The chief executive of Public Health England, Duncan Selbie, explains that further investment will not address health disparities; tackling wider inequalities will
"The NHS is vital, and I believe in a strong and thriving NHS. I do. It’s just that it’s not enough,” says Duncan Selbie. He joined the the National Health Service at the tender age of 17, and worked his way up – without either a degree on clinical background – to become a director in NHS England. But he left in 2013 to head up Public Health England, and now he wants to go much further in closing health gaps.
The solution is partly a focus on holistic care and integration, he believes, in line with the so-called ‘Marmot review’ into health inequalities (Fair Society Healthy Lives), as well as the Five Year Forward View, which he worked on “with Simon” (Stevens, chief executive of NHS England, who he mentions regularly and affectionately). The buzzword ‘integration’ here signifies health and social care integration, mental and physical health, primary and secondary care, even commissioners with local government. It is generally agreed that this would create better outcomes for people, improve patient experience and satisfaction, and create efficiencies in time and finances. However, Selbie’s utopia hinges on humble leaders, investment in relationships and an unnerving focus on local issues. Does it all stack up?
Q You were the first director of commissioning for the NHS. Do you think you’d go back to commissioning again at some point?
Essentially, the expertise that public health brings is like commissioning, it is an appreciation of the health gap and what you can do about it, and what’s driving it. Healthcare in that context is a contribution, but it’s not the most important contribution. We wouldn’t still be seeing the typical 10-year gap in life expectancy if it was just about healthcare, because we’ve seen a doubling in spending, and we’ve seen some fantastic improvements in outcomes, efficiency and performance. I’m old enough to easily remember when people waited 18 months to get their hip fixed, it is simply not the experience people have today.
We know that a strong and efficient and functioning health service is important but it’s not enough because it’s not what’s driving the gaps in life expectancy and life in good health. Those are more to do with having work as an enabler to good health, having somewhere decent to live where you feel safe, where you have enough money to turn on the heating, where you live with your family and friends and are not being isolated in your life, and a bit of genetics, and other things we don’t really yet understand. These are much more relevant and powerful in closing gaps in health and inequality than more investment in healthcare… We need to be concerned with the wider points of prosperity.
Q What do you think the biggest challenges are for clinical commissioners at the moment?
Gosh, I hope I give you a direct answer to this! I visit three places a week around England and I meet clinical commissioners and local government, each with their own experiences, joining them up and looking at the aims from a health perspective. I want to see that everywhere. The vanguards are very important and they are talking to others but it is essentially how does the NHS organise to better effect with greater efficiency?
The challenge is how to look up and out, that’s what the NHS is asking you to do – the secret’s in the title National Health Service – but also to be place-based. The challenge is to look out but think and act at a local level.
Q What about the future of CCGs, will they merge with councils?
What I see is an inseparable future. I think there’s a role for NHS clinical commissioning, yes of course there is, they’re the frontline army for prevention.
Q What would your tip be for commissioners to quickly improve relationships with authorities and organisations?
I should have said at the outset I’m not an oracle on anything, but what I say is that it all comes down to people and relationships, and they take time to invest in. I’m much more concerned about the strength of local relationships than I am by structural reform. So what I would say to people is run towards each other and realise that your future is inseparable.
The public isn’t bothered who holds a budget, what they’re concerned about is that when they need help it is there, and that does mean that people have to work together.
Humility matters I think. It’s not about your title or where you sit in the system but about the difference you make, and mostly that’s about local action.
We should invest, cherish, respect and celebrate what our local CCGs are doing, and thank them for remembering that what matters is how they work together at a patient and local level.
Q So, talking about workforce and leadership, a recent survey suggests that there’s a bit of a leadership crisis at the moment, with people being afraid to take on roles due to the fear of being blamed for the failures of their organisation. What’s your take on this?
The first thing to do is to create a culture where people feel able to do their best work, and when something goes wrong they feel able to say so...
We’ve not always got that right. If people are afraid to talk about things then organisations do not perform as well as they might. I think it’s a fundamental challenge for all of us in the system to talk about this. I believe we could do better.
Q Do you think that there’s anything specific that CCGs or local leaders can be doing to encourage more people to take on leadership roles?
For lots of perfectly understandable reasons people have cultivated their careers in a particular area, and haven’t moved around in the way that would allow them to see from different perspectives. I’d like to see more movement between the sectors at different levels, and outside as well.
I learnt, growing up in the Service, that people often think if you work at a higher level you are somehow more senior and more influential and important. I’ve come to understand is that what you learn is something different, because you‘re looking at it from a different perspective, and it enables you to see the world in a more rounded way. Of course there’s a great reason why we specialise – but it can be limiting. I would like us to get out a bit more. In my own career I’ve had the opportunity to work in mental health, sexual health, health visiting, and I bothered the NHS for a few years as a quietly spoken psychopath coordinating the work to get waiting times down.
The other thing is that in health people don’t see the advantage of spending time in the Department of Health. In the military if you want a bigger regiment or wider responsibility then part of your development is to spend time in the Ministry of Defence, so that the Ministry gets a fresh perspective of the frontline and you understand how decisions get made. But in healthcare that is very rare. People are often puzzled throughout their careers about why stuff happens, as they’ve not had that experience.
Q Any closing comments?
The NHS is vital, you can’t say that I don’t believe in a strong and thriving NHS. I do, it’s just that it’s not enough. That’s not blaming anybody. We can’t do anything about the persistent decade after decade gap in life expectancy by believing that the health service can make that better, because it can’t. But at a local level, the CCGs working with local authorities, they’ve got the best chances ever in closing those gaps.
They can concern themselves not just with the consequences, but crucially what are you going to do to avoid them? And the most important thing you can do to avoid early long-term illness and conditions is to have some reason to get up in the morning. It’s vitally important and it’s in combination with this that you can close the gaps.
When we think about the health service we’re not widening sufficiently to think that what we’re trying to do here is to improve the life chances of everyone. The health service contributes to that, but it can’t of itself improve it. That’s why Public Health England exists. Not to be the oracles but to be the conscience and the defender of the public’s health. And to keep saying the same thing again, and again, and again; that you cannot conflate good health with more investment in healthcare and expect to see inequalities addressed.