WRITTEN EVIDENCE
SUBMITTED BY
THE NHS CONFEDERATION
(LOCO 058)
The NHS Confederation is the independent membership
body for the full range of organisations that make up the modern
NHS. We have over 95 per cent of NHS organisations in our membership
including ambulance trusts, acute and foundation trusts, mental
health trusts and primary care trusts plus a growing number of
independent healthcare organisations that deliver services on
behalf of the NHS. We are pleased to have the opportunity to submit
evidence to this inquiry.
The NHS Confederation and the Association of Directors
of Adult Social Services (ADASS) have developed a joint programme
of work looking at the issues around the commissioning and provision
of integrated health and social care services. We also have a
programme of work on public health. The Government's plans for
localism and decentralisation of public services include a desire
to see the breaking down of barriers between local NHS organisations
and local authorities, particularly with regard to social care
and public health. Our submission focuses on the lessons that
could be learned from Total Place which would be helpful in the
introduction of place based budgets and community initiatives,
the policies needed to support integrated service delivery at
the local level, the role of central government and local accountability
for health, social care and public health services.
1. SUMMARY
¾ Closer
working between local authorities and the NHS will be crucial
as the public purse comes under increasing pressure and efficiency
savings continue to affect local services.
¾ The
acid test will be whether different, more integrated local models
can deliver public services that are high quality, cost effective
and tailored to personal need. To make this a reality means looking
at new models.
¾ Primary
Care Trusts' experience of the first wave of Total Place pilots
has been generally positive. The core message of taking a public
services-wide approach across a particular geographical area and
seeking to ground this in evidence-based assessments of local
needs and resources is one already filtering into the thinking
and behaviour of the NHS, social care and other public services.
¾ Lessons
from the first wave of Total Place pilots include:
¾ Greater
benefits could potentially be demonstrated if the next wave included
healthcare providers, particularly hospitals and community trusts.
¾ The
flexible approach the government took during the pilot—in
allowing places to adapt the methodology in many different ways—was
helpful.
¾ It would
be helpful to test the methodology in areas where relationships
between the NHS and local authorities have been more troubled.
¾ The
increased focus on place-based budgeting (for example, Total Place)
in the recent "Equity and Excellence—Liberating the
NHS" white paper could support integration and closer joint
working between local government and the NHS.
¾ We feel
the government should focus on playing an enabling role ie develop
a framework of policy for use with local interpretation.
¾ Clarity
about the relative roles of both the NHS and local government
in meeting social care and public health needs would support more
extensive joint working at local levels.
¾ The
regulatory framework should support local leadership through:
¾ greater
use of outcomes frameworks rather than targets,
¾ the
avoidance of competing, overlapping performance regimes, and
¾ reducing
bureaucracy to enable easier pooling of resources in localities.
¾ The
recent "Equity and Excellence—Liberating the NHS"
white paper included proposals for Health and Wellbeing Boards
to take on the existing scrutiny powers of local authorities in
relation to health services, but their precise role and accountability
mechanisms need further clarification.
¾ The
white paper also promises that local HealthWatch will provide
a strong and independent consumer voice for local patients and
the public. It will be important to maintain its independence
despite being commissioned, funded and held to account for performance
by the local authority. We believe the Government should consider
using Citizens Advice Bureaux to deliver complaints advocacy.
2. THE NEED
FOR INTEGRATION
AT LOCAL
LEVELS
2.1 Health, public health and social care should
not be seen in isolation from one another. Public health and social
care services are crucial in helping people stay well and live
as independently as possible for as long as possible. Unmet need
for social care or public health services will often lead to increased
demand for NHS services. Closer working between local authorities
and the NHS will be crucial as the public purse comes under increasing
pressure and efficiency savings continue to affect local services.
2.2 The Government's plans for localism and decentralisation
of public services include a desire to see the breaking down of
barriers between health and social care and closer working between
local authorities and the NHS to address public health challenges.
The NHS Confederation welcomes proposals in the recent "Equity
and Excellence—Liberating the NHS" white paper to strengthen
the role of local government in public health, including mental
health, given the impact this can have across departments and
sectors including education, transport, leisure, housing and economic
development. We support giving local authorities the responsibility
to facilitate joint working on health and well-being, with statutory
powers to underpin this, because this would encourage them to
fulfil their public health functions.
2.3 In the current financial situation, the acid
test will be whether different, more integrated local models can
deliver public services that are high quality, cost effective
and tailored to personal need. To make this a reality means looking
at new models which have the potential to work in new environments
and reflect the new landscape of the independent NHS Board, devolution
of budgets to GP commissioning groups and greater community control
of public health budgets. We hope to contribute to continuing
debates to develop such new models.
3. ACTIONS TO
ACHIEVE INTEGRATED,
DECENTRALISED SERVICE
DELIVERY
3.1 A recent survey by the Department of Health[1]
asked PCT Chief Executives and directors of adult social care
to what extent integration was already in place and what had helped
and hindered its development. The main factors that promoted integrated
working are locally determined—local leadership, vision,
strategy and commitment. Conversely, with the exception of changing
leadership, the top factors that respondents felt hindered integrated
working are nationally determined—performance regimes, funding
pressures and financial complexity.
3.2 Our recent discussion paper on health and
social care integration[2]
highlights that integration of services should be based on:
¾ outcome
measures rather than targets for effective organisational integration;
¾ developing
understanding cultures within council, health and social care
services to facilitate supportive environments for change. Children's
trusts are considered to work effectively because they provide
an opportunity to develop a different cultural environment;
¾ integration
based on place not organisation—the Health and Wellbeing
Boards proposed in the recent "Equity and Excellence—Liberating
the NHS" white paper should adopt a place mentality (ie take
into account local neighbourhood environments, and the needs of
specific local communities, rather than assuming a "one size
fits all" approach will work across a whole population) to
reframe service redesign focused on the user;
¾ delegation
of functions to each partner is preferable to transferring responsibilities
to partners. This can avoid power struggles that often result
from formal arrangements; and
¾ clinical
and professional engagement—public health, health and social
care front line professionals should be involved in and accountable
for the overall priorities of a locality.
3.3 The increased focus on place-based budgeting
in the recent "Equity and Excellence—Liberating the
NHS" white paper could support integration and closer joint
working between local government and the NHS. To aid successful
integrated, decentralised delivery of public health, social care
and local healthcare services, the following points should be
considered as the policy is developed further:
¾ GP consortia
will require engagement from public health professionals to support
informed commissioning decisions based on the analysis of local
population needs.
¾ Clarification
is required about how commissioning for some public health services
by the GP consortia and the Health and Wellbeing Board will be
organised, particularly as consortia boundaries may not be co-terminous
with local authority areas.
¾ Local
authorities and GP consortia will carry out joint local area assessments
of need, and we believe they should be asked to work together
to develop and deliver a joined-up health, public health and social
care strategy in response.
4. LESSONS FROM
TOTAL PLACE
4.1 A recent research project conducted interviews
with chief executives or Total Place leads from 14 Primary Care
Trusts (PCTs), covering 11 out of the 13 first wave pilot sites.[3]
These discussions highlighted some lessons from the pilots:
¾ Some
PCTs felt that the methodology provided a framework for a more
systematic approach to joint working—service area by service
area, local need by local need.
¾ The
process so far has excluded healthcare providers, to its detriment.
Hospital and community trusts, in particular, were identified
by many as priorities for the next stage of the work.
¾ Having
been complimentary about the flexible approach the government
took during the pilot—in allowing places to adapt the methodology
in many different ways—we believe NHS leaders would be supportive
of the multi-track solutions (single and innovative policy offers)
proposed in the Treasury's evaluation report.[4]
¾ Leaders
were keen to stress that they were not yet able to demonstrate
any concrete improvements in outcomes or realisation of savings
on which to call Total Place a success. This is likely to be because
of the very short timescale for the pilots. Some PCTs had only
been working on Total Place for seven months before they began
composing their final reports.
¾ Most
felt that their joint working was very good prior to becoming
a pilot, so as yet the methodology is untested in localities with
more troubled relationships. We feel it would be valuable to test
the methodology in areas where the track record of joint working
is less good.
4.2 The content of the programme is as much cultural
as it is methodological. The core message of taking a public services-wide
approach and seeking to ground this in evidence-based assessments
of local needs and resources is one already filtering into the
thinking and behaviour of the NHS, social care and other public
services. As such, we are wary of attempts to define Total Place
as producing fundamental shifts in the relationship between central
government and local areas.
5. THE ROLE
OF CENTRAL
GOVERNMENT
5.1 There are some things which only central
government can do, for example coordinating efforts to tackle
pandemics. However in the vast majority of local services we feel
the government should focus on playing an enabling role rather
than a delivery one—to develop a framework of policy for
use with local interpretation.
5.2 Competing government policies with differently
nuanced performance regimes can confuse and add complexity which
might otherwise be avoided. Following the recent "Equity
and Excellence—Liberating the NHS" white paper, we
would like to see overlapping outcomes frameworks for health,
public health and social care—rather than three separate
ones—which are developed against a co-ordinated timetable
to ensure that the content is consistent and professionals from
different sectors are working together to achieve shared outcomes.
5.3 National initiatives to push local partners
to work together may be ineffective. Placing duties on local leaders
to collaborate may send a strong message, but based on both responses
to a recent Department of Health survey of PCT Chief Executives
and directors of adult social care[5]
and the findings of our work on the impact of senior joint appointments
across PCTs and local authorities[6]
it seems unlikely to produce the more informal conditions that
local leaders feel are most important.
5.4 As the form and functions of the new Public
Health Service (PHS) are developed, central government should
develop a policy framework which offers greater clarity in key
areas, in particular:
¾ the
different roles for the PHS, local authorities and the NHS, to
ensure that commissioners and service providers are incentivised
to play their part and take responsibility for public health improvement;
and
¾ a clear
definition of what public health functions are. This would enable
localities to clarify the roles and responsibilities of different
parts of the system to improve the health of local populations.
5.5 Similarly, we would like to see the commission
on social care look at the need for clarification of the relative
roles of both the NHS and local government in meeting social care
needs, as this would better support joint working.
6. LOCAL ACCOUNTABILITY
ARRANGEMENTS FOR
HEALTH, SOCIAL
CARE AND
PUBLIC HEALTH
6.1 The recent "Equity and Excellence—Liberating
the NHS" white paper included proposals which would significantly
affect local democratic accountability for local health service
delivery.
6.2 The white paper makes clear that Health and
Wellbeing Boards will take on the existing scrutiny powers of
local authorities in relation to health services, but it is not
clear whether any additional powers will be available to strengthen
local democratic accountability and what accountability GP consortia
will have to local Health and Wellbeing Boards.
¾ We believe
the Government should clarify what role and authority Health and
Wellbeing Boards will have to scrutinise local health services,
how their role will relate to the existing local strategic partnerships,
safeguarding machinery and other systems, and what roles elected
members and local authority officials are expected to play on
these boards.
¾ We believe
local authorities should work closely with local GP consortia
and providers to develop and deliver a capacity building programme
to ensure that elected members and local authority officials who
will sit on or support Health and Wellbeing Boards have the right
expertise to scrutinise health and mental health services.
¾ As the
Health and Wellbeing Boards will sit in the upper tier of local
government, we believe there should be mechanisms in place for
them to be able to hold the lower tier of local authorities to
account to implement public health functions within their localities.
6.3 The white paper also promises that local
HealthWatch will provide a strong and independent consumer voice
for local patients and the public in relation to the NHS.
¾ Locally,
mechanisms are needed to ensure that HealthWatch can still provide
independent scrutiny of the social care decisions of the local
authority, despite being commissioned, funded and held to account
for their performance by the local authority.
¾ Local
HealthWatch must be representative of the local community and
users of services and build effectively on the existing local
structures for community and patient involvement.
¾ Even
with additional funding, local HealthWatch is unlikely to have
sufficient public profile or the resources or capability to deliver
effective complaints advocacy, particularly in complex complaints
or in helping people with complex needs, and HealthWatch England
is similarly likely to be too remote from the local issues to
adequately fulfil this role. We believe the Government should
consider using Citizens Advice Bureaux to deliver this.
October 2010
1 National survey of PCT Chief Executives and directors
of adult social care carried out by Richard Gleave for the Department
of Health. Presented as "Snapshot of integrated working"
to ADASS Spring Seminar, March 2010. The survey yielded 97 responses
from 150 localities across England. Back
2
Primary Care Trust Network in association with ADASS (2010). Where
next for health and social care integration? NHS Confederation
Discussion Paper Back
3
Primary Care Trust Network in association with ADASS (2010). Where
next for health and social care integration? NHS Confederation
Discussion Paper, p6. Interviews were conducted specifically for
this paper. Questions included how involved their organisations
had been, what the Total Place methodology had added to their
existing work, and what should be done with the programme once
the pilot phase was over. Back
4
HM Treasury and CLG (2010), Total Place: a whole area approach
to public service Back
5
National survey of PCT Chief Executives and directors of adult
social care carried out by Richard Gleave for the Department of
Health. Presented as "Snapshot of integrated working"
to ADASS Spring Seminar, March 2010. The survey yielded 97 responses
from 150 localities across England. Back
6
Roland J (2010). Putting our heads together: what makes senior
joint posts work? NHS Confederation Back
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