Health and care: beyond simply rearranging the furniture

By Francesco Tamilia

For years now, policymakers and health sector stakeholders have pushed for a joined-up system of heath and care. Yet, despite repeated legislative endeavours, there is a worrying lack of clarity as to what successful integration truly looks like.

Perhaps nowhere has this lack of progress been more acutely felt than in the care sector. Concurrent challenges of unprecedented demand, high staff turnover and poor levels of recruitment (in no small part thanks to Brexit) has left the sector on its knees. Then there is the not so small matter of a global pandemic – which cast a spotlight on the stark reality that is the state of England’s health and care system.

Amid widespread agreement that integrating the country’s health and care system drive improvements to patient outcomes;, it is hard to escape underlying feelings of scepticism, particularly, within the care sector, when it comes to the latest attempt at reforming the UK’s health and care system. This sentiment is driven, in part, by the daunting myriad of challenges facing the healthcare sector, creating anxiety amongst care providers that they will get receive support until the NHS can address issues such as the ominous elective care backlog.

The government’s answer? More policy. With its upcoming white paper on social care integration, Whitehall will seek to clarify the outstanding questions and (we hope) finally begin the transition from policy to practice.

To help crystalise these challenges and begin to turn policy into practice, Public Policy Projects (PPP) hosted an evidence session in January 2022 entitled: Integrating Health and Social Care: A National Care Service, as part of its report series: The Future of Social Care. Senior cross-sector stakeholders in social care were convened to highlight the most urgent issues regarding social care, as well as put forward solutions to help progress them within an Integrated Care System (ICS) context.

Unsurprisingly, a recurring theme was enhancing localised decision making within a nationally driven policy agenda –- a balance that has yet to be struck. ICSs must have the autonomy and flexibility to plan and deliver care strategies accordingaccording to the needs of their populations and this unlikely to be achieved through central control.

While the government has insisted that the bill aims to enhance local autonomy, there is considerable scepticism as to whether Whitehall is truly serious about allowing a ‘thousand flowers to bloom’ outside of its control. We may never find a nationally agreed upon metric to accurately and consistently measure the success of integration and there is still worrying lack of clarity as toon what this new “structural cohesion” is supposed to achieve. The fear is that supposed government enthusiasm for integration may turn into frustration when localised decision making inevitably delivers something different than what was exactly envisaged from the centre.

Rearranging the furniture

As far as the care sector is concerned, nothing less than wholesale service transformation will do. ICSs cannot simply be another attempt in a long line of efforts at just ‘moving the furniture’, or simply creating a structural change to hide a desperately under resourced and overwhelmed care sector. Funding disparities between different care settings must be corrected and the ICS agenda must come with new, brave and bold ways of delivering care.

Whatever the debate around integration, the lived experience of the people who are at the receiving end of services must remain central to service reform. The ‘holy grail’ of integration for the care sector is an assurance that people can receive care and remain safe, with dignity, within their own homes for as long as possible.

While care providers share these aspirations, the geographical separation of England’s 17,000 care homes makes local community collaboration difficult. The latest policy around integration does include some specific points to encourage local collaboration. Integrated care boards (ICBs) and local authorities are required to establish integrated care partnerships with the responsibility of convening a broader partnership and producing an integrated care strategy.

In striving for local collaboration, ICBs need not reinvent the wheel. The foundations for health and care partnerships were put in place with establishment health and wellbeing boards, committees tasked with addressing with improving the health of the local population by advancing service integration. The boards were classified as a ‘partnership forums’ with limited formal powers rather than an executive body, and therefore they have had limited impact. However, many stakeholders (particularly from local authorities) believe that the local knowledge of these boards can be used as the ‘glue’ for ICBs to build place-based partnerships and address health inequality in locality.

The money problem

The NHS has been faced with the most challenging period of service provision since its inception – convincing stakeholders to shift resources away from the acute sector will not be easy. But integrated care must come with a rebalancing of the books, or it will be doomed to fail. Can the care sector rely on the goodwill of policy makers and providers to share resources? Or will these sentiments and shared aspirations for place-based care be superseded by growing political pressure to meet targets and reduce hospital wait times?

If any lesson isto be learnt from, it is that the sector cannot consider health crisis under a purely acute sector bracket. If service challenges and the ICS model designed to address them become subsumed under just ‘health’, there is a risk that funding support will be allocated on an acute sector basis – essentially sucking money from the rest of the system. ICSs cannot somehow become an adjunct of the NHS. It’s got to be a completely reformed and reviewed model.

Crucial to securing shared investment across the different facets of an ICS will be the establishment of a shared strategic vision. Strategy drives investment and if systems get this right and allow ICBs to be the guardians of these visions, systems will drive investment.

A theme that has consistently appeared throughout PPP’s The Future of Social Care series so far is the need for patience. The government must give ICSs the time and autonomy they need, while also ensuring that appropriate funding gets to community care. PPP will continue to hold such discussions with key stakeholders to lead the integrated care agenda.

To find out more about this series please write to me at francesco.tamilia@publicpolicyprojects.com

NHSPS generates £53 million in cost efficiencies during pandemic

By Niamh Macdonald

NHS Property Services (NHSPS)’s annual report, published on 13 December 2021, has revealed that it generated £53 million in cost efficiencies for the health service during the first year of the pandemic.

NHSPS, which owns and manages 10 per cent of the NHS estate, exceeded its initial cost efficiencies target by £20 million. These savings helped to mitigate inflationary pressures on the NHS, enabling NHSPS to prioritise the pandemic response and keep its charges flat.

There was an additional twenty per cent increase on capital investment, which saw improvements to NHS sites, such as GP surgeries and hospitals across England.

To support the NHS Covid-19 response, NHSPS refurbished spaces to create capacity for over 1,500 beds across England between April 2020 and April 2021. NHSPS also worked with customers and local health systems to set up 250 vaccination sites.

In total, NHSPS delivered 110 transformational estate projects, as part of its ‘Healthy Place’ scheme. This will benefit over two million patients and provide 100,000 sqm of upgraded space for the NHS.

A new social prescribing programme was also launched, creating 21 more spaces, and contributes towards the goal established in the NHS Long Term Plan to refer at least 90,000 people to these services by 2023/2024.

Over the twelve-month period, NHSPS has prioritised reducing the carbon footprint of the health estate, in line with the NHS’ goal to become net zero by 2040. Initiatives have included switching the building portfolio to 100 per cent renewable energy, upgrading to LED lighting and installing smart meters. This has saved £10.6 million and 8,600 tonnes of carbon.

Martin Steele, Chief Executive Office for NHSPS, said: “2020 was a challenging year for everyone, both within and outside of our organisation but it has been incredible to lead an organisation that has been so committed to supporting the NHS during this difficult time.

“Through collaborating with Integrated Care Systems and local health authorities we have adapted existing buildings to support the vaccine rollout and explored how community-based health and wellbeing initiatives can be delivered locally. We have learnt important lessons that will help us to improve the health estate and ensure it is fit for patients both now and in the future. I look forward to continuing to work closely with our customers to deliver local solutions and the best value possible for the NHS at both a local and national level.”

Community Care, Digital Implementation, News, Population Health, Social Care January 17, 2022

The digital journey of adult social care

By Louis Holmes

In the face of unprecedented challenge for the sector, many adult social care providers are demonstrating their ability to deliver impressive tech systems. Louis Holmes, Senior Policy Officer for Care England writes for ICJ.

Digital transformation in social care is often overlooked, particularly by those outside the health and care sector; the perception is that care providers are not as technologically mature as their healthcare colleagues. Despite funding issues, the inability to invest in tech, and not having access to the same level of resources as their healthcare counterparts; adult social care providers have demonstrated that they have the capabilities to deliver impressive tech systems, even when facing a crisis.

Outlined below are three case studies from Care England members that demonstrate innovation in the sector. For more innovation to happen however, resolving the funding of new tech must be addressed. Each study shows the benefits of the independent care sector, but the challenges faced when trying to invest in care tech.

At Care England, England’s largest and most diverse representative body for independent adult social care providers, we have seen countless case studies from our membership where there is strong evidence of digital maturity and innovation. Through our Digital Special Interest Group (DSIG), Care England members can ask digital questions or share their experiences with other group members. This space allows organisations to learn about new software, or avoid, when browsing for what is on offer. Members have found this group incredibly useful, thus demonstrating communication and engagement as necessary when discussing digital transformation.

Blackadder

Blackadder is a family-owned and operated group of nursing and residential homes in the Midlands and can brilliantly demonstrate the power of remote monitoring.

At a recent Care England event on the subject, Finance Director Michael Butcher explained that, in 2018, Blackadder set themselves the objective of being able to monitor their care data remotely. The aim of this was to reduce time and administration work when gathering paper audits, and ensure that the right data was available to the right people at the right time.

Through Nourish’s Electronic Care Management System and Power BI, Blackadder can produce hourly, daily, weekly and monthly reports, efficiently and rapidly analysing core care data points within their homes. The next stage of their digital transformation is linking their current system further remote monitoring systems and eMARs.

Integration and interoperability are essential factors care providers need to consider as they expand their digital systems. It can be the case that a provider buys several different software solutions/pieces without realising that they are not compatible with one another, resulting in barriers being created between the different systems. However, it can also be the case where a regional CCG is rolling out a programme that is not yet compatible with the provider’s current system. Thankfully, more is being done to resolve interoperability issues, but it will remain a pertinent problem as we see more technologies become available.

Hallmark Care Homes

To help avoid such instances, Care England member Hallmark Care Homes are creating a business intelligence system through Yellow Fin that collects data from several different systems used by Hallmark. Building a data lake allows Hallmark to mine important information which can then be analysed effectively by the relevant employee.

Programme Delivery Manager Saad Baig has developed a visual traffic light system through intuitive thinking, enabling head office to monitor each care home. Using a traffic light system, Hallmark can identify which homes needs immediate support and which homes are starting to edge towards becoming a concern.

Sophisticated systems such as the one being developed by Hallmark provide further freedom when it comes to choosing the right tech and enables quicker response times and delivery of care. It buys the gift of time leaving health and care workers to focus on their core role of delivering high-quality care.

Canford Healthcare

Through Microsoft 365, Amanda Rae, Quality & Compliance Manager, has created a user-friendly system that brings together several data and compliance sources, minimising burden and time spent on administration work. Amanda can link and share important tasks and documents using SharePoint, Forms, Teams, Planner, and Power Bi. It allows Canford to create the correct compliance documents that can then be shared with the Care Quality Commission (CQC).

Although it may seem daunting for providers to build a similar system from scratch, Amanda, who led the project at Canford, does not come from an IT background, demonstrating how easy it would be for any provider to build. This sort of innovation needs to be applauded and the huge innovation in ASC recognised, learned from and built on.

Adult social care: going forward

With Integrated Care Systems (ICSs) introductions scheduled for the summer, we must continue these digital discussions and connect care providers to the right people within each new system.

NHSX, with the help of Digital Social Care, has already begun working with some systems and helping develop their digital capabilities. Tools such as the ‘Digital Social Care Records – Assured Supplier List’ helps care providers choose a supplier who has been rigorously selected, ensuring that they can meet and deliver against the national specification.

The Adult Social Care White Paper demonstrated The Department of Health and Social Care’s (DHSC) eagerness to digitise the sector and outlined some bold ambitions. £150 million shall be invested into the sector over the next three years to help drive care providers’ digital journey with the commitment to ensure that at least 80 per cent of social care providers have a digitised care record in place. This is welcoming news, and Care England looks forward to working with the DHSC in achieving these goals.

Through workspaces such as DSIG, we can actively promote and share successful digital stories that help show the digital maturity of the sector and bring care providers to the forefront of digital discussions.

Louis Holmes is Senior Policy Officer for Care England.

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Delivering primary care at scale

By Professor James Kingsland

Primary care at scale (PCaS) entered the lexicon of healthcare in the NHS in England over 10 years ago. It should be regarded as a set of principles rather than an organisational form, albeit when these principles are applied, a larger provider organisation often results. However, there are many ways of delivering PCaS.

It is well recognised that a predetermined ‘one size fits all’ approach to providing integrated care to populations with diverse needs rarely delivers the desired improvement in quality, safety and consistency in the outcomes of care for patients.

Therefore, any structures created to deliver PCaS should result from these functional principles and assessment of the needs of the population being served. Population health management is now the internationally recognised approach to this analysis of need.

This approach moves away from episodic care to managing the care of a population, utilising data that is also focussed on predictive and preventative care.

A cultural shift

PCaS is predicated on an ability to provide improved first contact care to a larger population than individual list-based general practice, but is more complex than just the aggregation of local practices.

Its purpose is to extend the provision of health and care services within a community setting through an integrated team-based approach. Many providers of primary care and other public services are usually incorporated into effective models of PCaS.

To be successful, a cultural shift is required by both clinicians and patients which changes the dependency on the GP being invariably the first point of contact and creates new models of care management.

Whole population budget

The last (but by no means least) core principle for PCaS is to improve the deployment of health and care resources (human as well as financial) and so reduce per capita costs of care.

This often requires the alignment of clinical and financial drivers through the management of a whole population budget. Entitling clinicians to take responsibility for the stewardship of resources usually results in improved utilisation and productivity. Also investing in value-based outcomes rather than the historical institutional focus on quality and safety at whatever the cost will reduce overall spend in healthcare services.

Ultimately, a PCaS organisational form needs to be ‘the right size to do the job’ and its size allows for a ‘one team’ approach to the provision of care to a defined population.

These principles should direct the core purpose of primary care networks (PCNs) as designed for the NHS in England. To do otherwise may result in PCNs simply trying harder at what has already failed in previous NHS reforms.

Control by letting go

Whatever the model(s) for delivering PCaS, policymakers need to learn the ‘art of control by letting go’ and empower the service to move away from a centralist approach. Enabling the freedom to make decisions at the right level creates the right environment for effective delivery and leads to sustainable system change.

Unfortunately, this has rarely been achieved in the past. There has too often been a malalignment of behaviours and incentives in the system and ‘engagement’ of the service in predesigned models of PCaS has failed. Only through the development of a consistent set of values and promoting co-production with the service can new models of care emerge.

Moving away from positional leadership to an approach of distributed leadership within a PCaS model also promotes an attitude of collaboration by the people doing the work. The liberation of the ‘leader inside’ the individual creates a more purposeful style of practice for improved provision of care.

Emerging operational change

The transformation from current primary care provision to PCaS can eventually be achieved through learning from the past, seeking knowledgeable advice and using an evidence base for reform.

Often, multiple small-scale redesigns over long periods of time involving a series of well managed sequential experiments is necessary. Reformers need to keep testing and prepare for feedback, mid-course correction and revision if the change is unproductive. Operational change should then emerge rather than be planned. Reformers should be prepared to forgive themselves when things go wrong, as no-one gets it right first time.

Initiating care reform programmes and, in particular, developing PCaS should start where the energy is and where people are ready for change. An incremental approach to implementation should then be taken.

Co-production and use of knowledge in the service is paramount in order to develop a feeling of ownership rather than engagement in someone else’s design.

The ability to deliver the principles and requirements of improved service delivery through a PCaS approach within PCNs is achievable. However, there may need to be a reset in future design. The current environmental factors and a contractual prescriptive approach may prove to be counterproductive to the ambition of the NHS Long Term Plan.

Don’t waste the chance to finally reform NHS dentistry

By Martin Skipper

The concurrent challenges of Covid-19 and longstanding issues with regards to dental access provides a unique opportunity to provide desperately needed reform to NHS dentistry.

As Covid-19 continues to restrict the public’s ability to access routine health services, increased attention is being paid to the precarious state of NHS dental services in England. It is becoming increasingly clear that dentistry needs ambitious reform if it is to play its part in reducing inequalities and improving health outcomes – both throughout Covid-19 and beyond.

The pandemic is amplifying longstanding issues of access to dental care. According to official NHS statistics, the number of people in England seeing a dentist within the maximum two year recall period dropped from 49.3 to 43 per cent for adults, and from 58 to 23.3 per cent for children.

Pre-pandemic data from August 2019 shows that access in deprived wards in London was already shockingly low, however. In Stanmore Park in Harrow adult access was 36 per cent, child access 34.2 per cent. While in South London the wards of West Thornton in Croydon and Bellingham had adult access of 47.6 per cent and 52.6 per cent respectively with children’s access at 31 per cent and 37.1 per cent. The third most deprived ward in London, Lansbury in Tower Hamlets, recorded adult access at 40.3 per cent and children’s access at 31.9 per cent.

Rethinking the NHS dental contract

NHS dental services are in the small minority of NHS services that charge most patients at the point of care. The British Dental Association estimates that patient charges are making up more and more of the dental budget, increasing from accounting for about 22 per cent in 2010 to over 30 per cent now. Local healthwatch report a great deal of concern and confusion among the public about dental charges. There is frustration too among the profession. Dentists do not enjoy acting as tax collectors for the NHS, nor do they benefit from the dynamic this creates with patients. NHS charges for dentistry are an anachronism that cause more problems than they solve.

As Integrated Care Boards (ICBs) begin developing plans for local health improvement and health inequality reduction, dental contract reform continues to pose obstacles to progress.

Dental contract reform must not take place in isolation from wider NHS reforms. If, as proposed in the Bill, dental commissioning is devolved to ICB level then it is vital that ICBs are involved in discussions about dental contracts. Dentistry will only be able to play its part in ICB plans if there is a contract which supports the delivery of ICB priorities.

Major problems will arise if ICBs attempt to drive local health improvement initiatives without reforming the dental contract.

If the 64 per cent of adults in Stanmore currently without access will require more care than the 36 per cent who have been going to the dentist, then they will require lengthier and perhaps more complicated treatment. This will inevitably reduce available appointments for others, delivering nothing extra towards contracted targets and cost the practice more money. At the same time the NHS is deprived of its ability to recoup its dental spend if these people are exempt. In this scenario, and it is replicated across the country, the existing contract will not be able to support ICBs in any meaningful attempt to reduce health inequalities or improve health outcomes.

If the Care Quality Commission takes responsibility for assessing whether services are accessible then there is an added incentive to change the system to ensure adequate funding. The alternative would be to rely on a primary care dental system which encourages episodic attendance and penalises routine care based on prevention. The very opposite of what we should be aiming for if we want to improve health and reduce health inequalities.

If dentistry is to play a meaningful role in health inequality improvement, then a dramatic increase in the dental budget is required, along with a move away from an overreliance on patient charge revenue. Without reform, ICBs will struggle to boost dental access in deprived communities without depriving access to others or hemorrhaging money from their limited dental budgets.

Leaders in the NHS and across government must be brave and take this opportunity to invest properly in NHS dentistry. The costs for inaction are stark. The estimated costs of hospital admissions in 0 to 19-year-olds for all tooth extractions was £54.6 million and for extractions due to tooth decay was £33 million in the 2019/20 financial year.

An integrated future for NHS dentistry?

A joined-up primary care service with dentistry as a fully integrated component would transform NHS approaches to reducing health inequalities and improving health outcomes.

The comprehensive integration of oral health considerations into existing care pathways will bring huge health benefits. For instance, current guidance around eating disorders makes barely a passing reference to dentists despite the impact on oral health of conditions such as bulimia. Diabetes and its relationship with oral health is becoming ever better understood, but pathways remain poor and local initiatives to join up services are sporadic.

Oral health is at risk of rapid deterioration for those who have had a stroke, been diagnosed with Parkinson’s, Alzheimer’s and other dementias – yet there is no joined-up approach to ensure that oral health plans are in place to support patients with these conditions. This is not to mention the potential for improving the oral health of those over 65 by using dental practices to provide immunisations, blood sugar checks, and so on.

The above issues are just some of the approaches that ICBs may like to consider in their efforts to reduce health inequalities and improve health outcomes. But without ambition and increased budget dentistry will remain a service outside of the rest of the NHS. If dentistry is to truly be a part of the NHS and a key part of the integrated health agenda, then it needs to be like the rest of the NHS: free at the point of service and available to all.

The local approach to health inequality

By Lottie Moore

Dr Chi-Chi Ekhator is a GP based in South London and a GP Appraiser of NHS England. She is also Chair of Five2Medics, an initiative within Ascension Trust, born out of the desire to build wellness and resilience in communities facing disadvantage.

She spoke to Policy Analyst Lottie Moore about how the health sector must radically rethink the ways it engages with the wider social determinants of health inequality.

Good health is crucial to a good life, but it is not the only ingredient. Understanding how health fits into the wider frames of people’s lives is essential if we are to truly enable people to live the healthiest lives possible.

Dr Ekhator knows this first-hand. Working as a GP in some of the most disadvantaged areas of London, she understands the disengagement many people feel with their health services and is working to change the narrative.

The power of community

The Ascension Trust (AT) is a faith-based charitable organisation that seeks to harness and equip local communities to work together. The AT is the architect of the well-known initiative Street Pastors, in which local Christians across the UK serve as a presence on the streets to make them safer during the night-time economy. This model is now used within railways and emergency response settings. “We work with the national railways to cover areas which experience high numbers of suicidal incidents,” says Dr Ekhator. “Likewise in response settings, we send out trained individuals who respond to emergency situations to be a presence with victims and provide support to professional services.”

The key understanding behind this work is that local people know their communities best – better than the systems and structures that are set up to help them. Equipping these systems and structures to embed themselves within communities must be an exercise in learning from those already working on the ground.

“We need to understand fully the deeper challenges at play here,” explains Dr Ekhator. “We might keep sending generic reminders to a woman who doesn’t show up for her smear test. Why doesn’t she turn up? Because she’s on a zero-hour contract; she can’t afford to come. We are surrounded by poverty but we don’t see it.

“Understanding these nuances and bringing health messages into communities in trusted spaces by trusted voices is key.”

A new approach towards vaccine hesitancy

Dr Ekhator believes the Covid-19 pandemic has really revealed these knowledge gaps. “It is all well and good having Public Health England releasing messages and advice. But some of it is falling on deaf ears because people think ‘well I don’t trust you anyway so why should I listen now?’ The pandemic has actually given us scope to go into communities and speak to them and begin gaining trust.”

AT’s Beacon Project, commissioned by South East London NHS Clinical Commissioning Group is doing exactly this. The project is a 12-month initiative aimed at providing Caribbean and African communities in South East London with the ability to make informed choices, recognise myths and fake news, and ask the questions that help them understand what is happening. The project is working with local faith communities in areas that have traditionally been hard to reach through conventional methods.

“Vaccine confidence and uptake is a real trigger for anger at the moment,” says Dr Ekhator. “This project is an exercise in listening and saying “we care about you and we want to approach your health holistically – on your terms.”

The Covid-19 vaccine only works so long as it is taken, and while it is therefore currently in the collective national interest for more hesitant communities to take it, the question must be asked: since when has the health of these people been a priority?

“There is no point saying to people, ‘get the vaccine, but actually we don’t care that you’ve been smoking for twenty years and have mental health issues’ That is not an integrous way to approach communities who have been disadvantaged for so long.”

Dr Chi-Chi Ekhator, Chair, Five2Medics

The Beacon Project is therefore doing much more than just addressing vaccine issues, by providing communities with a trusted and safe place to talk, on their own terms.

For Dr Ekhator, it is about saying: “let’s not just talk about your health when there’s a crisis, but constantly. Let’s talk about blood pressure, diabetes and nutrition…about unpaid carers and under confidence. In many ways, it is a GP’s dream: being able to access hard-to-reach communities rather than sending a letter.”

A national strategy, locally delivered

Much more must be done to integrate health services into the wider tapestries of people’s lives. It should not be the sole responsibility of charities to pick up the pieces where government-funded systems are failing to reach people. It is for national governments to recognise that real change starts where people live, work and breathe. To ensure health systems can fully serve their communities, national government must first recognise the value and importance of community-led approaches.

As Dr Ekhator concludes, “health has to look different. We need to take health into our communities. We can’t expect communities to come to us. We have to meet people where they are at.”