Mind the gap – Johnny Marshall

I boarded the train this morning with an ‘Advanced’ train ticket, offering me greater value for planning ahead. My intended outcome was to arrive at King’s Cross and catch the 07:05 to Leeds, or else I would have to pay a higher price. With such a focus on quality at the last FDG, the irony of the train breaking down on safety grounds was not lost on me! Fortunately, the train edged its way to a place of safety, the next station. In the absence of further instruction to calm my natural anxiety about making the connection, and incurring greater cost, I followed the crowd to another platform.

Still in need of some navigation, the ‘next train’ sign brought a glimmer of comfort that the underground system I had switched to would take me straight to King’s Cross. But would it get me there on time? My smartphone TubeMap app filled the data void and estimated the journey time. As the next train arrived, I boarded feeling remarkably calm expecting to board the train at King’s Cross with a good 4 or 5 minutes to spare. My previous experience had taught me how long it took to walk from the tube to the mainline. The data proved to be about 90% accurate, requiring me to take a little more personal responsibility for achieving my desired outcome by running part of the way. As the train pulled away, I had just sat down and was opening my netbook. I was left wondering how our information systems in the NHS compare with our journeys through the healthcare system, even in adversity.

Data was centre stage at FDG starting with the strategy, or was it a plan (I think it was dependent on what decade you last wrote one in), for Domain 1 of the NHS Outcomes Framework: Preventing People Dying Prematurely. It is clear that people with serious and enduring mental health problems have a significant reduction in life expectancy and homelessness is associated with an even greater reduction. Preventing people dying prematurely is surely a worthwhile aspiration. Indeed the intention to set a target for the future that takes into account the forecasted improvement because of interventions to date makes it even more genuine.

This presents a challenge around balancing the tension between delivering a national priority and addressing local healthcare needs. If the inequality gap in preventing people dying prematurely, for example, is too close then there will need to be proportionally a much higher gain in areas of greatest need. Thought was given as to how a national aspiration for improvement could form the basis of discussion between NHS CB and CCGs around improved local outcomes. Could CCGs each contribute to the delivery of a national improvement in a measure appropriate to address local health needs and reduce inequality? Could this deliver the aggregate benefit nationally whilst as the same time addressing variance in local health needs? A national plan built from the needs of the population upwards, perhaps?

Liver disease featured as an area of increasing premature mortality. The average practice of 10,000 patients can expect that 2.2 patients under the age of 75 will die from liver disease each year. Older and wiser heads than mine quickly pointed out that people come as a ‘whole’ and how we present data in a way that resonates with the audience we are trying to reach is an important factor in supporting change. In addition, this is not evenly distributed in every practice. I heard recently from a CCG colleague that the average life expectancy in the centre of Newcastle was the same as that of Guatemala, who spend a fraction of what we do on healthcare, with alcohol being one of the factors in that.  We need to target our efforts proportionately if we are to address this level on inequality.

If not counting someone at all is a problem then it could potentially be dwarfed by counting people more than once in calculating how many people have undiagnosed long-term conditions. With roughly a million people with diabetes undiagnosed, a million people with  chronic lung disease undiagnosed, a million people with chronic kidney disease undiagnosed etc. … there is a danger that there are more people with long-term conditions than people without. On the basis that the vast majority of people with a long-term condition have at least one other long-term condition then we need to take this into account as we make plans to support earlier detection and this is probably further augmented in addressing prevention (7 million people are at risk of developing diabetes).

One of the key issues about prevention is affordability. How can we afford to invest in prevention of disease when there is a need to spend the same money on treating disease? … that old chestnut! Within a flash, the question was turned on its head. How can we afford not to invest in prevention of disease when we are having to spend so much money on treating it, and this is only going to increase? … music to my ears! How to make it affordable remains the challenge, and one that the NHS CB seems prepared to own, and work in partnership with CCGs and health and well-being boards to address. I don’t underestimate how challenging this will be, nor how essential, but advanced planning certainly offers greater value on the rail network.

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One comment

  1. Christine Myers says:


    I am in awe of this passage that you have written! I was looking for info on Patient safety and you have literally blown me away!

    Thank you for your thought provoking write up!