A critical juncture for public services: lessons from COVID-19 Contents

Chapter 7: Empowering local public services and communities

“I have been amazed at how the Government and councils have managed to get the entrenched homeless off the streets. The help that these guys are getting in the premises they happen to be in, whether hotels or hostels, has given them a start in life and a chance to get access to addiction services and support workers. This might be the first step to getting a roof over their heads permanently.”

128.This is what we heard from Shay Flaherty, who is nine years into recovery from alcohol addiction and volunteers with Revolving Doors to support homeless people in Birmingham.135 The Government’s March 2020 “Everyone in” initiative requested that all local authorities provide accommodation for rough sleepers in their area, often in hotels or hostels.136 The Government reported that by May 2020 a total of 14,610 people in England who were sleeping rough, or who were at risk of sleeping rough, had found emergency accommodation.137

129.The pandemic has revealed long-standing fundamental weaknesses in public services, and exposed and exacerbated inequalities. But the evidence that we heard from people like Shay gave us cause for hope. We heard examples of how innovation by the Government, local services and frontline workers overcame structural hurdles. Providers continued to deliver—and in many cases improve—the services that people depend on.

130.The second part of this report describes how public services can build on such innovation. We argue that the Government and public services must now act to ensure that the progress made is not lost. Shay warned that some innovations were already being abandoned, such as the accommodation, addiction and mental health support for people facing homelessness:

“The Government and the councils have proved that they can and have the resources to do this … it would be brilliant if they could continue … Slowly but surely, the guys are coming back out on to the streets … The guys who for four or five months you would see around Birmingham city centre looking fit and healthy are now going back to square one because the accommodation is being withdrawn.”138

A ‘place-based approach’: integration and partnership working at the local level

131.In this chapter, we describe how a shared sense of place and purpose among local people, frontline workers and service leaders and the strong working relationships between local services that had formed before COVID-19 enabled local areas to:

132.The overly centralised response to COVID-19 hampered service delivery. But many local areas were able successfully to meet the needs of their communities during the pandemic by adopting a ‘place-based approach’.

Box 4: What is a ‘place-based approach’?

A ‘place-based approach’ enables collaboration among local services, statutory and non-statutory, to meet an area’s unique needs.

Services work together to use the best available local resources and assets, such as:

  • the skills and capacity of local voluntary and community organisations;
  • local knowledge and insight;
  • a shared sense of place and purpose among local people, frontline workers and service leaders;
  • good working relationships between public services at the local level, based on a culture of trust;

By working collaboratively with the people who live and work in an area, public services can better understand the local perspective. They can deliver integrated services where they are needed, irrespective of any departmental or sectoral silos at the national level.

Source: Iriss, ‘Place-based-working’ (28 July 2015): https://www.iriss.org.uk/resources/irisson/place-based-working [accessed 7 November 2020] and What Works Scotland, ‘Place-based working’ : http://whatworksscotland.ac.uk/topics/place-based-approaches/ [accessed 7 November 2020]

133.Nick Davies of the IfG told us that “any future programme of public service reform needs to recognise the interdependences between different services” and that many of the “wicked issues”139 facing Government required “seamlessly knitting together or coordinating the support provided by different arms of the state”. He argued that this was “inevitably much easier to do locally by taking a ‘place-based approach’ in response to local need”.140

134.Despite the constraints on collaboration caused by national departmental and sectoral silos, many local areas rapidly integrated their public services during the pandemic. Sarah Pickup of the LGA said: “What the crisis has shown is that, when empowered to do so, local areas can collaborate to deliver change quickly and efficiently.”141

135.We heard that advances in service integration during the first lockdown often occurred in local areas where strong partnership working pre-dated the pandemic. Chris Naylor of the King’s Fund told us: “The crisis has accelerated … integrated working in many parts of the country. [But] it is very variable in different places.”142 He said that the most impressive innovation had occurred “in parts of the country where they have invested a lot of time in working in a place-based way, building relationships across different agencies”.143

136.The LGA described how Leicester, Leicestershire and Rutland councils had accelerated the integration of health and social care and responded quickly to COVID-19.144 Due to their “history of strong working relationships”, these authorities were able to “establish a care home cell at the start of the pandemic to ensure a joined-up and coordinated approach [with] the Clinical Commissioning Group (CCG) and the local Community Health Trust”.145

137.NHS Providers highlighted the role played by Integrated Care Systems (ICS) in overcoming the barriers to integration of health and social care that we highlighted in Chapter 5. ICSs bring together local NHS organisations, councils and other local stakeholders to manage resources and improve the health and care of a local population. NHS Providers said that these bodies acted as convenors in “facilitating planning across the local health and care system … supporting trusts and other providers in their delivery roles”. For example, the Buckinghamshire ICS Workforce Group was set up “to support care providers and facilitate staffing levels. The group coordinated support from the Buckinghamshire Health Trust, which shared their key staffing agencies, thereby providing care homes with access to a wider cohort of staff during the first wave of the virus.”146

138.Witnesses said that central Government could build on these successes, and encourage stronger partnership working on the ground by granting increased autonomy to local service providers. The LGA called for a review of the NHS Long-Term Plan. It proposed that the Plan should emphasise the need for “a locally led approach [and] partnership, and place-based leadership”.147

139.The pandemic has demonstrated the need for local authorities, health care, social care and other service providers to operate as integrated components of local systems. Given the hurdles to public service delivery that COVID-19 has revealed, service providers should give careful consideration to which services are best coordinated at national level, and which services should be coordinated at local level.

140.The Government should set out in the white papers on English devolution and social care how it will ensure that local areas have the means and autonomy to develop a placed-based approach to delivering public services. This should be the default approach to reform of public services, rather than the current tendency to drive change from the centre.

141.The Government should set out in the white paper on English devolution how the tension between the NHS as a national service provider and the aims of the Government’s devolution agenda—which seeks to give more autonomy to local areas—may be reconciled. It should explain how the NHS will work with local authorities to ensure that the strategy for service integration laid out in the NHS Long-Term Plan aligns with place-based plans for integration in local areas.

Working with local voluntary sector and community groups

142.Fundamental to the success of a ‘place-based approach’ to delivering services during the first lockdown was the ability of service providers to draw on the knowledge, skills and capacity of local voluntary organisations and community groups. There was a surge in civic action in many communities across the UK. We heard how millions of citizens supported the most vulnerable in their communities by volunteering with the NHS, charities or community groups.

143.A significant number of mutual aid groups were formed in response to the pandemic. There are now over 4,000; many are informal groups of volunteers who use social media to organise.148 Nottinghamshire County Council created a new community hub to link these groups with vulnerable people. More than 600 volunteers contacted mutual aid groups to deliver food, collect and deliver medicines, look after pets, provide advice on health and help people with their transport needs.149

144.We learnt how community groups and volunteers formed a bridge between service providers and ‘hard-to-reach’ individuals.150 Camden Council wrote: “The energy and commitment shown by our citizens in taking action and developing mutual aid groups within neighbourhoods has been inspiring.” One mutual aid group, the Hampstead Volunteer Corps, worked with Camden Council to identify where food distribution centres were most needed.151 Camden’s experience was not unique—95 per cent of council CEOs reported that community groups had made a significant contribution to their COVID-19 response.152

145.Ian Jones, Chief Executive of Volunteer Cornwall, an organisation which supports Cornwall’s 4,500 charities to recruit, develop and manage volunteers, told us how working with the voluntary sector enabled better integration between health and social care provision:

“In early March … we started to [recruit] volunteers … 4,000 volunteers signed up in Cornwall to support people. We work with 280 COVID mutual aid groups … We quickly set up something called community coordination centres; an integrated service between health and care … When a referral came in from health or care, we could quickly evaluate and see whether it was a clinical need where we could give some volunteer added value, or something that the community could do with volunteering so that it did not have to be escalated to clinical need.”153

146.Community groups and volunteers have played an invaluable role during the COVID-19 pandemic in forming a bridge between public services and ‘hard-to-reach’ individuals. There are now over 4,000 COVID-19 mutual aid groups supporting vulnerable people across the country. When commissioning public services in future, commissioners should recognise the valuable experience of service delivery gained by the third sector during the pandemic.

147.Areas where local authorities had built strong links with community organisations before the pandemic were able to harness the surge in civic action. Local charities and established voluntary and community organisations were better placed than centralised national bodies and charities to coordinate volunteers.

Holding local areas to account

148.While witnesses welcomed the acceleration of a place-based approach to delivering services, we heard that a stronger system of local accountability was now required. Methods to assess whether local public service systems were meeting people’s needs also needed to improve.154

149.Witnesses warned that targets set by central Government, including joint targets agreed across Government departments, would not be sufficient. They pointed to delayed transfer of care targets—which aim to reduce the number of patients who are clinically ready for discharge, but who cannot leave hospital because the necessary social care provision is not in place—as an example of a joint NHS and social care target set by central Government that did little to improve wellbeing outcomes for a local area. Sarah Pickup of the LGA warned: “Top-down targets can have perverse implications, like the delayed discharge target that has been around for ever … it diverted resources away from keeping people out of hospital and supporting people in the community.”155

150.Saffron Cordery of NHS Providers called for top-down targets to be replaced by “locally drawn targets that a local system agrees” with central Government “that it is going to achieve”. These shared targets should focus on outcomes, such as the health of the local population rather than limited performance targets, such as delayed transfer of care targets.156

151.Kate Terroni of the CQC referenced her organisation’s local system review process, which looks at how well local health and social care services work together to care for people aged 65 and older in their area.157 She explained that the CQC currently holds only individual providers to account, but that in the future the CQC may place greater emphasis on how well an individual provider works with other public services in its local area to “to ensure that people get joined-up care”.158

152.Sarah Pickup advocated peer review as an effective approach to developing accountability. She said that the LGA had operated “a sector-led improvement approach”:

“The LGA operates with councils to run peer reviews … we have been working with NHS Confederation, NHS Providers and others to put in place peer reviews across health and care systems, and to take a cross-sector approach looking at outcomes and what we need to do together … Advice from your peers and other places that have achieved learning from good practice is what will help to deliver an integrated approach.”159

153.The Government should set out in the white paper on English devolution how it will empower local NHS providers, councils, and other local public service providers to draw up agreed measurable outcomes for their area. It should delineate how regulators will work with local areas to agree such outcomes and hold individual service providers accountable for partnership working. The outcomes should reflect the specific needs and priorities of local areas.

135 Q 146. See also Q 72 (Caroline Bernard).

136 Ministry of Housing, Communities and Local Government (MHCLG), ‘Communities Secretary’s statement on coronavirus (COVID-19): 18 April 2020’ (18 April 2020): https://www.gov.uk/government/speeches/communities-secretary-robert-jenrick-on-covid-19-response-18-april-2020 [accessed 7 November 2020] and HC Deb. 3 June 2020, col 51WS

137 Ministry of Housing, Communities and Local Government (MHCLG), ‘£105 million to keep rough sleepers safe and off the streets during coronavirus pandemic’ (24 June 2020): https://www.gov.uk/government/news/105-million-to-keep-rough-sleepers-safe-and-off-thestreets-during-coronavirus-pandemic [accessed 7 November 2020]

138 Q 146

139 A “wicked problem” in policy-making refers to a problem that is difficult to solve because its effects are not easy to define; it affects various stakeholders differently; it has many and varied causes; there is no single, clear solution; and many different arms of government are involved in tackling it. See Australian Government and Australian Public Service Commission, Tackling wicked problems: a public policy perspective (2017): http://www.enablingchange.com.au/wickedproblems.pdf [accessed 7 November 2020]

140 Q 9

141 Q 21

142 Q 69

143 Ibid.

144 Written evidence from the Local Government Association (LGA) (PSR0063)

145 Ibid.

146 Ibid.

147 Ibid.

148 Written evidence from Dr Chris Cocking, Principal Lecturer, School of Health Sciences, University of Brighton (PSR0033)

149 Written evidence from County Council Network (PSR0016)

150 Written evidence from National Council for Voluntary Organisations(NCVO) (PSR0052)

151 Written evidence from London Borough of Camden Council (PSR0082)

152 Written evidence from National Council for Voluntary Organisations(NCVO) (PSR0052)

153 Q 56. See also Q 58.

154 Q 22; Q 23 (Sarah Pickup, Saffron Cordery and Kate Terroni)

155 Q 22

156 Ibid.

157 Care Quality Commission (CQC), ‘Our reviews of local health and care systems’ (22 March 2019): https://www.cqc.org.uk/local-systems-review [accessed 7 November 2020]

158 Q 22

159 Q 23

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