Localism - Communities and Local Government Committee Contents



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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