Public Sector Focus

Better care?

Integrating Care brought together leaders from the health, local government and social care sectors making better
co-ordinated person-centred care an everyday reality. Adam Hewitt reports.

That resources will we need to shift, and how, in order to make integrated health and care a reality for everyone? That was the question at a major discussion event attended by PSE.

The roundtable, supported by the LGA and the NHS Confederation, was hosted by Integrating Care and presided over by its chair Sir John Oldham, who created and headed the National Primary Care Development Team, and was national clinical lead for quality and productivity at the Department of Health until the end of 2012.

That ‘potholes’ comment

Sir John began the event with a rebuke aimed at NHS England medical director Sir Bruce Keogh and his widely-publicised suggestion that it may not be possible to trust councils to spend pooled money wisely if they are too focused on ‘potholes’.

Sir John said: “I have to say I was really quite disappointed to hear Bruce Keogh’s comment last week that councils were more concerned with potholes than people. I think that was unworthy of his role, but not necessarily surprising given that the medical director of NHS England has 18 national clinical directors for body parts, and the thought leadership comes from 27 of the 28 royal colleges. But I think that...attitude is one that will need to change, as we move towards trying to get the relationships better between health and social care.”

Speaking to the Health Select Committee in January about the pooled budgets and the Better Care Fund, Sir Bruce said that there was a need to be “absolutely clear” about how it would be spent, and said: “There is a fear that the labels be taken off the money and that it will be used for filling in potholes and other significant things.”

Regaining the momentum – the Better Care Fund

Discussing integrated care more generally, Sir John said: “When I left the Department [of Health], we had about 11% [of CCGs] actively, with community providers and others, creating integrated teams between health and social care. The year of care capitation tariff, we had eight pilots but 26 so-called fast followers buddied up, which is practically 20% of the system, of health economies.
Sadly I think that momentum has somewhat been lost by NHS England. But I get the sense that it’s a question of when and how,
not if.”

The roundtable focused heavily on the £3.8bn Better Care Fund (the new name for the Integration Transformation Fund), and the extent to which it could be transformative or whether it is just a short-term political fix to cover the fact there is less money in the system.

Geoff Alltimes, representing the LGA, chairs the Health Transformation Task Group (HTTG) and the London Integration Collaborative.
He was previously chief executive of the London Borough of Hammersmith & Fulham and NHS Hammersmith & Fulham, and co-wrote the report on integration for the NHS Future Forum.

He began by noting that co-ordinating care for the person is more important than organisational structures – and that there are “phenomenal challenges” in the delivery of the Better Care Fund.

He said joint plans between councils and CCGs are do-able, but that there are often issues in the background to consider, such as balancing the interests and demands of different health providers in an area, and the possibility of “significant deficits”. Better Care Fund money is drawn from existing budgets, so depends on almost instant transformation and improvement if services are not to suffer.

He called it ultimately a “political fix, a way of dealing with the fact that there’s less money in the system in 2015/16”.

“But it seems to me that it will not be an issue [after the bids are in] because every place will have done their local story and will have had to say what’s happened to the money – what it used to be, and what it is now. Those plans won’t be signed off unless they’re specific, and used to fund new services enabling nursing and social care at home.”

He said it was important for local areas to set their own agendas, to tell the national parts of the system what they are doing and what support they want – “not wait for them to tell us what to do”.

Empowering leadership – not command and control

Michael O’Higgins, NHS Confederation chair, said that integration has been on the cards for a long time, and that some areas have seen real successes already that can be replicated elsewhere, including Cornwall.

He said it is often about changing a person’s belief about what they can do themselves – such as leave the house, if they consider themselves housebound.

He described his organisation’s ‘2015 Challenge’, and its two-fold message; firstly to politicians to make a commitment that if local reconfiguration plans are agreed between commissioners, clinicians and other relevant stakeholders, that they won’t be rejected for “short-term political reasons”. The other message is to localities to ensure they have plans in place to prepare for the new environment.

John Wilderspin of the NHS Central Southern Commissioning Support Unit made the point that “if we start with reconfiguring hospitals, we’ll keep going round in the same loop”. He said that the predominant, traditional leadership style in the NHS especially has been ‘command and control’, telling people what to do and why it’s better for them – to which people in other organisations may just respond: “Who are you to tell me that?”

He made the point that command and control “may be good for waiting times”, but the people doing the best work on integrated
care have a different leadership style emphasising empowerment, shared narratives, and win-win opportunities.

He said that if nothing else, and even if isn’t big enough, the Better Care Fund has “got everyone’s attention”. “People who were not interested in integrated care because they had more pressing things now have to talk about it.”

Whose responsibility?

Will Tuckley, chief executive of the London Borough of Bexley, agreed that leadership is vital, but said it’s often a big ask for organisations to simply disregard their own interests. He noted that in south east London, although “extremely good progress” was being made on integration and reconfiguration at one point, the area ended up with “one part of NHS trying to sue another part over commissioning strategy”. He added: “Progress can be so easily diverted by issues vital to one part of the system, but not for joined-up patient care.”

John Sinnott, chief executive of Leicestershire County Council, said a new forum is needed above health and wellbeing boards to
encourage political involvement and ownership. He said the “elephant in the room” is the Care Bill and Dilnot proposals. 

Matthew Winn, chief executive of Cambridgeshire Community Services NHS Trust, said two sets of people were “massively missing” from the Better Care Fund conversations: NHS England, and GPs in their role as providers as opposed to commissioners of care.

Chris Ash, integrated services director for Southampton & West Hants, Southern Health NHS Foundation Trust, agreed and said that the Better Care Fund is currently seen as more the responsibility of CCGs and health & wellbeing boards.

‘It isn’t new money’

Matt Tee, chief operating officer of the NHS Confederation, said he wanted to explain what might be perceived as “bad behaviour” on the part of health.

He said: “There are two things about the Better Care Fund that cause irritation in health. I’m not asking local government to do
anything about them, I’m just asking that they’re recognised.

“The first is that our ministers, and I think it’s true of yours [at DCLG] as well, but it’s particularly true of ours [at the Department of Health], have a temptation to portray this as new money. It isn’t new money. It’s coming out of existing budgets, and it irritates the hell out of our members when [ministers] do that.

“Second is what I, as a shorthand, call the ‘DGH issue’; it’s true of all providers, but particularly of district general hospitals. That is, the effect of the Better Care Fund and the effective revenue it will move from providers. Even if the Better Care Fund worked perfectly and reduced demand on those providers, because of the cost that is tied up in estate and staff, there is no way that what happens as a result of the BCF can do anything other than be a significant cost pressure on providers. All of that, I perceive, is leading to some behaviours on the part of health which are defensive and are not about achieving the best on integration.”

He said the communities where integration has worked well are those where health and local government have come together without thinking about ‘winners and losers’, but just concentrating on patients and service users.

“[That] means health and social care might have to ‘give a bit’, find ways of cushioning budget impacts on each other, [or] bend the rules slightly. Where there is goodwill, and a focus on the individual, that’s where things are working well. But it’s very easy for people to fall back into tribal, defensive behaviours.”

He added that NHS and LGA leaders should be highlighting and encouraging those collaborative behaviours, because they can then point to the areas where that produces a win for both sides and for the patient or service user. “It’s not about structures or tariffs, it’s about behaviours,” he said. “In health, we need to change the model by which you’re perceived to win and show success as a leader.”

Personal responsibility

Margaret Carney, chief executive of Sefton Council, was critical of the Better Care Fund, saying it “could be a distraction”, that the timescales are “mad”, and that there is simply not enough money available to achieve the stated aims. She suggested it could end up being a tick box exercise, diverting capacity and leadership when transformation is what is required.

“No matter what service we put in place, the public will go the place they perceive as right place.”

She emphasised the need for people to take personal responsibility for their own health, and the importance of self-care messages.

Simon Morioka, of PPL consultancy and Integrating Care, who has worked in the NHS, for a local authority and at a charity, 
was more positive about the Better Care Fund.

He said that “no-one disagrees the timescales are mad”, but that’s because it’s driven by a pressing need. He added: “In reality we’d have all liked to have started this a few years ago. But it’s not the Better Care Fund that’s going to create cost pressures on trusts in 2015/16; it’s QIPP, and a failure to meet demand.

“The fund is as big and as ambitious as local areas prepared to make it. It’s got to be about looking at this as a solution to pressures, and putting in the right level of investment to create a shift to move demand. If just the minimum effort and money are put in, yes it could just be a cost pressure.”

He said he used to be “fundamentally sceptical” about involving people in their own care – that someone just diagnosed with physical and mental health problems would want to be involved not only in the design of care but its delivery. But he said the People
Powered Health programme (our sister title National Health Executive interviewed Morioka on PPH in the May/June 2013 edition) changed his view. The lessons from Stockport, Leeds, Lambeth and the other places involved in that award-winning programme showed him the impotance of co-production, he said. “If it isn’t a core part of what the Better Care Fund ends up doing, we’ve missed a massive trick,” he added.

The right path

Chris Bull, the former joint chief executive of the council and NHS trust in Herefordshire, now local government adviser to Public Health England, discussed the policy changes required to make integration work, while Claire Kennedy, also of PPL and Integrating Care, said that reconfiguring organisations and buildings is actually the “easy part”.

Behaviours, by contrast, are often seen as ‘softer’, but in fact financial targets and hard-headed thinking need to be applied to that. “Leadership and management have to change, and we need to change the way we manage staff,” she said.

John Marshall, associate director for strategy & collaboration at NHS Wigan Borough CCG said in areas like his with co-terminous local authorities, commissioning groups and hospitals, the Better Care Fund is just a distraction, as they were already on the
path to integration. He said the bigger issue is cuts to social care, and integration health services across different pathways.

Other speakers said many in the health commissioning and provider sectors say the Better Care Fund is too short-termist, and seems to be about quick wins for politicians and the Department of Health rather than long-term progress.

This led to more discussion about the fundamental need for reconfiguration of acute hospitals: always a thorny issue. More than one speaker suggested their area had one too many acute hospitals, but said the time and energy involved in making the case for
change could be crippling, and that the local NHS can often “freeze” when such proposals are made.

Michael O’Higgins of the NHS Confederation said that “change is difficult and needs lubricating”. He added: “If the headline
is ‘hospital closures’, you know you’ve got a problem.”

He suggested it could often be far better to change the use and services offered at a hospital to make it more specialist, rather than close it. He explained: “The energy involved in closing things as opposed to changing what they do in response to changing demand is an awful lot of energy to waste. It’s not a rational world! It’s about what’s do-able.”

Professor Paul Corrigan made a similar point, arguing: “Almost certainly, if you had a district general hospital turned into a really decent long-term conditions centre, more people would go through that in a year. We’ve turned that into a defeat!”

Personalisation

Ray James of ADASS (the Association of Directors of Adult Social Services), said that integration needs to be about personalisation, with service users at the centre of redesigns and with a different sense of what’s possible and what’s right.

“Integration works when we turn on the head the knowledge that A&E is most effective place to go,” he said. But it needs more
honesty about the scale of the problem, and the potential risks.

Sir John concluded the event by urging a “partnership of everybody, including providers, to tackle one of the most fundamental challenges the health and social care system has faced for generations”.

Attendees at the roundtable discussion

Sir John Oldham OBE – Chair, Integrating Care and Independent Commission on Whole
Person Care

Michael O’Higgins – Chair, NHS Confederation

Geoff Alltimes CBE – LGA; Chair, Health Transformation Task Group

Professor Paul Corrigan – Chair, PPL / Integrating Care’s advisory board, healthcare
commentator

Simon Morioka – Integrating Care / PPL

Claire Kennedy – Integrating Care / PPL

Matt Tee – Chief Operating Officer, NHS Confederation

Will Tuckley – Chief Executive, London Borough of Bexley

John Sinnott – Chief Executive, Leicestershire County Council

Martin Smith – Chief Executive, London Borough of Ealing

Margaret Carney – Chief Executive, Sefton Council

Matthew Winn – Cambridgeshire Community Services NHS Trust

Martyn Diaper – Clinical Director, South East Hampshire, Southern Health NHS Foundation Trust

John Wilderspin – Managing Director, NHS Central Southern CSU

Chris Bull – Adviser, Public Health England

Charlotte Goldman – Policy Adviser, Monitor

Chris Ash – Integrated Services Director Southampton & West Hants, Southern Health NHS
Foundation Trust

John Marshall – Associate Director, Strategy & Collaboration, NHS Wigan Borough Clinical
Commissioning Group

Steve Russell – Improvment Director, NHS Trust Development Authority

Sarah Kennedy – Director of External Affairs, Turning Point