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NHS & local government: Complex needs merit a joined up response

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Improving the health of UK residents demands more integration between local government and the NHS. Jimmy Nicholls reports

Participants

  • Helen Atkinson, executive director of health, wellbeing and adult social care, Surrey CC
  • Jon Bunn (chair), senior reporter, LGC
  • Richard Carr, STP lead Bedfordshire, Luton and Milton Keynes; chief executive, Central Bedfordshire Council
  • Dr Amanda Doyle, STP lead, Lancashire and South Cumbria
  • Peter Fairley, director of transformation, Essex CC
  • Rachel Flowers, director of public health, Croydon LBC
  • Nick Hulme, chief executive, The Ipswich Hospitals NHS Trust and Colchester Hospital University NHS Trust
  • Dr Karen Kirkham, assistant clinical chair, Dorset CCG
  • Dr Jane Moore, director of public health, West Midlands CA
  • David Pearson, corporate director, Nottinghamshire CC
  • Robin Tuddenham, chief executive, Calderdale MBC
  • Rob Webster, STP lead, West Yorkshire and Harrogate; chief executive, South West Yorkshire Partnership NHS Foundation Trust
  • Julia Weldon, director of public health and adult social services, Hull City Council
  • Rob Whiteman, chief executive, Chartered Institute of Public Finance & Accountancy
  • Keith Willett, director for acute care, NHS England
  • Cathy Winfield, chief officer, Berkshire West Federation of CCGs

”The National Health Service is the closest thing the English have to a religion.”

The remark, by former Conservative chancellor Nigel Lawson, is rarely contested, and politicians often strain to prove their devotion to the faith. In June prime minister Theresa May promised £20bn a year more of funding by 2023, up from the current £114bn. The yearly rise in spending of 3.4% is slightly less than the average rise of 3.7% since the NHS was founded in 1948.

For local government such a pledge contrasts with the cuts it has endured this decade. But the view among health and local government experts at a recent LGC and NHS England roundtable is that too much focus on health at the expense of other services is counterproductive, even in the narrow pursuit of health.

“Yes, the NHS is evidencebased,” said Robin Tuddenham, chief executive at Calderdale MBC. “Yes, the NHS has seen clinical outcomes which have improved lives, longevity, quality of life.

“But there’s also an issue about why you are throwing all this money into one part of the system. Where’s the evidence for that? If we were really evidence-based, would we be devising a social care infrastructure?”

While British people are living longer today than in 1948, their health needs have become more complex, with patients presenting with more conditions than previously – in part because medical advances have made some health problems surmountable.

“I think we all understand that medicine has changed, population has changed, and what we can do is very different,” said Keith Willett, director for acute care at NHS England. “Public expectations probably have also changed.”

Rachel Flowers, director of public health at Croydon LBC, said: “We’re now seeing children who weren’t expected to live beyond two surviving longer, who are now moving through the children’s services supported into the NHS, and transitioning – some with complex physical issues, some with mental health issues – into the wider system.”

It’s not just about health and social care, it’s the wider determinants

Rachel Flowers, Croydon LBC

“When I started as a social worker in 1982, the average life expectancy of somebody with Down’s syndrome was 23, which was the age I was then,” said David Pearson, corporate director at Nottinghamshire CC. “With a good prevailing wind I will reach the age of 60 in January, and the average life expectancy of somebody with Down’s syndrome now is 60.

“Beyond any time in history we’ve got the greatest level of growth of longevity and complexity of [health] needs. The way in which most well-known systems across the world have responded to this is to integrate what they do, but to blend the best of the traditions.”

Ms Flowers agreed. “The big issue around this is the wider system,” she said. “It’s not just about health and social care, it’s the wider determinants. It’s about housing; it’s about jobs; it’s about income; it’s about education; it’s about the poverty of opportunity, the poverty of jobs, the poverty of income across the country.”

This is where local government can aid the health service in its goal of promoting good health.

“Local government is the home of the wider determinants agenda and it’s part of the everyday conversation,” said Helen Atkinson, executive director of health, wellbeing and adult social care at Surrey CC. “There’s a real opportunity around local place if the NHS and local government work together around place and use the opportunities.”

Examples of this were provided by Rob Webster, sustainability and transformation partnership lead and chief executive of South West Yorkshire Partnership NHS Foundation Trust. “My trust paid for a derelict mill in Halifax to be converted into a free art school, because we know that will support local people and their wellbeing,” he said.

“How do we support unpaid carers? What about the million pounds we just put into loneliness from the £8.7m that we got from becoming an integrated care system? All these things are supported by leaders across the NHS and the care system and communities and the third sector.”

As Mr Webster’s examples indicated, there is a belief that local government and the NHS are ideally situated to deal with this complexity together. But there are also barriers to effective collaboration.

Part of the problem is lack of integration. “It’s a real nonsense that we have a disconnect between the benefits of what’s done in social care and local government and what’s done in health,” said Mr Willett.

“I think we all understand what we’re trying to do with integrated care and place-based commissioning and services. I think we see the barriers, but we probably see them from two different sides and don’t quite understand the other side as well as we should do.”

It’s a real nonsense that we have a disconnect between the benefits of what’s done in social care and local government and what’s done in health

Keith Willett, NHS England

The view is not unique to NHS staff. Mr Pearson said: “Several decades of policy and legislation have created schisms within health, as well as between health and social care, and vacillation between competitive approaches – things like foundation trusts, internal markets – and the imperative to integrate.”

“The local government sector and the health sector do operate against the background of very different systems of accountability, governance, funding, cultures,” said Richard Carr, sustainability and transformation partnership (STP) lead and chief executive of Central Bedfordshire Council.

“Some of it goes back to the NHS being populated by people with strong professional backgrounds working to protocol. I think what that encourages is looking at bits of people rather than whole people, which I think as a sector local government is perhaps a bit more sensitive to.”

Julia Weldon, director of public health and adult social services at Hull City Council, said: “We’ve talked about population health and individual focus approaches, but local government is really well placed for population health. Population health is what we’ve been doing for a very long time.”

However, Mr Webster disputed generalisations about sharp differences between health services and local government. “I think we’ve got to make sure we don’t talk ourselves into that corner where we say there’s loads between us which is going to separate the work we do,” he said.

“As a chief executive for more than 11 years now my closest relationships have usually been with local government chief executives, whether I’ve a been a commissioning chief executive or a trust chief executive. I don’t quite buy this idea that we are separate.”

Whatever the view on differences between the NHS and local government, there was agreement that more long-term planning is needed in both sectors.

“We absolutely have to be thinking about the way our population is going to change over the next 10, 20 or 30 years, because otherwise whatever we do in the near term the system will be absolutely swamped by the impact of that changing population,” said Mr Carr. “It’s not just a numbers game. It is trying to anticipate the way the requirements of our population will change.”

Peter Fairley, director of transformation at Essex CC, said: “I don’t think either sector is good at long-term planning, and there’s good reasons for that. There’s politics, there’s finance, there’s the problems of today.

“We talk about population health management: you can manage the present you can’t manage the future. Somehow, we’ve got to get better about planning the resources, the way in which we work in 15 years’ time.”

He added that some of the joint-working bodies were rectifying this. “I think one of the benefits of the STPs and the ICS [integrated care system] I’m involved in is we are starting to come together to think about whole systems. The challenge is I’m not convinced the same join-up is happening nationally.”

Jane Moore, director of public health at West Midlands CA, said: “If we get this wrong the implications for society are enormous. You talked about demographics in terms of ill health, but the demographics in terms of the people who are actually going to care for the people and deliver the economics have to be right.

“It’s the gap between healthy life expectancy and life expectancy that is at the heart of the big problems about demand [for health services]. And if that widens, that significantly increases costs. But it doesn’t just increase costs, it actually is a drain on productivity.”

Discussing the UK’s productivity, Rob Whiteman, chief executive of the Chartered Institute of Public Finance & Accountancy, noted that the UK was good at “technical productivity” – doing or producing more with the same resources – but bad at the “allocative productivity” of spending money effectively to boost overall system efficiency.

“The UK is notoriously dreadful at allocative productivity,” he said. “Health spending is an example of that where to some extent we’re macroeconomically cheap. We spend a little bit less on health than some other major economies.

“In a way that’s because – I don’t mean this is a pejorative way – we don’t have local government. We have councils which are local institutions alongside another lot of local public sector which is managed by the state.”

I really want to understand how we step into a new space where we take our local government democratic accountability with us

Julia Weldon, Hull City Council

While many stressed that a lack of long-term planning was hurting health and social care, some argued a stronger focus on the future would also open new opportunities. Karen Kirkham, assistant clinical chair at Dorset Clinical Commissioning Group (CCG), was one of them.

“One opportunity is about really driving integration of services of health and care, because we know that makes a real difference to the people who work within those teams and patients,” she said. “It reduces inefficiencies. It allows us to start thinking about joint training and employment, where we can start working together with caring agencies and our NHS.

“I think it allows us to bring together physical and mental health. If we don’t have any silos of single management or single conditions, and start thinking in a more holistic way, we stand to make greater gains and bring in personalisation.”

Explaining the untapped benefits of population health management, Cathy Winfield, chief officer of Berkshire West Federation of CCGs, said: “We’ve got a connected care programme which means we’ve got social care data. We should be able to get some much better predictive capability into our system about who is emerging as having risks and the impact of some of interventions.

“I see population health management as a tool for managing the now, but also as a tool for predicting the future and a tool for evaluating impact, looking at changes and risk profiling in quite a systematic way. I’d quite like to see much more of a strategy about that. I think in the long-term plan it’s loosely going to get called prevention – but I think it’s so much bigger than that.”

Contrasting this, Amanda Doyle, STP lead for Lancashire and South Cumbria, cautioned against fixating on lofty policy outcomes that patients are less interested in.

“Health inequalities are absolutely stark [in Blackpool],” she said. “But when you ask people in that place what their concerns are about what we’re offering, they’re not bothered about that. They’re bothered about access times and all those sorts of things.”

There was a broad sense that local government and the NHS should take a less “patrician” attitude to health and ensure patients had control of their healthcare. Ms Weldon said: “I really want to understand how we step into a new space where we take our local government democratic accountability with us.”

However, Dr Doyle said the democratic deficit in health services was overstated.

“We sometimes act as though commissioners and providers of care services aren’t democratically accountable. We are, but we’re just democratically accountable on a national basis. And the drivers of votes and that level are access and lots of things. They’re not how wide health equalities are.”

Nick Hulme, chief executive of the Ipswich Hospitals NHS Trust and Colchester Hospital University NHS Trust, argued that some of the incentives within the NHS were wrong in the current setup. “We need to start rewarding, developing and incentivising leaders for successful organisations – and do it for system,” he said.

“The NHS for 70 years has been perfectly designed for the needs of the people that work in it. It’s designed around the staff perfectly – so we get that system. For me that’s the biggest challenge in the NHS.”

As remarks like this indicated, disagreements about how to improve public healthcare in the UK are likely to continue. But there is consensus that better integration and a wider view of health are the way forward.

As Ms Flowers put it: “It is about the whole system. The third sector play an important part, and the private sector has to as well. But more importantly the communities and the people have to be at the heart of this.”

This roundtable discussion was sponsored by NHS England. The topic was agreed by LGC and NHS England. The report was commissioned and edited by LGC. See LGCplus.com/Guidelines for more information.

Health and local government integration is already reaping benefits

Michael Macdonnell, national director for system transformation, NHS England

Both NHS organisations and councils are under pressure, asked to deliver more and better services under considerable resource constraints – and these services are pivotal to the health of local communities.

Many of the factors that impact on our wellbeing, such as housing and public health, fall under local authority remit, and of course the challenge of meeting the needs of older residents is one that’s shared across the two sectors.

That’s why the NHS and local government need to collaborate, joining forces to improve the lives of the local population and make best use of collective resources. This isn’t always easy, but the roundtable showed what can happen when local leaders work together.

That’s the point of the 14 integrated care systems (ICSs) now operating across England, covering more than 12 million people. David Pearson, director of adult social services and leader of the Nottinghamshire integrated care system, described how better GP support in 22 care homes has led to a reported 29% reduction in A&E visits and 23% reduction in admissions.

There are similarly impressive results in Wakefield under Rob Webster’s leadership, where hospital bed days have fallen by a reported 28% since 2015-16 and investment in training will help the local system create 750 jobs per year by 2025, as well as a 50% increase in care home workers from the current 14,250 to 21,000. This great work in care homes is being picked up by integrated care systems around the country.

But of course, it’s not only the ICSs that are making progress. St Helens is home to an award-winning integration project bringing together NHS bodies, the council and housing providers to help people live independently for longer.

St Helens Cares has the potential to save up to £80m of public funding and covers a variety of initiatives, including a new contact cares team which is joining up staff and services including occupational therapy, discharge teams, community nurses, physiotherapy and adult and social services, which has led to quicker response times, reduced hospital admissions and improved detection of dementia.

In Croydon, director of public health Rachel Flowers is helping connect local NHS services, GP practices, Croydon LBC and Age UK Croydon. Initially focusing on older people, personal independence co-ordinators have been introduced and are delivering co-ordinated support for those living in the borough.

The success of the partnership has seen it expanded to cover all age groups and multiagency meetings known as ‘huddles’ have been set-up between GPs, social workers, pharmacists and other healthcare professionals, to plan and review the care and support available for their patients.

GPs taking part saw a reduction in unplanned hospital admissions while they increased for those GPs not involved in the scheme. Not surprisingly, all practices in the borough are now running weekly huddles.

This is just a small flavour of the exciting approaches that harness the different strengths of local authorities, the NHS and the voluntary sector to help keep residents healthy in communities up and down the country. They illustrate why we need to overcome narrow organisational interests and professional boundaries.

Local government has been doing system leadership for a long time. These examples show what can be achieved if the NHS and local government – perhaps the two most important public institutions in any community – are determined to be more than the sum of their parts.

 

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