Conviction or just politics

The week before last a new Health and Social Care funding deal was announced for the Greater Manchester Combined Authorities,gmca_small_logo1 and whilst it is built on the city region deal that has been worked on for months, the scope and size of the pooling was a surprise to many of us. i.e. the completely pooling of all of the city region’s Health and Social Care funding under the control of a sort of super-sized Health and Wellbeing Board. Of course as with all things, the ‘devil is in the detail’ but it’s fair to say the deal is clearly not something matured and nurtured by the Department of Health and DCLG but a Treasury and more specifically a George Osborne big bang.

I think I can speak with some knowledge on this process given that in my role at the LGA Community Wellbeing Board where I hold the national Portfolio for Health and Social Care integration, and we are currently grappling with the minutiae of the Better Care Fund’s modest proposals all councils are having to work thought, well that is apart from it seems, the Manchester combined authorities!

So it is to be welcomed rather than the rather negative response from Labour’s Shadow Health Minister Andy Burnham who despite speech after speech that he wants to see just such an acceleration of the pooling, came out against it on twitter as it was leaking out. It is a shame he could not be more supportive of the very thing he has been saying he wants to see, but that politics!

Hospital A&E Winter Pressures & Social Care

A&E sign imageYesterday saw the latest figures for A&E waiting times published and Addenbrookes Hospital at Cambridge, our local major trauma centre declared a ‘major incident’ which are early warning light systems that we have a problem, of course all businesses have peaks and troughs but these figures are particularly worrying is that it’s not a harsh winter rather mild actually and we are out of the ‘perfect storm’ period of closed GP Surgeries over the Christmas period. All of us must use the right services at the right time but interestingly records show that predominately those who present at A&E are right to do so, so what’s the problem? Essentially it is our ageing population, that long talked about issue is now starting to ‘bit’, with unplanned admissions of elderly people at the front end and bed blocking at the far end. With bed blocking perhaps being the first signs that the cuts in local government funding to provide social care and an increasing number of people needing services are making discharge of elderly patients ready to go home increasingly problematical. The figures bring into focus the need for the whole system to work better from GP services, to pharmacists, out of hour’s services, intermediate care beds (that’s what used to be called convalescence) to social care.

The debate rages about Health and Social Care which is the single biggest interface and spend area for Local Government (about 40% of most upper tier authorities budgets) and the NHS spends about £1 in every £6 of national total spend. As Portfolio Holder for Health and Social Care integration at the LGA’s Community Wellbeing Board and LGA CWB Health and Wellbeing Board Ambassador for the East Midlands I firmly believe we have the structures in place to tackle an Ageing population but need Westminster’s continued backing for the Health and Wellbeing Boards to be the place this integration is championed by and driven forward from.

The danger is that as the issue starts to impact hospital’s ability to cope with admissions, Government looks towards the NHS to quick fix the problem and I tend to think reading between the various lines out there, not least Simon Steven’s, the new CE of the NHS, 5 year vision speech, the NHS is quietly lobbying to take control of social care.

This would have two fundamental impacts firstly the cost of social care would rise dramatically, as frankly however well the NHS does things it never does them cheaply. Local Government is the most cost effective part of government for a reason, firstly it’s local, and secondly, and far more importantly, Local Government is articulating a different approach to services built around community capacity and how communities and individuals develop care services in part for themselves. This cannot be done centrally or nor by organisations trying to begin to learn what this thing called ‘community’ and ‘capacity’ is all about. Much of Local Government has for some time been cutting costs and at the same time working differently with communities and developing services in communities and to dismiss it as not clinically valid (in the NHS sense of the word) and start again is a serious mistake. Local Government and the health services in their many forms, through the Health and Wellbeing Boards must be the start and finish point for Health and Social Care integration to solve these problems as our population ages.

First Train to Liverpool

Ely Station with no a single other person about!

Ely Station 5:25am with not a single other person about!

A couple of Wednesdays ago I left home at an unnatural hour and caught the first train of the day from Ely Station at 5:30am to get to Liverpool in time for the annual TLAP Conference at Aintree Racecourse. I had intended to travel the day before but could not due to a Lakenheath Parish Council meeting I wanted to attend and I spoke about in my one of my last blogs.

Having got to Liverpool just in time to hear the conference opening words from Clenton Farquharson MBE who is Chairman of Healthwatch Birmingham and Co-Chairman of the National Co-Production Advisory Group and Sam Bennett who is the Chief Executive of the National TLAP programme, both of whom I sit on the National TLAP Board with, after which I settled down for the rest of the morning to hear the words of speakers at this important conference. TLAP stands for Think Local Act Personal, a nation programme board with many partner organisation promoting the personalisation of our Care Services and if you been kind enough to read this blog, you will know I sit on its Board representing the Local Government Association.

After lunch I co-chaired a workshop session called ‘Building strong inclusive communities. A Framework for Health and Wellbeing Boards’ where we talked about the new Framework for Building Community Capacity and how different Health and Wellbeing Boards are rising to the challenge it provides to put building the capacity of their communities at the heart of their thinking.

In the last Plenary of the day I took to the stage alongside. David Pearson, President of ADASS, Alex Fox of Shared Lives Plus, both of whom are fellow TLAP Board Members alongside Kathy Roberts from the Mental Health Providers Forum and Sherone Philips of the Nation Co-Production Advisory Group. The session was chaired by Richard Humphries of the Kings Fund who is one of this country’s leading thinkers on Health and Social Care. I was asked to speak briefly about the LGA First 100 days (of a new Government from May 2015) and what the LGA is asking for in respect of Adult Social Care and on behalf of Health and Wellbeing Boards across the Country. For the end of a long day it was heartening to see so many people remain for what was a very interesting Q&A session exploring the future of Social Care in a changing environment, relationships with Health and the cuts agenda that will be around for many years to come. Then it was back to the trains and the long day ended at 11:15 as I arrived home.

National Public Health England Conference

Public Health England logoJust before the Conservative Party Conference I was invited to speak and chair a session at another Conference, the Annual PHE Conference where with Public Health Professionals, myself and fellow panel members discussed Health and Wellbeing Boards progress against backdrop of the Better Care Fund.

Caroline Tapster CBE who heads up the work programme of the LGA’s work on Health and Well Being Boards, and was formerly the Chief executive of Hertfordshire County Council spoke first. Then Jane Milligan who is the Chief Officer of Tower Hamlets Clinical Commissioning Group and finally we heard from Tim Baxter Lead on Public Health at the DoH.

Caroline reflected in this the second year of their establishment, HWBs are beginning to consolidate the partnerships they have developed. It is now time to take on fully their role as strategic leaders of the health, social care and wellbeing systems of their areas. Recent reports suggest that in some cases, boards are already grasping the challenge, but have more to do in making the step change required from wherever on the journey they are starting to become effective system leaders. How this is done will differ according to local circumstances and Jane spoke about how their board in Tower Hamlets are facing this huge challenge.

The Better Care Fund (BCF) has dominated the agenda for HWBs over the past few months and will continue to be a key focus but it is vital that this is seen within the wider context of reconfiguring services, the importance of the prevention agenda and the role of public health in moving forward with integration  and continuing to deliver local priorities through Health and Wellbeing Strategies and Tim spoke about these issues from the DH perspective.

For my part I spoke about the interesting emerging picture around the Public Health spend, after all the scare mongering about Councils using Public Health monies for other things now its moved across. Beyond the flat Public Health allocation of £2.79 billion in 2015/16 (the same as last year), spending in Public Health is up some £150m. Information derived from DCLG Revenue Account Budget returns submitted by local authorities in England and published in July shows Councils plan to spend 6% (£150m) more on public health this year despite overall fall in local government spending. Figures show Councils rebalance towards higher priority needs with the headline figures spending on physical activity (children and Adults) increased investment of up to £78m this year compared with £43m last year not including the £905m councils are committed to spend on sport and recreation and the £797m spent on open space. Which is an extra £54m extra committed by Local authorities, above and beyond the grant received from the Department of Health. District Councils are also spending more with a commitment of £1.5m from their budgets to Public Health.

I concluded by saying that this increased spending is a testament to Councillors and Public Health teams who have come together to leverage the new environment. Public Health is back where it belongs and is having a greater impact than ever before.

The role of Health and Wellbeing Boards

Last Wednesday saw an update conference on Health and Social Care Integration in the splendid setting of Ickworth House’s Historic West Wing. The meeting was facilitated by Richard Humphreys of the Kings Fund, whom I have met on a number of occasions as Health and Wellbeing Boards were being formed and the thinking around them matured.

As I sat and listened to a wide range of speakers giving their views as to where we are at, it seems to me that we are some way off a joint vision for the spectrum of services and the mechanism to support the proper joint commissioning of those services, or in other words how we move money around the system.

As always the elephant in the room was the acute sector or more correctly how do we alter the system and close hospital beds without  a. the hospitals going bust b. MPs and the public chaining themselves to the hospital front doors and c. protests in the street about ‘Save our hospital’.

We all know that Big money is in hospital beds and we all know how protective people are of those beds, yet an admission to hospital must be seen and the system must be designed and funded to acknowledge that such an admission is a complete failure of the Health and social care system, yes we need beds and hospitals for when we are ill but far, far too many and in particular older people are going into hospital when that is precisely where they should not be, far too many people are in hospital who could, with the right primary and social care support, could be treated in their community and supported at home, far better outcomes for the resident and far less cost to the system.

One of the things that interests me most is the emerging picture from the United States health care system where major insurers who are not hung up on jobs and the beloved citadels of the system but on the actual costs of providing care. Once they have a person’s insurance contributions, they pump prime money into prevention health and social care programmes and this saves them significant sums of real money, further down the system in their hospital admissions. Just imagine if we took money out of the actues and put it into sports centres, a motion that would seem ridiculous but when you look at actual ways to save money in the long term perhaps not such a crazy idea at all. An analysis of the joint care pathway showing service interventions size, spend and an understanding of what will need to change and the impact of this demographically and financially is not an easy task but one we should be undertaking and its the local Health and Wellbeing Boards not Whitehall mandarins who are best placed to know their local area and what will work best.

Of course the first thing that would have to be tackled is the core stumbling block of payment by results funding mechanisms of the acute hospitals which is actually payment by activity, so less activity would mean less income and the current model would fail. The next stumbling block would be us residents who want the hospital there just in case and are deeply suspicious of any change because we simply do not believe that it’s about improving services but actually about cuts to our beloved NHS, however if waiting times were reduced then perhaps we might start to warm to the idea that we can increasingly be treated away from a hospital setting and more effectively.

One of the acid tests of this at the moment is the out of hours service, I don’t know a single person who if really worried for themselves or a loved one would trust the service rather than simply get the ill person in the car and drive to A&E, with the current performance of the ambulance service in the East of England we even worry about that turning up.

The scale of the challenge before the system and Health and Wellbeing boards is immense but so are the rewards to us as residents and the system as a whole that the difficult times ahead and are worth every effort to get this right. To some extent this is of course now not a new agenda but there is a new imperative to deliver the plan, cope with our ageing population and realise the savings that can be made at the same time as servicing residents needs better, now that’s something worth having the difficult discussions about.

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