Late last year it was announced that four more Greater Manchester clinical commissioning groups were to begin sharing senior leadership teams with their local council under moves to establish ‘single commissioning’ functions in the conurbation’s 10 boroughs.
In Tameside MBC in the east of the conurbation Steven Pleasant has headed the council and Tameside & Glossop CCG on a permanent basis since August 2016, the first such joint role. The two organisations now have a single leadership team, based within the council, while health and care commissioning decisions are taken by a joint committee of GPs and councillors overseeing a budget of £500m.
LGC Interview: Bringing CCG into the council has helped drive reform
Speaking to LGC about the impact of the new model, Mr Pleasant reels off a long list of achievements he believes would not have happened without working this way.
He says the organisations have taken “£36m out of their base costs”, reduced elective referrals by 16%, moved secondary clinicians into the community to provide a response for the frail elderly and created a digital clinical hub which has “deflected” 70% of care home ambulance callouts and GP visits.
In addition they have moved primary care leaders, such as GP neighbourhood and disease pathway leads to create a new neighbourhood-based model of service provision.
Meanwhile, social care is being transferred into the integrated care organisation.
Mr Pleasant, who has headed the council since 2009, says developing a “single version of the truth” shared by all partners has been crucial to making these service changes. “We don’t have the better care fund conversation because it’s immaterial,” he says.
However, most of these service changes have, and are, being tried elsewhere in varying combinations and with varying degrees of success.
Mr Pleasant acknowledges funding from the Greater Manchester transformation fund, agreed as part of the area’s health and social care devolution deal, has been important in delivering improvements. And while he insists devolution is not a prerequisite for greater integrated working, he says Greater Manchester’s health and social care devolution deal has “provided significant space” to get on with making changes and has helped develop “stronger” local relationships.
Longer term, Mr Pleasant says the success of the model should be judged not on the performance of the urgent and emergency care system but on “more profound changes” to the health of the conurbation’s population who as a whole live in one of the fifth most deprived local authority areas in the country.
While the Greater Manchester health and social care devolution deal puts Tameside in a different position from other parts of the country, the Health and Social Care Act 2013 still applies. This means the CCG retains its statutory status and Tameside has had to find workarounds to stay within the law.
For example, only about a third of the joint committee’s £0.5bn spending – which includes all the CCG’s budget as well as the council’s adults, children’s and public health budgets – can be pooled under section 75 of the NHS Act 2006. This means decisions taken by the committee sometimes technically have to be ratified elsewhere, such as by the CCG governing body or the council’s cabinet.
He said good relationships between the council leader, cabinet member and chair of the CCG are critical to making this work, as well as spending time developing relationships at a managerial level across the health economy and genuinely sharing risk.
Mr Pleasant says: “God forbid you don’t want guidance on all this because there’s not a single way of doing it, but if you start creating mutual accountabilities in places, so I feel as accountable for the performance of the hospital as the chief exec does, it creates the right conditions for that conversation.”
In recent years councils’ executive management teams have shrunk, with individuals often taking on responsibility for a number of services areas. Tameside is no different – Mr Pleasant says he has lost “about half” of his management team over the past few years.
However, he says conversely combining the council and CCG senior leadership teams has added capacity. For example, the CCG’s director of nursing has become director of quality and safeguarding across both organisations.
“I have a concern that a lot of our local government managers are carrying too much, this allowed me to spread the load, particularly around children and adults,” he says.
From a personal perspective, Mr Pleasant stresses the joint role is not a job share with allocated days for each organisation but a “different leadership role”.
The former town planner, who started his local government career 30 years ago, says working directly for the NHS has made him realise he didn’t previously understand the health service as well as he had thought.
While noting that the NHS is more hierarchical than local government, he cites the complexity of the environment and working with clinicians as two differences he had perhaps underestimated before.
He says: “Sometimes local government managers, probably me included, thought that an NHS manager’s life was simpler. Well it isn’t, it’s just different.