that excess weight brings with causes of obesity, erroneously it an increased risk of many framing living with obesity as a diseases. These include type-2 choice that can be fixed by diabetes, cancer, heart disease, liver campaigns telling people to make Caroline Cerny disease and associated mental better ‘choices.’ Alliance Lead, health conditions. But it’s not just Obesity Health Alliance long-term conditions, having a very The UK population has not suffered high BMI has also been shown to a collective failure of self-control in increase the risk of complications the last 50 years. What has been “It is now vital that the and death from COVID-19. transformed is the environment in Government does not which we live with changes in how waver in its The impacts of obesity go far we work and travel and a seismic commitment to beyond the health sphere. Living shift in the food system. addressing the drivers with obesity can influence a person’s of obesity and ill health life chances, ability to work and The majority of us live in an and avoids allowing attainment. At a societal level, environment where high calorie, itself to be steered off medical costs combined with nutrient poor food is readily course by the industry productivity losses mean the wider available and cheap. Our high giants that profit from cost of obesity to the UK is around 3 streets are dominated with the unhealthy status per cent of its GDP (£60 billion in fast-food outlets, supermarkets quo.” 2018). There is also a stark inequality stuffed with deals on sugary foods in obesity prevalence, with those and everywhere we turn we see from the most deprived adverts telling us we deserve the backgrounds more likely to live with chocolate, we’ve earned the pizza, obesity, largely due to the wider our teenagers will magically become drivers of inequality that influence communicative over a burger. And poor health. this is all available with minimal effort, simply tap an app and a But despite excess weight being so delivery will appear on your widespread, significant stigma is still doorstep. associated with obesity. Much of the 11 - The biggest health challenges of the 2020s

We have a paradoxical system that soft drinks by nearly 29 per cent, drivers of obesity and ill health and encourages and facilitates people the Government has committed to avoids allowing itself to be steered eating more, while simultaneously regulatory approaches restricting off course by the industry giants blaming them. how unhealthy food and drink can that profit from the unhealthy be marketed in shops, on TV and status quo. Governments must play a key role online, along with additional in addressing the structural factors investment in weight management These new approaches all that drive obesity. Just as and support services. represent small steps, but together government intervenes to ensure improved diet. they signal an acceptance that that the water we drink is clean, while obesity is not a choice we the cars we travel in are safe and These policies are supported by make, it is not inevitable. After 30 that we can work and socialise in health charities and medical years of ineffective approaches, smoke free spaces, it also has a organisations and largely false starts and u-turns, we are role to play to ensure our food welcomed by the public, who want finally starting to head down the system does not make us ill. to live in an environment that right track. It’s now time to facilitates health. It is now vital that accelerate towards a goal of After the success of the soft drinks the Government does not waver in improved health for everyone. industry levy in reducing sugar in its commitment to addressing the 12 - The biggest health challenges of the 2020s Lessons from Hepatitis C elimination in Tayside: Building community health in Britain Eliminating a virus is a rare and difficult challenge. Tayside in Scotland has achieved WHO elimination targets for the Hepatitis C virus (HCV) 10 years ahead of the global target, becoming one of the first regions in the world to do so. Tayside’s experience offers evidence that a clear, collective vision and collaborative effort can overcome daunting odds.

HCV is a blood-borne virus that can epidemic off at its source by treating seriously damage the liver with fatal individuals who still actively use consequences if left untreated. It is drugs and are the main source of spread mainly through blood from new infections. an infected person and in developed countries the main route of However, although treatment is transmission is recreational injection highly effective, the people most at drug use. risk of contracting HCV and suffering its consequences are among the HCV is often referred to as the “silent most marginalised and stigmatised Professor John Dillon, epidemic”. By December 2006, an in our society, and often find Professor of Hepatology and estimated 50,000 people in navigating complex healthcare Scotland and 71 million globally had systems challenging. This raises Gastroenterology been infected with HCV. But many significant challenges when we University of Dundee who are infected are unaware they consider the “how” of eliminating have contracted the virus, and often HCV. show no symptoms over long periods. The outcome of HCV varies In the mid-2000s, conventional considerably between individuals – wisdom still held that it was not while the infection clears possible to engage people who use spontaneously in approximately 25 drugs in treatment and models of per cent of individuals, the care remained confined to medical remaining 75 per cent become specialists operating from hospitals. chronically infected, leading to the Challenging this received wisdom development of serious liver has required sustained advocacy diseases, including cirrhosis and with key decision makers. hepatocellular cancer over a period Ann Eriksen of 10 to 40 years. Our advocacy efforts have focused Executive Lead and on establishing the wider societal Commissioner – Sexual Health While there is no vaccination for benefits of changing our approach and BBV, NHS Tayside HCV, the discovery and introduction to HCV treatment. This has involved Directorate of Public Health of directly acting anti-viral using case studies to demonstrate treatments (DAA) in 2015 has the impact of treatment and created a revolutionary new era in elimination for individual lives. treatment. DAAs have demonstrated Together with aligning the case for their safety profile, have short change with wider policy treatment durations and are curative imperatives, these case studies have in over 97 per cent of people. Their been key to releasing significant advent raises the possibility of using investment. treatment as prevention, turning the 13 - The biggest health challenges of the 2020s

Ways of working and the views of shared experience is the most They are often co-located at sites policy makers have begun to shift, effective recruiter – combatting of drug services or needle but commitment from frontline persistent myths linked to historical exchanges, allowing health staff and health services treatment regimens and giving workers to liaise with management to find ways to solve people confidence and motivation organisations who have existing the problem remains essential to to overcome perceived barriers to relationships with people in need providing effective treatment for care. of treatment. HCV. It also requires tailoring our response to meet the needs and As knowledge developed, it Building knowledge of the preferences of the population became clear that because DAAs communities most at risk from groups most affected. were very safe and effective, the HCV, facilitating their access to number of pre-treatment or diagnosis and treatment and the The first stage in providing on-treatment checks could be need to underpin new initiatives appropriate HCV care is the dramatically reduced. These with data and evaluation has acknowledgement that the people changes meant that delivering reinforced the need for a the service is trying to reach can be testing and treatment could be multi-partner network to fearful of new environments and rationalised, allowing services to coordinate Tayside’s response. often have extensive experience of be delivered by a more diverse being stigmatised in health care workforce. To solve this complex challenge, interactions. productive collaboration between Nursing staff and care workers are academic researchers, NHS Key to Tayside’s success in able to test and treat, clinicians, and public health teams eliminating HCV has been a de-medicalising the service and has been essential in attracting recognition that individual enabling truly community based significant investment, enabling therapeutic relationships based on care – 80 per cent of all testing in continuous improvement and mutual respect are key to engaging Tayside is performed in the evaluating success. This whole and maintaining people in care. community by non-clinical staff system approach to the design and Positive experiences of diagnosis, working in non-governmental or delivery of an intensive treatment treatment and care are important third sector agencies. These programme has been crucial to the for building trust in the affected changes allowed services to be effective eradication of HCV from community. Word of mouth and made widely available in facilities Tayside. peer support from people with that were local and familiar.

“Key to Tayside’s success in eliminating HCV has been a recognition that individual therapeutic relationships based on mutual respect are key to engaging and maintaining people in care.” 14 - The biggest health challenges of the 2020s Leading the way in integrating health and social care

For many years, integrating health and social care has been a cental tenet of reform. From NHS England's Five Year Forward View (2014), to the Long Term Plan (2019), significant attention has been paid to joining up care for the benefit of patients and communities. The White Paper, released in February 2021 marked a deepening in government’s commitment to this agenda, whilst building on the NHS’ recommendations for legislative change.

Legislation is one crucial element in on our staff and carers. delivering integration. However, Making good on the White Paper’s looking at the history of NHS reform ambitions will require bold ambition reveals that other, tougher obstacles for positive integration in practice must be overcome for us to succeed. and the removal of obstacles that remain to achieving it. More In the 1990s it was felt that welding advanced care systems can play a together different organisations crucial role in sharing their would make integration a reality. experience with those at an earlier These changes never put the person stage of their integration journey. or community at the heart of the model and often placed In West Yorkshire and Harrogate, the organisational form over service vision described in the White Paper delivery. Because of this, they failed aligns closely with how we are Rob Webster to build a sense of shared purpose currently working - partners in the Chief Executive, West or consider the values, culture and NHS, local government and in the Yorkshire & Harrogate the motivators for bringing voluntary, community and social Partnership and organisations together in service of enterprise sector (VCSE) working Chief Executive Officer people. closely together to improve health South West Yorkshire and tackle inequalities, facilitated by Partnership NHS Trust Long-standing cultural and mature provider collaborations and institutional differences between transparent and inclusive leadership health and local government can, on arrangements. Good governance “Our experience the surface, make integration and good relationships frame shows that challenging. The NHS is a ‘free at the everything we do. The former should collaborative working point of use’ monopsony, whilst be helped by legal changes. social care is largely means tested, at all levels helps often paid for directly by the Our Partnership brings together improve the recipient, and operating as a NHS, commissioners, providers, experience of regulated market of public and local authorities, hospices, the patients, build private providers. This builds in voluntary community social healthy communities complexity from the start and enterprise sector (VCSE) and and ultimately save neccessitates partners working Healthwatch, at a local place and lives.” effectively across institutional system level. All, including local boundaries. political leaders and chairs of health and wellbeing boards, are influential True integration requires a long term members of our Partnership Board sustainable solution for social care, setting strategy and overseeing an asset based approach to working delivery. Their collective strength with people and a continuous focus provides greater opportunities 15 -The biggest health challenges of the 2020s to deliver on our ambitions, work. Our commission on this topic suicide prevention strategy and the reducing future demand for focuses on real action, from Grief and Loss Support Service. healthcare by working to ensure housing and jobs to improved that people are given the best start planning, representative leadership Partnership working across West in life, with every chance to remain and improvements in mental Yorkshire and Harrogate is healthy and age well. Financial health services. underscored by an entrenched management is a collective ethical framework, focused on endeavour and risk is shared for This solid foundation has been valuing respect, fairness, the benefit of citizens. crucial in our handling of the reciprocity, and collaboration. pandemic. Issues like maintaining Shared values helped individual Over the last five years, partnership PPE supply, coordinating testing, clinical decision makers and working has accelerated with each helping over 100,000 people multidisciplinary teams maintain tangible improvement or challenge shielding, and successfully rolling confidence and integrity during we have collectively overcome. out the vaccine programme have COVID-19 and will be crucial to This has not been straightforward been led by individuals working for accelerating system working as we or easy. It requires constant work the collective. We have avoided recover from the pandemic. and attention. Effective disaster by working to ensure that collaborative working has been the resources necessary to work in We are a mature integrated care strengthened by a shared local streets, neighbourhoods and system that has navigated its way commitment to putting local places are in place. through the past five years and a people rather than organisations – catastrophic pandemic. Integrating or our egos - first. Investment has been directed care is a difficult logistical and towards issues like loneliness and cultural challenge. Our experience Many examples in our system bear carer support, as well as cancer shows that collaborative working this out, including our work on and urgent care. On top of local at all levels helps improve the stroke, cardiovascular disease, place funding, a slug of our experience of patients, build learning disability and leadership, transformation money – £2.5 healthy communities and and our intention to tackle health million – has been given to the ultimately save lives. With inequalities head on. COVID-19, VCSE sector for its essential work. permissive legislation and social with its disproportionate impact on care reform, perhaps we can finally particular groups, including The VCSE are equal partners in our deliver that central tenet of reform minority ethnic communities and work – supporting for example – truly integrated care. colleagues, added urgency to this men’s mental health as part of our 16 - The biggest health challenges of the 2020s Conclusion Meeting the health challenges of the next decade will require a concerted effort to tackle the drivers of ill health and ensure that health improvements are shared by all communities. Top-down changes to make health a priority across government will need to be complemented by local level innovations targeted at delivering truly citizen centred care. Some of our most pressing health argues that addressing social challenges are global in nature and inequality will be central to tackling addressing them will require close this acute health challenge. engagement with our international partners. As Professor David Health providers will play an essential Heymann argues, the UK can and role in driving improvements in should use its G7 Presidency to secure wellbeing in their local communities. international support for better Yet to do so effectively will require responding to infections wherever active engagement with partners that they emerge in the world, helping us fall outside the traditional boundaries avoid the catastrophic toll of of health care provision. As John Dillon infectious diseases of which we now and Ann Eriksen argue, engaging far more aware. Tayside’s drug injecting community with vital Hepatitis treatment Sebastian Rees International scientific collaboration programmes has necessitated Researcher, Reform and investment will be key to meeting collaboration between health teams another of our most complex health and community organisations to challenges – the impacts of deliver care that is more sensitive to “Building a healthy demographic ageing. Cham Herath the needs of vulnerable service users. population will notes that R&D investment in require examining the immunology, neuroscience and Rob Webster’s piece shows how determinants of clinical innovation will all be central to successful community engagement wellbeing at a much keeping an ageing population healthy. and joint working can occur on a more local and larger scale. By fostering close However, high-tech, globe spanning relationships between NHS personal level.” policy initiatives will not drive organisations, local authorities and sustained health improvements on the third sector, the West Yorkshire their own. Building a healthy and Harrogate Partnership has population will require examining the delivered its ambition of putting the determinants of wellbeing at a much interests of local people first. more local and personal level. As our Collaborative working at all levels has contributors point out, social improved the experience of patients, deprivation and inequality remain key built healthy communities and drivers of ill health and addressing ultimately saved lives. them will be vital for ensuring that health improvements are shared by all As we recover from the COVID-19 communities. pandemic we must not be content to settle for restoring “business as usual” In this vein, Deborah Arnott argues to our health system. We must that reducing smoking rates will embrace clinical innovation, new ways necessitate providing targeted of working and the principle of support to help disadvantaged collaboration to make health smokers quit, including the third who improvement a shared priority. Only live in social housing and the third by turning bold thinking into action who live with poor mental health. In will we equip ourselves to meet the the case of obesity, Caroline Cerny next decade’s most pressing health notes that unhealthy weight is closely challenges. associated with deprivation and @reformthinktank REFORM [email protected] www.reform.uk

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