Lessons from the Complete Care Community Programme

There is more focus on health inequalities than ever before. Addressing health inequalities is much needed, but it isn’t easy. That’s why the insights from the Complete Care Community Programme (CCCP), which was launched in April 2021, may be valuable.

As a nation, we are continuing to live longer. Life expectancy in 2023 is 81.77 years, up from 77.67 years in 2000. Increasing life expectancy in the 21st century has resulted from multiple factors, including improvements in societal health behaviours. It could also be considered a sign of a successful health and care service. However, unless a longer life is accompanied by increasing healthy life expectancy, it will result in increasing numbers of older people requiring care.

The gap between total and healthy life expectancy increases with deprivation. So, the biggest health gains could be achieved by a more targeted approach to those individuals and groups who are the most socio-economically challenged.

Unfortunately, the NHS does not have a strong track record of this more targeted approach. For the first time in modern history, UK gains in life expectancy have stalled. First, there was a slowdown in life expectancy improvements between 2011 and 2019. And then, the Covid-19 pandemic hit, resulting in England’s largest fall in life expectancy since World War II.

So, does this question the impact the NHS currently has on health inequalities?

The Complete Care Community Programme seeks to investigate some of these issues and explore the extent to which the NHS can maximise its contribution to addressing health inequalities.

What is the Complete Care Community Programme?

The Complete Care Community Programme is a national programme which supports Primary Care Networks (PCNs) to identify and narrow health inequalities in their local area. The programme encourages local networks to adopt a systematic approach to addressing the wider determinants of health inequalities, including using data to inform action.

The CCCP is undertaking fieldwork in 46 demonstrator sites across all seven NHS England regions and currently covers nearly 3 million citizens.

More specifically, the Complete Care Community Programme has adopted an approach that;

• moves forward from merely describing the challenges to enabling a better understanding and rationale for them and then developing strategies for change through new service development
• develops and uses multi-level designs and methodologies that facilitate a focus on the factors that impact people’s everyday lives and who are living with deprivation
• acknowledges the complexity, diversity, and reciprocity of the relationship between socioeconomic status and health
• provides an explanation of the increases in health inequalities from a local community causation perspective
• adopts a life-course approach and investigates the aetiology of socioeconomic health inequalities in defined population groups
• applies the science of spread and scaling to the findings from the CCCP demonstrator sites.

This is a multiyear task in a very challenging area of research. However, a programme has now been established that is providing data and starting to inform an approach which is demonstrating success in tackling inequalities in health.

While the CCCP methodology can – and is – producing many varied forms of delivery, the extent of the demonstrator sites’ effectiveness does depend, at least in part, on several factors. These include whether social-ecological principles underpin the adoption of strategies and whether they are targeted and inter-sectoral. It also depends on the level of community participation and whether they simultaneously focus on multiple entry points to care.

The programme has now been running for two years. And the first report from the programme highlighted significant findings in four key areas that can be summarised as the CCCP 4Ts. They are:

Trust

For individuals within defined population groups, successful care provision requires building a relationship between the recipient and the provider at an individual level. For systems, this trusting relationship is developed between the agencies involved.

For the marginalised population ‘segments’ that the CCCP is interacting with, the recipients have found problems developing trust with agencies at various stages of their lives. Therefore, a key aspect of the successful CCCP sites is how care providers have sought to engage with the recipients and to build a relationship in which the latter feel listened to and supported on their terms. This ‘trusted healers’ relationship is the cornerstone to supporting ‘hard-to-reach’ individuals.

The CCCP has now developed the concept of ‘language empathy’. This means that conversations are at a level of understanding and expectation of the person with whom a carer or healer is speaking.

The NHS still has a need to improve health and care encounters and correspondence in which the NHS and the patient converse at a consistent level of comprehension. CCCP sites have found that ‘demonstrative listening’ – that is, listening with the same intent with which you wish to be heard – is particularly important for people who have previously experienced some societal exclusion.

A social concordance between care provider and recipient has also been found to be very important in connecting with ‘hard-to-reach’ people and groups.

Transparency

The Complete Care Community Programme espouses transparency. This refers to the extent to which an organisation allows recipients of care to monitor and understand its operations.

It has historically been difficult to involve sections of the community in public participation exercises, not least to help them feel included in decision-making about their health and care services. A key principle of the CCCP is that clarity should be given to how decisions are made and ensuring that recipients of care are involved in the process. Integrated Care Boards should be researching and understanding their own hard-to-reach groups in this way.

A finding in the first stage evaluation report highlighted a mismatch between what the care system was claiming – for example, public inclusion – and an individual recipient’s actual experiences of it. Whilst there was a recognition that some variation would occur, especially if explanations which resonated with the recipients were provided, all too often such an approach was absent.

The CCCP demonstrator sites saw this component as having significant importance and are actively engaging their population groups in service design.

Training

At both undergraduate and postgraduate levels, considerable emphasis is placed on clinical aspects of care provision. However, successful project development in the CCCP demonstrator sites was equally dependent on non-clinical competencies.

Given the background to the recruitment of health care professionals, especially undergraduate selection, their experiences and appreciation of understanding of the marginalised groups’ problems were found to be limited.

The successful CCCP sites reported that care providers who worked with other agencies, especially voluntary sectors, were able to understand better the problems of the very groups that they were working with. Furthermore, a key finding in the initial work centred on the role of the Clinical Director in driving through the CCCP proposal within their PCN and the wider agencies involved.

Time

The Complete Care Community Programme cannot comprehensively address system shortcomings against a backdrop of variable and wide-ranging challenges. It is not designed to do so.

Addressing the three aspects above requires significant time and resources, whether at an individual or system level. Time is needed to listen and gain a deeper understanding of the local and global issues that lead to inequity and inequality in care provision. Time is required to build relationships with organisations that have different cultures and use different language to the NHS.

What next?

The current allocative value in the NHS will need to be examined if adequate resources (time, people and funding) are going to be deployed in addressing one of society’s greatest injustices.

A different relationship and approach to care need to be developed between the NHS and underserved groups of people if the NHS is to achieve its ambition to reduce disparities and inequity in health and care.

The CCCP is helping to inform policy and strategies for change to enable the NHS to improve its impact in reducing health inequalities, both locally through its demonstrator sites and nationally through its evaluation of this collaborative approach with other organisations seeking to address the wider determinants of health.

We now wonder if Abraham Lincoln was referring to the gap in total life and healthy life expectancy when he purportedly said: “And in the end, it’s not the years in your life that count. It’s the life in your years”.

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