Building place-based care on foundations of trust - a round table discussion
With the NHS's long term plan receiving hours of debate and hundreds of column inches, a recent round table event in Manchester sought to cut through the hyperbole to get to the heart of the issues surrounding place-based models of care. Hosted by NHS Shared Business Services and management consultants Project Rome, the event was chaired by Mike Farrar, formerly CEO of the NHS Confederation. Guests included senior representatives from primary and secondary care, as well as Clinical Commissioning Groups (CCGs) and local authorities.
A sense of purpose?
Mike Farrar opened the debate by asking guests to reflect on whether the health and care system currently has a genuine sense of shared purpose. Delivering seamless, patient-centred health and care demands an entirely new way of working - one built on trust and collaboration. Do we have the foundations in place to achieve this?
Guests gave examples of the different drivers affecting the health and care system - from the pressure to deliver immediate physical care, experienced by acute trusts, to the cornucopia of social care support organisations delivering multiple services to a wide variety of users. With Dr Jaweeda Idoo, Chair of Viaduct Care, the Stockport GP Federation, pointing out there are more than 1,000 voluntary, community and social enterprise organisations delivering non-statutory support in the Stockport area alone, true integration is likely to prove challenging but we must tap into the wider capability within communities. Grenville Page, Non-Executive Director at Manchester Health and Care Commissioning agreed, saying "Far too often, the public sector thinks it must solve the problem. We sometimes don't fully recognise the great work being done by the multitude of community organisations out there. Our challenge is to fully leverage their potential."
Despite this, there was a general consensus that change is possible. Examples included a recent visit to Sweden, where emergency hospital admissions can take place straight from the community, without the patient having to visit A&E. Another example was Barcelona, where sensors placed around a patient's home help monitor their activity and flag up any concerning changes to both the patient and their healthcare provider.
Such examples are not limited to our European neighbours. Ian Williamson, Chief Accountable Officer of Manchester Health and Care Commissioning, described how the GM and City's programme to support people who are homeless grew from the recognition that the average life expectancy of women who are rough sleeping in Manchester is just 42. The health and care commissioners across Greater Manchester, with partners, have committed extra money to address this, including extending and developing the "A Bed Every Night" scheme which offers a bed, food, hot water and support to anyone who is rough sleeping across Greater Manchester.
Yet these initiatives often happen despite the current health and care landscape, not because of it. As Tony Bruce, leading the transformation of ICS in Bury noted, the current system "seems to legislate to divide us". Change is easy to talk about, but difficult to deliver when organisations are incentivised to protect "their" budgets and achieve "their" outcomes.
The case for change
Despite the intention from NHSE/NHSI set out in the NHS Long Term Plan, that the whole country should be covered by an integrated care system by 2021, change is generally happening slowly, with some areas making more progress than others.
Guests identified funding streams and leadership behaviour as a key driver. As Hugh Mullen, Deputy CEO of Stockport NHS Foundation Trust said: "It's easy to give lip service to collaboration, but remove 10% of an organisation's funding and put it in a shared pool, and you'll be told that's a step too far." The divide between prevention and treatment is a particularly hot topic, with some guests querying the evidence base for preventative interventions, whilst Dr Claire Fuller, GP and Chair of the Surrey Heartlands ICS pointed out that, for example, intervening more actively in the first 1,000 days of life reduces health inequalities and rates of mental illness.
Some forward-thinking regions are making progress. Representatives from Surrey praised the work of the Surrey Heartlands Integrated Care System (ICS) and Primary Care Network (PCN), guided by a population outcome strategy, and the active leadership of the local authority in the ICS. ICS members "hold each other to account" and are developing trusting and personal relationships. The PCN is realising the value of social prescribing, and recognising that partnership is about realising that many organisations are better than the NHS at signposting and supporting people who are vulnerable or socially isolated. In these cases, the role of the commissioner is to support, not to replace.
Despite such encouraging signs of progress, Jonathan Wood, the Director of Finance and Deputy Chief Executive of East Lancashire Hospitals pointed out that "the very language that we have developed, endemic to the system, encourages barriers."
Whilst the requirement and desire is for NHS and Local Authority colleagues to work as systems rather than as commissioners and providers, commissioners and providers often regard budgets as "their" money, with Payment By Results prioritising a narrow spectrum of easy-to-measure outcomes, to the detriment of service users with complex needs requiring a multi-agency approach. Redefining success to include shared outcome measures was agreed to be a priority by all guests.
Structural issues notwithstanding, guests around the table agreed that progress could only be made when vested interests are put aside and trust is given a chance to grow. Despite the perennial cry of "too many meetings", regions where ICS representatives spend dedicated time together, away from the pressure of their day jobs, tend to be most successful in delivering functional integrated care. New ways of working need to be established which call for a change of habits and culture at all levels. As Daniela Valdes, Chief Officer of Nexus Health Group noted: "We need courage - and courage can only come from integrity."
Encouraging a shift in mindset away from "I answer to the Secretary of State" and towards "I answer to people in my local community" is important. Consulting the public and hearing their stories helps to bring issues into sharp focus in a way which sitting behind a desk can never do.
Having an independent third-party involved in the establishment of an ICS can be beneficial in helping to address parochial mindsets which hinder the development of an effective delivery system. External expertise can also be invaluable in some of the more specialist aspects of ICS development, such as re-designing the wider provider landscape and contracting in new ways to drive collective performance.
So what are prerequisites for delivering effective integrated care?
- Thinking broader than your own organisation - including accepting the need to share funding, resources and risk to design services around people and their communities.
- Local authority and wider public sector involvement is critical if ICSs are to be successful in maximising the use of community assets by leaders agreeing to work together to design services to meet the health and wellbeing needs of local populations.
- A changed set of leadership behaviours, including spending quality time with co-creators of the system, and a willingness to break down organisational boundaries - modelling this way to all colleagues in the system.
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