On Tuesday 20 February 2018 five members of the Health and Social Care Committee visited South Yorkshire and Bassetlaw STP, at which we held a focus group with national and local leaders from NHS and local government.
South Yorkshire and Bassetlaw (SY&B), led by the Chief Executive of Sheffield University Hospitals NHS Foundation Trust, Sir Andrew Cash, is part of the first wave of integrated care systems announced in March 2017. As well as being one of the leading local areas, SY&B was an example of a large, politically diverse area with some challenging population health needs. For example, governance in SY&B is very complex, with 20 local bodies involved in the STP, including a mix of both Labour and Conservative councils.
SY&B is an excellent example of an STP in which integrated care partnerships–alliances between local providers–have formed around subsections of the STP population. Within SY&B, five integrated care partnerships have formed in the five main towns, cities and areas covered by the STP: Sheffield, Doncaster, Rotherham, Barnsley and Bassetlaw. These partnerships are working to integrate services in these five sub-sections of the population. The area decided to opt for an alliance between organisations (an integrated care partnership model), rather than adopt an accountable care contract.
The following Committee members attended the visit:
This note provides an outline of the visit and a summary of the key points heard.
The Committee visited Doncaster Royal Infirmary to hear from frontline staff about two local initiatives, Consultant Connect and the Integrated Discharge Team. Consultant Connect is an initiative that enables GPs at the borough’s 43 practices to ring hospital specialists at Doncaster Royal Infirmary for immediate advice about how to manage a patient’s condition, often while the patient is still in the consulting room.
The Integrated Discharge Team is a partnership between Doncaster and Bassetlaw Hospitals, Nottinghamshire County Council and Nottinghamshire Healthcare NHS Foundation Trust, where services work together to plan the safe discharge of patients from hospital.
Larwood Practice is one of several practices in the area involved in the Primary Care at Home initiative–a way of working that connects primary care, secondary care, social care and the voluntary sector.
The Committee held a focus group in Sheffield with senior representatives from the NHS, including STP leads and national leaders, and local government, including councillors and chief executives. The group represented STPs at different stages of development, including representatives from integrated care systems. The discussion was facilitated by Professor Chris Ham, Chief Executive of The King’s Fund and specialist advisor to the Committee’s inquiry. The discussion covered the following five themes:
The following section provides a summary of the key points that were raised in discussion.
The governance arrangements vary between STPs and some are extremely complex, because of the number of organisations involved. The group opened with a discussion of the governance arrangements in Greater Manchester from one of the local councillors. The Committee heard the number of partners involved brought significant gains, but also challenges.
More generally leaders spoke about the fragility of the system. The governance arrangements are largely considered to be workarounds of the existing legal framework. However, local leaders were clear that they retained responsibility for their individual organisations. The point was made that local leaders do not cede responsibility unless they agree to do so through a joint board.
As in many other leading areas, there was a strong focus on sub-sections of the STP population, often at a neighbourhood level. For example, local representatives mentioned how Greater Manchester had concentrated on the formation of neighbourhood units covering 30,000–50,000 people.
Despite the fragility of the arrangements in place in many areas, there was little appetite for imposing top-down legislative and regulatory requirements on the system as it is evolving. However, it was acknowledged that there needs to be “some bite somewhere.” For example, one participant mentioned that a lot of the changes are built on a consensus between the partners involved. Therefore, if one organisation says no then there is “an immovable object in the system.”
While there are aspects of the legislation, particularly competition and procurement regulations, that local bodies are working around, there are also aspects of the law that require collaboration, for example, Joint Strategic Needs Assessments by Health and Wellbeing Boards.
There was an acceptance that changes to primary legislation would be needed eventually. One of the senior local leaders described the need to “dock in” with a legislative superstructure at some point. Matthew Swindells from NHS England mentioned that he expects “two to three flowers to bloom” out of the models that are evolving locally. There was wide support for an evolutionary approach in which successful arrangements locally inform future changes to primary legislation.
There was also brief discussion about how the regulatory structure would need to change. In particular, there was a sense that regulators need to embrace a genuine acceptance of local decision-making. Similarly, regulators perception of failure is needs to be carefully considered, given the risks involved in transformation.
Local relationships were widely perceived as pivotal to the process. There was a strong sense that it is not possible to mandate the sort of changes that are happening locally, but rather that these changes need to be created by local leaders. A critical aspect of this is building relationships locally and identifying a shared purpose. Working to achieve consensus was also considered to be very important. Leaders spoke about a need to broker deals between parts of the system and to be aware and mitigate risks to the different partners involved, particularly in relation to their accountabilities. Rob Webster from West Yorkshire STP described the importance of local relationships saying that “change proceeds at the speed of trust.”
Relationships between the NHS and local government was another theme of the discussion. One representative from local government spoke about the challenge for councils in joining STPs and the importance of focusing on how these partnerships can help councils with their problems not just the NHS’s, such as housing. There were areas of shared interest such as IT, workforce and public health. For example, the point was made that local government can borrow money cheaper than NHS. This is an advantage for local areas if the focus is not on hospitals, but on the wider community, health and jobs.
Participants spoke with enthusiasm about the prospect of contributing not just to health and care, but to the wider local economy. The NHS was seen as a critical part of the local infrastructure. Therefore, links between STPs and local enterprise partnerships was another area for potential development. Rob Webster, STP Lead in West Yorkshire, described the potential role the NHS could play in supporting the life science industry in his patch, thereby contributing to local economic growth.
There was an appreciation that realistically the NHS is 5 years into a 15-year transformation. There are significant challenges in the short-term. Funding and workforce pressures were mentioned as significant problems that limit the ability of the system to transform. There is a recognition that different local areas are at different stages. As such it is important to move a piece at a time.
There was concern that the prominence given to communities in the NHS Five Year Forward View has been diluted. However, participants spoke about the importance of realising the value of community assets and the value people can bring to changing their own lives. Participants spoke about the need to co-produce plans with stakeholders, including staff and local communities. This involves sitting down and understanding their perspectives.
One participant described how locally the NHS and local councils through the STP went out to hard-to-reach groups with low levels of engagement (e.g. commuters). The council helped NHS colleagues to target these groups, which was then used to develop a public panel with 2000 people to go out too.
Published: 11 June 2018