PPP calls for adequate social care funding to end postcode lottery

By Integrated Care Journal

Public Policy Projects (PPP) has launched its first Social Care Network report, Mind the Cap: choices and consequences for financing social care, addressing the need for radical financial restructuring within the UK social care system.

The report, launched on 14 March, finds that the standard and financing of social care in the UK is subject to a postcode lottery. Given that social care is funded locally, there is vast regional inequality in the standard of care in the country.

Even with some level of means-tested support, and the newly introduced cap, the PPP Social Care Network found it a system unaffordable for many. The report concludes that these measures do not protect some low-middle income households from having to spend entire savings on social care.

PPP brought together 25 senior stakeholders and experts within the sector to discuss solutions to the crisis ahead of the spring budget. The report is sponsored by Radar Healthcare and the Royal Voluntary Service.

In September, parliament agreed to increase National Insurance Contributions by 1.25 per cent to establish a new ‘Health and Social Care Levy’ and introduced a new measure to cap care costs at £86,000. However, only a small proportion of money generated by the levy will go to social care, and the cap does not protect low-middle income individuals or families.

PPP’s social care network find that the Levy proposed by the government will not even begin to address the costs of care required by the system, and the cap protects those who are least likely to use the system.

Speaking at the report launch event, former Deputy Prime Minister Damian Green, said: “The current Health and Social Care Levy falls on the working age population, all of whom will be faced with inflationary cost of living pressures which we haven’t seen since the 1970s. It is falling on a particularly vulnerable portion of society.”

Key recommendations from the report include:

The government must focus its attention on how best to stimulate a wider insurance-based approach to care, encouraging individuals to participate in voluntary insurance schemes to cover costs up to the cap
The government should widen the scope of the Health and Social Care Levy; other forms of income and wealth for which National Insurance does not apply, such as rental income for private landlords, should also be considered for a social care levy
The government should explore greater flexibility around the Health and Social Care Levy, including the option of directing a proportion of the levy to an individual’s social care insurance scheme and/or contributions being made up by employers, as with pension schemes

The report emphasises that there is insufficient funding overall in the sector and that local authorities and care providers must be adequately funded for any improvement of the social care system. It also outlines that this funding should come from both private payment and higher state provision.

Mr Green said: “The adequate financing of social care is vital for the proper functioning of the system. Once we inject an appropriate amount of money into the system which has, quite frankly, been on its knees for years, we will begin to see the problems of the social care system begin to melt away. The measures proposed by the government are not sufficient, and more must be done to support those in need of care.”

Commenting on the report, Dame Esther Rantzen, Broadcaster and Founder of ChildLine and The Silver Line, said: “I know how crucial adequate funding is, both for those who offer care, and for those who receive it. The caring profession needs far better funding to give carers the opportunities and status they should have and enable them to give their work the time and skill it needs. And vulnerable people who need support should not have to worry whether they can afford the right care. Without proper funding carers will continue to be undervalued and their work unappreciated when in fact more and more people depend upon it.”

A new network to drive the integration agenda forward

By Chris Skidmore

Historical divisions between hospitals and family doctors, between physical and mental health, and between NHS and council services, have resulted in too many people experiencing disjointed care. All too often, it has been those from the most disadvantaged backgrounds and communities who have borne the brunt of disjointed care delivery, experiencing worse health outcomes than others.

Integrating both health and care has become a central mission both for the government and the NHS, with a clear focus on recently established integrated care systems (ICSs) as the driver of change.

Having been in development since 2018, July 2022 will see ICSs take up new statutory footing, providing a legal obligation to deliver joined up care and arrange services along a place-based approach. This will help ensure that decisions about how services are arranged should be made as closely as possible to those who use them. For most people their day-to-day health and care needs will be met locally in the town or district where they live or work. Partnership in these ‘places’ is therefore an important building block of integration, often in line with long-established local authority boundaries.

Yet the formal legal constitution of ICSs and their underlying new structures and governance, underpinned by integrated care boards (ICBs), can only be the start of a journey towards a fully realised vision of integrated care. With ICSs soon to be legally independent entities, the focus must now turn to their decision-making processes, and how they choose to adapt their services to meet local population needs.

Within this decision making will come the opportunity for more agile and rapid procurement processes, that allow for a more collaborative approach. Already the Department of Health has sought to support ICSs in their decisions, and has recently conducted a consultation on a new approach to arranging services – the Provider Selection Regime – which should make it easier to develop stable collaboration and to reduce some of the costs associated with the current procurement rules.

The government’s Integration White Paper: driving digital change in ICSs

Further to ICSs being established in law, the government’s Integration White Paper, published on 9 February 2022, goes further in ascribing a future strategic direction for ICSs and sets out a roadmap for better integration of services.

ICBs are expected to agree a plan for embedding population health management capabilities and ensuring these are supported by the necessary data and digital infrastructure, such as shared datasets and digital interventions. ICSs will use population health management (PHM) to help deliver personalised and predictive care based on an individual’s risk – which will be determined based upon an individual’s wider determinants of health.

Real-time insights from aggregated data will be crucial to achieving success in the fields of multi-disciplinary working, clinical decision support and waiting list management, at the same time as ensuring new diagnostic centres in the community can become a real success.

The Department of Health has also set out in the white paper an ‘ICS first’ approach, which will encourage organisations within an ICS to use the same digital systems, this will provide care teams with accurate and timely data, encouraging ease of information sharing. The department has set out a goal of 80 per cent adoption of digital social care records among CQC-registered social care providers by March 2024. To achieve this, ICSs must work with partners to drive adoption. Digital investment plans are expected to be finalised by June 2022, which include the steps being taken locally to support digital inclusion.

While more than 60 per cent of NHS trusts have made good progress into digitisation, with 21 per cent now digitally mature (as set out in the What Good Looks Like Framework), and only 10 per cent continuing to rely heavily on paper, the picture is often much more challenging in social care. Only 40 per cent of social care providers have electronic care records, and this is only improving slowly, at around three per cent per year. The Integration White Paper outlines a plan for adult social care that will ensure within six months of providers having an operational digital social care record in place, that staff are able to access and contribute to their local shared care record. Work is also underway to enable citizens to be able to amend their shared care records.

With these clear ambitions now set out in the Integration White Paper, there is a clear need to link policy ambition with the reality of enabling healthcare providers to deliver care within new ICS structures. As facilitators of joined up care delivery, ICSs will not be able to improve health outcomes without working closely with partners who share their vision of integration.

Integration can only be achieved by working alongside organisations with expertise in delivering patient management records and improved data collection methods – as well as with the pharmaceutical and health technology communities to deliver improved early-stage diagnostics and early access to treatments and therapies.

It is indeed these four areas of focus that represent the greatest opportunity both in the short and long term for ICSs to deliver real population health improvements in their local areas:

The future of healthcare data and the single patient record
The digital provision of healthcare
The improvement of diagnostics
The enhanced access to treatment and therapies

While the priorities for each ICS will rightly vary depending on the local patient needs and wider demographic demands, there is now a clear need to establish where common interests between ICSs exist, in order to enhance best practice. If ICSs are truly to become the benchmark of healthcare integration, then their own standards and performance will be monitored at a national level. It will therefore be incumbent for every ICS to engage fully in the wider policy debate about how they can deliver on the modernisation of healthcare through data, digital, treatments and technology. A wider forum is needed to help instruct ICSs on the right pathways to take for the future.

Public Policy Projects (PPP) has, for 25 years, been at the forefront of the healthcare policy debate; as an independent policy institute chaired by former Health Secretary Rt Hon Stephen Dorrell, it is recognised as a leading policy organisation that works with thought leaders across both health and social care, pharmaceuticals and more recently genomics. PPP has made the policy framework around the provision of integrated services a central mission of its work, and is responsible for publication of the Integrated Care Jounral.

ICJ brings together leaders in health, social care, local government, policy and research to engage with the latest insights and analysis surrounding the future of health and social care in the UK. Content is produced by and for the very leaders tasked with delivering joined up care across the country – covering every facet of ICS development.

To spearhead its outcomes-based approach to content, ICJ has recently established an Editorial Advisory Board. The board oversees content production pipeline, ensuring that our articles are insightful, practical and credible. The board is made up of some the country’s leading health and care experts and features system leaders at the very forefront of UK integrated care.

As part of its policy work for 2022, PPP is now seeking to establish a new Integrated Care Network which, alongside Integrated Care Jounral, will help provide ICS leaders with the policy guidance and support to make the best decisions for achieving improved patient health outcomes. PPP has already hosted a number of ICS related events, including a recent roundtable alongside IQVIA.

The start of this new Integrated Care Network work will begin with an ‘Integrated Futures’ roundtable series, beginning this Spring 2022, to mark the formal adoption of ICSs into law.

As part of the ‘Integrated Futures’ series, PPP will organise four roundtables focusing on the core areas of partnership between ICSs and healthcare providers which can deliver the greatest impact and benefit:

The future of healthcare data and the single patient record
The digital provision of healthcare
The improvement of diagnostics
The enhanced access to treatment and therapies

These roundtables will bring together both ICS representatives and leaders, together with healthcare partners at the forefront of working with ICSs to deliver on better care through innovation and improved access to data, digital technologies and enhanced treatments and therapies.

The Integrated Futures series will seek to position PPP as the forum for the high quality exchange of ideas and future policy, with those ideas intended to influence both NHS strategy and ICS leaders. As such, this will be an important forum for companies and organisations to be involved in, at a time when the future direction of ICSs both at a local and national level is still to be fully established.

The local voice is key to dental success

By Martin Skipper

To achieve the NHS Long Term Plan goal of preventing health inequalities and improving health outcomes, the voices of those delivering and receiving dental care on a local level must be prioritised.

Top-down change, if not informed by local experience, will fail to address issues faced by service users and service providers. Therefore, the voice and experience of local councils, local Healthwatch and local service providers is key to creating an environment through which NHS dentistry can play its part in reducing health inequalities and improving health outcomes. This is why building strong relationships with these bodies is central to the role played by Local Dental Committees (LCCs).

The LDC Confederation is a membership body for LDCs which represent primary care dentists delivering care under an NHS contract. We actively support our member LDCs to engage with local stakeholders, to take the time to explain the complex NHS dental contract and to make clear how, if properly supported, NHS dentistry could help meet their local objectives. These local relationships have created sympathetic alliances and a strong desire at the local level to see a reformed dental contract introduced that would remove barriers to care, which in turn would help to reduce health inequalities and improve health outcomes.

The local councils and local Healthwatch know their populations, understand their issues and seek to identify areas for improvement. Even before the pandemic, we were pleased to see a growing interest in NHS dental services from local stakeholders. Since then, of course, we have seen access to NHS dental services and appropriate provision of NHS dental care grow into a burning issue for almost every local authority.

Member LDCs have enjoyed close working with their local Healthwatch partners, helping with reports and speaking at events throughout London. During the pandemic we provided updates and patient facing information for our local partners to help them and their communities to navigate NHS dental services. This interest has increased dramatically throughout the pandemic as services have struggled to meet patient demand.

Barriers to access

The barriers to access exacerbated by the pandemic have existed since 2006. The pandemic simply brought them to the fore and demonstrated the historic neglect that NHS dentistry has suffered, but also the huge importance that the public place on NHS dentistry. Time and again we have seen reports which show clearly that dental services are highly valued and that satisfaction with the quality and outcome of the care received is high.

NHS dentistry should be one of the great success stories within the wider NHS: a high achieving clinical specialty, with high patient satisfaction, providing clinical care able to give instant pain relief and rapid functional outcomes. Instead, sadly, it is treated as an ancillary service which is not vital to health and wellbeing.

Local stakeholders know differently. They hear stories from patients in pain on a regular basis, from parents of children in pain, from those who are ashamed to go out or eat in public, from people who are afraid to access care because of the NHS charges and those who simply cannot navigate the system and end up at the GP or in A&E. We have been working hard with local partners to press for improvements to holistic care, especially for the most vulnerable such as those in residential care homes and those with conditions such as Alzheimer’s and other dementias, diabetes and stroke rehabilitation. These groups in particular need the system to work with them and for them if they are to lead lives free from avoidable pain and discomfort. Integration of services at the local level will support a holistic approach to care which would pay dividends in improved general health outcomes and quality of life.

Dental contract pilots

Dental contract pilots, later termed prototypes, have been the great hope of the profession since they began in 2010. These pilots were testing new models for the contracting of NHS dental care and were based on blends of capitation and activity. Appointments were longer and the focus was on prevention.

According to the Department of Health’s own press release in 2018:

90 per cent of patients had reduced or maintained levels of tooth decay
80 per cent of patients had reduced or maintained levels of gum disease
97 per cent of patients said they were satisfied with the dental care they received

At the start of 2022 the NHS announced the end of the prototypes and all dental practices operating as prototypes for the NHS are now reverting to their previous contracts. Despite the models showing such promise it is not clear how much of the valuable information taken from these pilots will be applied to a reformed contract in the future.

Local voices are vital

The current Units of Dental Activity (UDA) contract, is based on activity and the NHS is heavily reliant on recouping funding for dentistry through patient charges. This creates a disincentive for the system to increase access among those with the highest need, as a greater number of treatments take longer and in doing so will reduce the amount of activity delivered, throughput of patients and the amount of funding the NHS can recoup from patient charges. The current activity based contract is not able to support local objectives of reducing health inequalities, and the focus on treatment rather than prevention does not support the local objective of improving health outcomes.

If the local councils, and in the future local care partnerships and Integrated Care Boards, want to see a reduction in health inequalities and improvement in health outcomes then a dental contract which supports those objectives is needed. The LDC Confederation ensures that local stakeholders understand NHS dental services and the role they can play in meeting these priorities. We will continue to work with our local partners to make sure local voices who know their populations best will be heard at the national level. Local voices are vital to inform dental contract reform and to make sure that the dental contract is fit for purpose.

The Minister for Primary Care, Maria Caulfield, recently outlined the aforementioned problems with the dental contract on BBC Radio Sussex, and also affirmed the importance of contract reform. Both of these statements are to be welcomed but real improvements will only be seen if that reform is based on the experiences and priorities of those delivering and receiving care at the local level.

Is the answer to improved health hiding in plain sight?

By Dr Anne Elliott and Professor Tim Evans

The UK is suffering from a major gap in the provision for exercise as a prevention or management tool for chronic disease. Outlining this growing healthcare crisis is Dr Anne Eliott, Senior Lecturer in Physical Activity for Special Populations and Healthy Ageing, and Prof Tim Evans, Professor in Business and Political Economy at Middlesex University London.

Over and above record NHS waiting lists¹ and the adverse effects of the Covid pandemic, there is a tsunami of chronic disease on the horizon, and it is flowing towards us at a stately and predictable rate². We can see the wave growing and developing, we can gauge its potential cost, we can foresee the amount and quality of resources that will be needed, and we can estimate the number of specialist healthcare professionals that will be required to address it – and yet we seem unable to avert what increasingly appears to be an inevitable disaster.

We cannot lay the blame for the growth in long-term illness on a lack of health education, as positive health messaging from both the state and private sectors is prevalent in all popular media and easily accessible for all age groups and populations. At the bare minimum, the general public understands the importance of ‘eat less’ and ‘move more’. Over the last 20 years, successive governments have sponsored numerous initiatives that have attempted to address such issues, from Change4Life (PHE 2009) that aimed to encourage families to exercise together, to the recent adoption of an old idea, social prescribing³ (NHS 2020), that targets loneliness and depression at a local community level.

However, differing socio-economic determinants have been identified as obstacles to participation. Although authorities try to address these barriers, sedentary behaviours and lifestyles are responsible for 40 per cent of premature mortalities and continue to be the weak spot for ‘preventative medicine’⁴, a term now well established within Parliament and across the UK’s broader political discourse.

Cost is consistently found to be one of the biggest barriers to moving towards a healthier lifestyle. Through physical activity in the private sector and with levels of economic status found to be correlated to health outcomes⁵, it would be beneficial to make access to exercise easy as both a preventative tool in the public sector and as a response to the onset of many diseases further adversely impacting the medical sector.

A gap in provision

There is a clear gap in provision for exercise as a prevention or management tool for chronic disease and there isn’t availability or knowledge in the existing medical workforce to bridge it

At present, general practitioners are the most efficient and effective pathway to intervention and support for people in local communities. However, there are limited options, such as exercise referral schemes⁶, found to be too short for exercise adherence and too expensive for most practices to utilise, or referral to a scheme such as the NHS Diabetes Prevention Programme. Apart from these ‘schemes’ the next level of physical specialism is physiotherapy and associated disciplines which are geared to address more clinically acute rehabilitative issues.

It is against this backdrop that there is a clear gap in provision for exercise as a prevention or management tool for chronic disease and there isn’t availability or knowledge in the existing medical workforce to bridge it. However, with some creative change and investment, the workforce required to fill this gap could be closer at hand than most commentators realise.

Currently, there are approximately 66,300 fitness instructors in the UK, of which 22,032 are personal trainers. They are well placed to work with the general public with diagnosed or undiagnosed chronic conditions – it is common for sufferers to live with low level conditions for up to 20 years before they seek help from their doctor, when the condition interferes with their quality of life. The Chartered Institute for the Management of Sport and Physical Activity (CIMPSA), acknowledges this specialist need and has drawn up professional standards for fitness⁷. Ukactive⁸ also discussed using trainers more within a wider community based social prescribing framework. We see professional bodies turning their consideration to this in light of Covid, which has created an awakening of understanding for the need to improve the physical and mental health of an ailing population.

Upskilling the workforce

While such upskilling requires investment, the costs will not be as great as leaving health outcomes to an unnecessarily disjointed and unreformed skills base

The fitness workforce has historically been eschewed by the medical profession on the basis that too many of its practitioners lack appropriate levels of educational attainment. Personal trainers are shown to have qualifications that range from a ‘two-week online course’ to a Masters degree in a sport specialisation such as Strength and Conditioning. Industry regulation has mitigated this to a certain extent by registering most practitioners with a vocational qualification equivalent to an A level. However, these fitness qualifications are not mapped to any NHS accreditation and qualification requirements and so a divide between health provisions runs deep.

An obvious solution to this division is to bring existing fitness qualifications into parity with the medical regulatory framework. The workforce can be upskilled into the range of existing NHS levels of qualifications and pathways, such as apprenticeships, which may then provide an opportunity to create roles acknowledged by the Health and Care Professions Council.

While such upskilling requires investment, the costs will not be as great as leaving health outcomes to an unnecessarily disjointed and unreformed skills base. At a time when the NHS is facing its largest ever backlog, it would be wholly inappropriate to invent a new category of worker, train them from scratch, or alternatively do absolutely nothing.

Workforce planning

While in the past the pressures of electoral politics have often prohibited effective workforce planning, inaction with regards to the country’s fitness workforce is contributing to a multifacted healthcare crisis

To mitigate the ill effects of both the waiting list backlog and the coming tsunami of chronic disease outcomes, it is important to make key investment and workforce planning decisions now. These plans should ideally be locked into our health system for the longer term through a robust cross-party agreement.

For decades, successive British governments of all stripes have avoided workforce planning issues. Incentivised by shorter-term electoral cycles, they have instead left the healthcare system dangerously exposed to the fragilities of professional overstretch. This is why the UK has so few doctors and nurses in comparison to other comparable countries in the developed world⁹.

However, with today’s spiralling costs, waiting lists setting ever higher records and more than 21 per cent of people now opting to use private healthcare¹⁰, the NHS urgently needs creative solutions if it is going to have space to develop and implement better planning.

It is in this context that this proposal to upskill and realign existing professional skills and resources makes so much sense. As a swift and effective solution to overcome a current and costly chasm in our health system, the objective has to be not only holding back the looming wave of chronic disease but to enact comparatively inexpensive reform that will mitigate its most damaging and costly effects.

Faced with an unprecedented and systemic crisis of demand, the time for imaginative supply side reform is now more pressing than ever. If several tens of thousands of people are not empowered to fill the gap in our health economy, then the NHS – and the electoral support that it has hitherto enjoyed – could become irreparably damaged. While in the past the pressures of electoral politics have often prohibited effective workforce planning, inaction with regards to the country’s fitness workforce is contributing to a multifacted healthcare crisis.

References

1 https://www.theguardian.com/society/2022/feb/09/englands-hospital-waiting-lists-may-exceed-10-million-by-2024-ministers-told

2 https://evidence.nihr.ac.uk/alert/multi-morbidity-predicted-to-increase-in-the-uk-over-the-next-20-years/

3 https://collegeofmedicine.org.uk/social-prescribing-is-as-old-as-the-hills-dr-michael-dixon-gives-a-potted-history-of-integrative-medicine/

4 https://www.gov.uk/government/consultations/advancing-our-health-prevention-in-the-2020s/advancing-our-health-prevention-in-the-2020s-consultation-document

5 https://www.health.org.uk/publications/reports/the-marmot-review-10-years-on

6 https://www.nice.org.uk/guidance/ph54

7 https://www.cimspa.co.uk/standards-home/professional-standards-library?cid=18&d=320

8 https://www.ukactive.com/news/leading-the-change-report-calls-for-government-to-help-reduce-pressure-on-nhs-by-backing-social-prescribing-in-fitness-and-leisure-sector/

9 https://www.thetimes.co.uk/article/britain-has-fewer-doctors-than-most-of-developed-world-35r6c68xf

10 https://www.theguardian.com/society/2021/sep/18/private-hospitals-profit-from-nhs-waiting-lists-as-people-without-insurance-pay-out

Mind the Cap: choices & consequences for financing social care

By Francesco Tamilia

The government has announced its plans for social care reforms – but do they go far enough to address the issues endemic to social care?

Reforming social care – particularly with regards to financing it – has been a major challenge for successive governments over the past decades. Despite widespread acknowledgment of the need to reform the system, it remains in flux. In 2019, Prime Minister Boris Johnson pledged in his maiden speech that he was going to “fix social care”. Following the Covid-19 pandemic, the government has put forward clear proposals for reform – including addressing financing issues by increasing National Insurance contributions by 1.25 per cent to establish a new ‘Health and Social Care Levy’.

To discuss the financing challenges in social care, Public Policy Projects (PPP) hosted a roundtable with senior stakeholders in the sector as part of its “The Future of Social Care” report series in January 2022.

Lack of funding a chronic issue

The new social care reforms were broadly welcomed by participants, although many also expressed concern that the reforms do not go far enough to comprehensively address the depth of the issues in the sector.

“We simply don’t spend enough money on it.”

Lack of funding was, by far, the most recurrent theme of the discussion, with one attendee citing lack of adequate funding as the root cause of current market distortions in the first place.

He argued that “we simply don’t spend enough money on it. Every year, the Budget comes around, and when the social care system continues to be completely on its knees, the Treasury simply adds an extra billion pounds. This is immature. If we have to put an extra billion pounds into social care every year, then let’s say ‘over the next five years, we are going to put an extra billion pounds every year into social care’ so that care providers can plan. And then we don’t have the ludicrous chaos that we have at the moment, there is a barrier to planning there. We have to spend more on social care – and this is not just about older people, it’s about working-age adults as well.”

Where’s the money?

Speaking on the same issue, another attendee referenced historical funding in the care sector and highlighted how insufficient funding has led to an unsustainable market. He illustrated how social care expenditure over the last decade has increased since 2015-16, peaking at record levels in 2021 – largely due to the extra money that went into the system due to Covid-19. Roughly half of spending is on working-age adults and the other half is on older people. Money is indeed coming into the sector, but the question is: where exactly has the money been spent, and is it anywhere close to what is needed?

“The money coming into the system has not been spent on improving access and bringing more people into the system/”

Addressing the first question, the same attendee said, “the money coming into the system has not been spent on improving access and bringing more people into the system.” Consequently, eligibility for care has continued to tighten and has not risen in line with inflation, thereby excluding more people from the publicly funded system.

If that money hasn’t gone on improving access for more people, where has it gone? The answer seems to be on the average fees that local authorities pay for care homes. Indeed, there has been, in real terms, a 4 per cent increase in what local authorities pay for working-age adults and a 17 per cent increase in what they pay for older people’s care. “I don’t think you could argue that the extra money has gone on improvements in quality. Quality measures have stayed static over this period and Care Quality Commission (CQC) ratings have nudged up. Satisfaction ratings of publicly funded clients have also stayed pretty much the same. It seems much more likely that [the extra money] is going to fund home care and care home fees,” the same participant added.

Risk pooling a welcome step

“The private sector will never provide pooling of this catastrophic risk.”

A move by the government that was particularly welcomed by attendees was the notion of risk pooling social insurance. Rather than facing a potentially very uncertain risk profile, everybody effectively pays the same amount and is then covered against those risks. “That is undoubtedly what we should do.” said one attendee. “Social care is the only big risk that we all face where neither the state nor the private sector provides risk pooling. The private sector will never provide pooling of this catastrophic risk, it must be done by the state.” According to him, taking away the catastrophic risks gives us a chance of getting a market that will work not just for individuals, but for providers as well.

Overall, there was widespread agreement that although the new proposed legislation is a step in the right direction, more needs to be done to properly address the chronic financing issues in the sector. Yet, it’s equally important that any money that comes into the system is allocated wisely. Achieve this, and the many other issues in the care sector such as workforce and market fragility, can then be addressed.

This write-up forms one part of the wider Public Policy Projects Social Care Policy Programme. Drawing together key stakeholders from across the private sector, PPP intends to lead the debate on social care reform, to scrutinise and discuss the Government’s plans as they are delivered. Led by the Rt Hon Damien Green, the network continues to convene regularly for high-level strategic roundtable discussions in order to gather intelligence, insight and experience to deliver its recommendations through the publication of four reports.

1. Integrating Health & Social Care: A National Care Service

2. Mind the Cap: choices & consequences for financing social care

3. The Social Care Workforce: Averting a Crisis

4. A Care System for the Future: Digital Opportunities and the Arrival of Caretech

If you are interested in learning more about this significant programme of work, get involved in our work and partner with Public Policy Projects, please reach out to carl.hogkinson@publicpolicyprojects.com

Digital Implementation, News, Population Health February 17, 2022

Experts call for ICSs to embrace industry and harness the “patient voice” to drive innovation

By David Duffy

During a crucial period for UK health and care policy reform, Public Policy Projects and IQVIA convened over 500 healthcare stakeholders for a special online discussion to identify the challenges and opportunities for UK life sciences within a new future of integrated care.

The topic was more than timely. Only hours prior to the event, the government published its eagerly anticipated Integration white paper, seeking to clarify exactly how integrated care will improve the patient experience and bring better value to the taxpayer. The white paper follows the publication of the Elective Care Recovery Plan published on Tuesday, which sets out the NHS plan for bringing down the elective care backlog and addressing the longstanding issue of waiting times, both of which have been exacerbated following Covid-19.

In the context of these flagship health policy proposals from government, this session was quickly brought into sharp political focus. “What we need to do through integrated care systems (ICSs) is learn lessons of recent history and apply them to develop more joined up integrated care – this is as important for UK life sciences as it is for health providers,” reflected PPP Executive Chair, Stephen Dorrell.

While this end goal has never been in question, the exact role of ICSs, and by extension ICS leadership, in delivering this joined approach has often been subject to debate. Dr Penny Dash, Chair of NW London ICS and Co-Chair of the Cambridge Health Network, likened the role of an ICS to one of the key facilitator of joined up care rather than a direct provider of it. “While we [ICS leadership] have control over funding, we do not have direct control over the health service provider portfolio, nor do we have commissioning control and we cannot simply move contracts around the system,” she said. The key benefit of ICS frameworks, she insisted, was to convene key parts of the system and build a robust population health strategy.

“We are rapidly moving towards borough-based partnerships (accounting for some 300,000 people in a locality). We want to see those services delivered much more at scale, with much better ability to coordinate and deliver a population health approach.”

Matthias Winker, Head of Strategy at Oxfordshire and Berkshire West ICS, also stressed the importance of ICSs acting as conveners of care transformation. “Our function as a facilitator is crucial, we are introducing a ‘learning culture’ by bringing different capabilities from different organisations to the table. This is particularly relevant when discussing commissioning skills, provider capabilities and local authority expertise.”

A new model of coordinating care also signals profound changes to the relationship between pharmacy and the wider healthcare sector. Brian Smith, Chief Pharmacist, Applied Insights, Access & Value, UK at IQVIA, stressed that ICSs have the potential to alter focus from measuring inputs to focusing on outputs. “Community pharmacists, for example, are remunerated on the number of prescriptions they dispense rather the value they provide – this dynamic has to change to bring community pharmacy further into system wide healthcare provision.”

Life sciences: “Seizing the opportunity”

Industry should be and will be round the same table as colleagues in the ICS landscape – playing an important part in delivering innovation

The agenda to join up health and care service provision wherever possible runs parallel to developing the UK into a life science powerhouse. ICS frameworks present new opportunities to enhance access to care, develop transparency and choice, and ensure that innovative treatments reach the people who need them – the patients.

Also speaking was Dr Ben Bridgewater, a former Professor of Cardiac Surgery at South Manchester NHS and now CEO of Health Innovation Manchester – an academic health science and innovation system, at the forefront of transforming the health and wellbeing of Greater Manchester’s 2.8 million citizens.

Reflecting on the opportunities for advancing health and care innovation, Dr Bridgewater said, “There is an extraordinary and exciting opportunity in ICS development to build momentum for those innovations and exciting projects and move as quickly as we can from the same old statutory functions. We must seize the opportunity.”

Building on this positive tone was Russell Abberley, General Manager, UK & Ireland for Amgen and Chair of the American Pharmaceutical Group (APG). Insisting that the pint glass was “half full” when it comes to UK life sciences innovation, Mr Abberley outlined his excitement over the prospect of industry, “building a stronger partnership” with the health and care sectors. “Industry should be and will be round the same table as colleagues in the ICS landscape – playing an important part in delivering innovation and data to solve issues around workforce and diagnostics and moving patients through the systems.

“I think we [industry] can play a really important part in communicating the value proposition of the solutions: the data, the technology, the medicines, the diagnostics, whether it be to solve some of the challenges around workforce and diagnostics and moving patients out into primary care or out back into the community.”

Mr Abberley went on to stress that the longer-term challenges are around health inequalities, driving uptake and access to treatments, as well as delivering treatments for patients in locality.

The voice of the patient

It is not about having the patient directly in the room, it’s about ensuring the system represents their voice

An increasingly important part of the integrated care debate has been the concept of building care around the patient – putting the patient in control of their own care and ensuring the system works for them. These themes were affirmed in the recent Integration White Paper, which placed particular emphasis on the value of “personalised medicine”. However, if providers truly want to develop personalised medicine, then they will need to take opportunities to better understand the people receiving it.

The extent to which patients should be included as an active participant in system transformation has proven to be a challenging and interesting debate and speakers on the day did not shy away from this discussion. Dr Bridgewater pointed to the inclusion of the voluntary sector as an important and necessary step to securing the patient voice in system transformation.

While certainly conscious of the fact that the people sitting at an ICB meeting may not be best placed to help patients understand how to live a healthier life, Dr Penny Dash played down the idea of direct patient involvement in transformation processes. She argued that if providers consider the idea of the patient ‘voice’ too literally, it could end up encompassing an entire ICS population (in Ms Dash’s case that would include the 2.2 million residents of NW London ICS).

“It is not about having the patient directly in the room, it’s about ensuring the system represents their voice, understands their needs and challenges and [about] tackling population health and…addressing health inequalities.”

Addressing health inequality is as important for life sciences as it is wider health and care – treatments and innovations brought into the ecosystem must not inadvertently exacerbate disparities through unequal access. As Dr Dash explained, “ensuring equitable service uptake while addressing the perennial issues of obesity and smoking is the priority; this is a huge and complicated agenda but we can no longer have an environment where sections of the population are ‘hard to reach.’”

Dr Bridgewater argued that what is considered the concept of a patient ‘voice’ in healthcare might be referred to as ‘customer centricity’ in other sectors. “Software companies understand the importance of user-centric design, but this concept has not always fed through to healthcare. Achieving this will require some co-creation with people who have lived experience of this issue – as well as ensuring collaboration with industry colleagues.”

Delivering innovation

If you do not open yourself up to power of industry you are missing a trick

Industry has a huge role to play in guiding system transformation. Ahead of ICSs taking up statutory footing in July, this webinar was a timely opportunity to dissect the debate and ensure that industry has a ‘seat at the table’.

“There must be incentivisation for both sides of the equation,” said Mr Matthias Winker, “commercial innovation has yet to truly mature for ICSs, however this could rapidly develop over the next few years – but we are still a long way off from where the life sciences sector is in terms of utilising commercial opportunities to encourage innovation adoption.”

Where pharma was once considered the ‘dark side’, there is now acknowledgement that its capacity for harnessing innovation presents a powerful opportunity to deliver lifesaving treatments to patients. Evidence in recent years of this shift in mindset can be seen with the Cancer Drugs Fund, presenting a faster means of appraising new drugs and treatments – harnessing industry innovation earlier. The ICS framework presents a unique opportunity to expand such opportunities.

“If you do not open yourself up to power of industry you are missing a trick,” said Dr Bridgewater who outlined the importance of the concept of ‘agency’ in encouraging innovation adoption. This concept has allowed Health Innovation Manchester to shift the dynamic in favour of innovation, allowing organisations to craft relationships and drive technology within the ICS structures.

Life science innovation in an ICS future

Whatever happens over the next few years, the whole system must be engaged in this transformation process

“While specific roles and duties of ICS leadership will change over time, it should become, and remain, the place where strategy is developed before handing to local providers for delivery,” said Dr Dash, “and developing strategic visions for innovation, as well as measuring and assessing its impact, is absolutely the role of the ICS.”

What most refer to as a care pathway, some in other sectors would consider an ‘innovation supply chain’, and this mindset should help turn the dial in favour of quicker innovation adoption. Ensuring this supply chain works requires making priority calls about what to do next, managing the benefit of innovation against the complexity of implementing it across the system.

Whatever happens over the next few years, the whole system must be engaged in this transformation process. As Mr Dorrell concluded, “this process cannot simply be about which compound to use specifically while the rest of the system remains unchanged. Why even bother innovating if it is used in an unchanged health system?”

Evident from the outset of this webinar was that the principle of integration must extend far beyond linking service providers. ICSs have a special responsibility to ensure that the health and care ecosystem includes industry partners, harnessing their innovative potential while ensuring the ‘voice’ of the patient is a key consideration in the transformation process.

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Can Levelling Up help us Build Back Healthier?

By Chris Skidmore

With the publication of the government’s White Paper, finally we have some definition and direction to what ‘levelling up’ actually aims to achieve.

The most illuminating part of the 700-page document came in the announcement of twelve levelling up missions, most to be achieved by 2030. Looking suspiciously like a return to the Public Service Agreements of the Brown-era, mission-based policy has been back in vogue, thanks mainly to the efforts of Mariana Mazzucato, whose work had been highly influential on the UK government’s now dormant Industrial Strategy.

Certainly that strategy seems to be making a return (it is worth noting that Andy Haldane, now on secondment from the RSA to lead levelling up policy was the Chair of the Industrial Strategy Council), with some of the missions reflective of the government’s previous ‘Grand Challenges’. Public Policy Project’s Social Care Policy Network Chair, Damian Green, highlighted this in the House of Commons, welcoming the focus on maintaining a commitment to five years of extra healthy life.

Yet missions are but words on a page without a clear and deliverable strategy behind them. How these missions are to be achieved remains unknown: what is known, however, is that there is unlikely – at this point in the spending cycle at least – to be any new money to deliver them. A rejuvenation of local economies on the scale that was seen in post-reunification Germany will require a level of sustained investment that is simply in a different league to the UK’s own Levelling Up agenda.

These twelve missions are an accurate and timely depiction of why Levelling Up must succeed – but without the cash required to turn these policies into a nationally transformative reality, they risk crashing and burning. And with at least two general elections to pass before 2030, who will finally be held accountable to deliver them?

The White Paper can only have a positive impact on society if locally led initiatives are given the necessary help to scale their success. This objective is central to PPP’s 2022 Health Inequalities policy programme.

Turning an aspirational slogan into a tangible reality

The white paper correctly acknowledges central government’s role in driving these reforms, but the results of local health rejuvenation will, naturally, be delivered locally

The 12 missions are central to the government’s policy and the Levelling Up agenda is designed to “give people control over their lives” and perhaps nowhere is this principle more important than with regards to health.

Recent data shows that, even before the Covid-19 pandemic, life expectancy was stalling and declining for poorer people in most regions. Successive governments have failed to address the crisis of health inequality – Covid-19 has now laid bare and worsened this growing ‘syndemic’.

In this context, perhaps a more fitting mantra would be ‘Build Back Healthier’.

It has been long established that healthcare alone cannot close the health inequality gap. It is the social determinants of health, such as employment, education and housing that make the real difference to people’s health outcomes.

The white paper correctly acknowledges central government’s role in driving these reforms, but the results of local health rejuvenation will, naturally, be delivered locally. As such, the government’s focus on devolution is welcome news for health providers, as there is a growing body of evidence to suggest that the most effective health interventions are undertaken at a local level.

Building on Sir Michael Marmot’s ground-breaking work on health inequality, PPP has highlighted a series of compelling case studies as to how collaboration between local government, the health service, voluntary sector, business sector and the wider community can create tangible improvements to health inequality. The report can be found here.

The road ahead

The results of the Level Up agenda will be demonstrated through localised endeavour and led by a new generation of system leaders and innovators

It is clear that much more work needs to be done. This year, PPP is launching two major health inequality policy projects, Build Back Healthier: The role of business in tackling health inequalities and The Digital Divide: reducing inequalities for better health.

Sir Michael has long made the case that health is a good indicator of how ‘well’ society is doing as a whole. It is therefore reasonable to argue that health inequality statistics can be used as a clear metric of how equal a society is across a broad spectrum of indicators. In the same way that we use GDP to measure economic growth, it is not unreasonable to argue we can consider population health metrics and their relationship to ‘social growth’ in a similar way (of course this in no mean neglects or fails to acknowledge the inextricable link between economic and social growth).

Gathering together a commission of businesses, Build Back Healthier will seek to take evidence on and lead the policy debate on what businesses can do to reduce health inequalities in 2022.

Covid-19 has revealed huge inequalities when it comes to digital health. The pandemic accelerated what has always been an inevitable move towards digital over the past decade.

The debate is often pitched as binary: either we move towards digital and leave underserved populations behind, or we don’t move technological advancements along to accommodate for those people. The Digital Divide will focus on what digital health can do for underserved populations. Digital transformation is the future of healthcare and as such, good policy is in urgent demand when it comes to addressing those at risk of being left behind. We aim to meet that demand with this exciting piece of policy work in 2022.

The results of the Level Up agenda will be demonstrated through localised endeavour and led by a new generation of system leaders and innovators. Public Policy Projects is pursuing a programme of works throughout 2022 and beyond to not only showcase this work, but scale the success across a marginalised society.

To find out more about PPP’s Health Inequality series, please write to lottie.moore@publicpolicyprojects.com

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

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.