In June 2018, the Centre for Progressive Policy (CPP) commenced a 12-month inquiry into the future of health and social care in England with the report Diagnosis Critical. This report, Beyond sticking plasters, looks further into the health impacts of place-based inequalities including presenting new research about the consequences of local areas having complex and fragmented healthcare institutions.

The relationship between health and economic prosperity is long established. The ‘Preston Curve’ shows that individuals born in richer countries, on average, can expect to live longer than those born in poorer countries. Critically the relationship is two-way – health gains boost prosperity while increased prosperity can result in health improvements.

There are many reasons why health is important for prosperity. Healthier workers will stay in the labour force for longer, while increased life-spans increase the incentives to invest in education, raising productivity. Health improvements may also impact productivity via increased investment since people respond to longer lives by saving a greater proportion of their income. It has also been shown that healthier children are more likely to attend and thrive at school increasing their knowledge and cognitive ability. Health is therefore crucial not only for the physical and mental wellbeing of individuals but also their economic potential. It is the fundamental human asset enabling meaningful economic activity. For these reasons, delivering good health must be a key pillar of any inclusive growth strategy.

In this context, CPP has embarked on a 12-month inquiry into the future of health and social care in England informed by three overriding principles:

1. Good physical and mental health must be a key pillar of any inclusive growth strategy, and this is health in the widest sense of the word, not just healthcare. The NHS plays a significant part in this debate but is not the only delivery mechanism.
2. Place must quickly be recognised as the determining factor of health – but before this can happen a common definition of what this means needs to be created.
3. The system needs to change; increased funding cannot be used for marginal efficiency gains or merely to help health and care delivery stand still.

The Fragmentation Index

Currently, the lack of a clear concept of place is hindering an effective treatment of its role in the nation’s health. CPP research has highlighted the complexity and geographical fragmentation of the institutions accountable for the delivery of health and social care in England. Furthermore, the research has shown that this fragmentation is associated with being more likely to end up in hospital and finding it harder to be discharged.

CPP’s new Fragmentation Index illustrates how fragmented the system is in each local authority. Use the interactive map below to look at your local area – the higher the score the less the relevant institutions are geographically aligned (i.e. the less they share common boundaries). You can also use the drop-down box on the right of the map to toggle on and off the boundaries of the different institutions or click on an area to see its details.

The need for a whole systems approach: our key findings

Since commencing our inquiry into the future of health and social care we have undertaken a comprehensive programme of engagement with members of the public, policymakers and politicians across the main parties. Based on publicly available data, this interim report presents our key findings to date:

1. The nation’s health, as measured by life expectancy, is stagnating. Life expectancy among older women in areas situated in the bottom four deciles of deprivation saw flatlining or falling life expectancy. It is likely that rising place-based inequality is driving the overall slowdown in UK health improvements.
2. The use of different definitions and boundaries across economic and social policy institutions and public services agencies creates challenges in delivering the place-based coordination and accountability necessary to improve health outcomes. CPP’s new Fragmentation Index shows that people who live in areas where the different bodies responsible for healthcare are geographically misaligned are more likely to end up in hospital and find it harder to be discharged if they do. Specifically, we find:
   
   - For each point a local authority moves down our fragmentation index, there will be around 5% more unplanned admissions to hospital.
   
   - If the local authority you live in doesn’t geographically align with the CCG (Clinical Commissioning Group), Delayed Transfers of Care are, on average, 32% higher.
   
   - In a local authority where the different bodies responsible for healthcare do not geographically match up, there will be around 15% more unplanned admissions to hospital and 30% more people will be delayed in being discharged from hospital.
3. The challenge posed by misaligned institutions and structures may be exacerbated by recent NHS policy developments. The emergence of regional teams and regional geographies covering both NHS England and NHS Improvement functions are intended to promote integration, but they may add yet another layer of complexity to already complicated and fragmented local health systems.
4. The NHS cannot solve health inequalities in isolation. Employment, education, skills and training, access to better quality housing and other public services are integral to health and the relationship between health, wealth and income inequalities.
5. Addressing health inequalities requires cross-departmental action and resourcing as well as improved coordination at a local level. If better health is the goal, then place-based investment and coordination in education, skills and training, increasing access to quality housing and active labour market policies to reduce unemployment and low pay may be just as relevant as more funding for local hospitals and GP surgeries. Cross-departmental strategies in central government do not do enough to make collaborating easier or more effective while funding and accountability incentives are not sufficiently aligned to allow for integrated ‘whole place’ approaches to supporting health at a local level.
6. The long-term failure to think holistically about health is having a particularly detrimental impact on adult social care. Adult social care is failing with declining standards, insufficient funding and significant inequality in access and provision. CPP analysis of Care Quality Commission (CQC) data shows that in some local authorities only around half of care homes are rated as good or outstanding when it comes to safety whereas amongst the top 10 local authorities this rises to over 90%. There are even greater variations in terms of the availability of residential care.
7. Local differences in care provision help underpin the health inequalities outlined in this report. Our analysis finds that a lower proportion of good or outstanding care homes and a higher number of older people per care home are both strongly related to areas having a higher avoidable mortality rate.

Our central thesis is that we must consider alternative models of health delivery that focus on addressing place-based social determinants of poor health, underpinned by the development of complementary governance arrangements, financial and accountability mechanisms. This does not necessitate top-down structural change, but more effective coordination between multiple agencies and stakeholders will be critical. There are already innovative examples of such approaches in operation today. Our first key challenge is to evaluate the success of these new models and understand how to build on them at scale and at pace.

In this context, the inquiry’s final report to be published in the spring of 2019, will set out a compelling alternative, sustainable, whole systems model for health and social care in England. It will explore in detail what national, regional and local policy changes are required to deliver better health and explore their possible economic costs and benefit.