A report earlier this month by the Commons health and social care committee said “extreme” financial and workforce pressures are undermining efforts to integrate services.
It warned the scale of the ambition to develop greater collaboration between the health organisations and councils, as outlined in the NHS Five-year Forward View, “has not been matched by the time and resources required to deliver it” and systems are struggling in “survival mode”.
Progress in Nottinghamshire is the exception rather than the rule. It is held up as one of 10 areas, based on the footprint of the sustainability and transformation plans and partnerships, which are developing integrated care systems and turning the Forward View theory into effective practice.
However, it is worth noting the county has benefited from significant inward investment, with five of the 50 NHS Vanguards established there resulting in an additional £26.6m in funding since 2016.
David Pearson, Nottinghamshire and Nottingham STP lead, Nottinghamshire CC corporate director for adult social care and health and an advisor on the green paper, told LGC during our visit to the county that a history of local collaboration has established the required “positive relationships, common purpose, mutual understanding and the ability to tackle difficult issues honestly and effectively”.
He acknowledged that additional funding has helped significantly to lay the foundations for embedding transformation and admitted other areas could now find it harder to implement system-wide change in the current financial climate.
“I think my experience of large scale change is that you need capacity and resources to kick start the change, Mr Pearson said. “In a situation of ever tighter finances it is increasingly difficult to find the resources from core overstretched budgets to do this.
“There is no doubt transitional transformation funding is hugely significant, as are relationships,” he added.
To see at first hand how the system is working on the frontline, LGC visited Mansfield which is part of the Mid Nottinghamshire Better Together integration Vanguard and has received additional funding of £13.2m over the last two years.
The Poppy Fields extra care housing scheme in the town was designed and developed by Mansfield DC at a cost of £8.4m.
The site includes 64 homes including 10 bungalows for people with advanced dementia and 12 short-term reablement apartments.
These are mainly for older people who would otherwise be unable to leave hospital, discharged straight into a care home or struggle to live independently.
Residents receive 24-hour support from council support workers, occupational therapists and social workers during an average stay of six weeks, which enables Mansfield to find alternative housing if necessary.
For Mansfield chief executive Hayley Barsby, the opportunity the facilities provide for people to live independently for as long possible is a part of a broader effort to tackle health and social inequalities in the town – and housing plays a key role in addressing wider social determinants of health.
She told LGC her council works beyond its legal requirements in a bid to influence future demand and improve lives.
“[In local government] there is continued focus on ‘does this fall into the criteria for statutory services?’
“I don’t focus on statutory and non-statutory services – they are out of date. We need to understand the impact that the community has on itself.”
Mansfield’s advocacy, sustainable, supporting independence and safeguarding team (Assist) provides a 24-hour response service, help with housekeeping, small repairs and companionship.
Members of the Assist team work in partnership with Nottinghamshire social workers and clinical staff at Kings Mill Hospital as part of a single team to identify patients who may be in hospital unnecesarily.
Two members of the team from Mansfield (“Council Cath and Council Carol”) spend their days working with patients identified as having a housing need which is delaying their discharge.
During a meeting with the team, LGC is told these patients would often be emergency admissions with no family and living in isolation without support.
Prior to the team being stablished, nurses would routinely spend a significant amount of “valuable time and resources” filling out housing forms on behalf of patients.
Delays were often caused by relatively minor issues which would not fall within the thresholds of medical or social care need, contributing to delayed discharges.
LGC was told these could include the need for very small modifications to the home such as grab rails or patients forgetting the entry code to their block of flats, issues which now take hours rather than days to resolve.
The team says the arrangement has significantly improved efficiency, enabling clinical staff to focus on practice and improving outcomes for patients, who can opt to receive ongoing Assist support in the community for a small fee.
The first detailed evaluation of the Assist discharge project by Nottingham Trent University found it had dealt with between 600-660 cases a year and generated savings across health services, social care, housing services, welfare services and criminal justice of £1.4m, with an annual running cost to Mansfield DC of £340,000.
The financial return on investment to the Nottinghamshire health and social care system was found to be more than 900%.
The most recent evaluation found the team was still dealing with between 50-55 cases a month but operating costs had fallen to £149,500 because of staff development, improved processes and better inter-organisational collaborative working.
It adds: “The scheme continues to have a significant beneficial impact on a considerable cohort of some of the most vulnerable patients/clients as well as significantly reducing direct and indirect costs to the NHS and social services.”
When outlining the seven principles which will guide the social care green paper, Health and social care secretary Jeremy Hunt said there is a need to relentlessly focus not just on joining up structures, but also the care experienced by vulnerable adults.
The innovations found in Mansfield, with collaboration between two tiers of local government and health partners, offer a prime example of an approach that has a strong thread of prevention and a wider perspective on what social care is, while binding all-to-often disparate services through a unity of purpose.
But as Mr Pearson points out, the pace and scale of transformation Mr Hunt alludes to is likely to be out of reach without first bolsering the resources required for effective and sustainable change.