Integrated Care Systems – Accountable? Transparent?
The irony of giving people hardly any time to respond to a consultation on transparency and accountability of Integrated Care systems seems to be lost on the Department of Health and Social Care (DHSC) Hewitt Review.
Their consultation was launched on the 13th of December 2022 and closed on the 9th of January 2023. I reckon that is 14 days working days to respond.
I have to say that I am confused because there was a DHSC enquiry in 2022 which covered very similar ground.
Here are extracts from two of the witnesses to that enquiry
Kings Fund
Local Government Association
Problems
Government seems to think that it is essential to restructure the NHS every 5 to 7 years. One of the consequences of this is that most people have little idea of who is making local decisions about what gets funded in the NHS and how to influence them.
Speaking as a former lay member of the Clinical Commissioning Group in Sheffield – There were still many people in Sheffield who had no idea what a CCG was by the time it was abolished. So the new ICS structures will be little understood by most people.
When Integrated Care Boards were established it was clear that their main accountability would be to themselves and to central government
This centralised control and constant reorganisation – can lead to a feeling that the only accountability that ICB leaders really need to worry about is to central government. This is so distant that control tends to end up focussing on activities that can be easily measured such as budget deficit, waiting times and ‘never events’.
It takes exceptional principled local NHS leaders to give equal weight to complex local challenges that cannot be so easily measured, inequality, lived experience, diverse needs etc.
I think it is really hard for public bodies – particularly the NHS – to admit that there are areas where they are struggling or have made mistakes. This is dangerous. In less than a year we have moved from praising primary care and the NHS to seeing the government and national media attacking them. This has contributed to antagonism from members of the public as they have struggled to access services.
In my view there is a shameful silence from local health systems – who have not pointed out loudly or clearly enough the demand, financial and quality challenges that are faced by front line staff.
This failure to do so creates a dissonance between what the local NHS is saying and what patients and staff feel they are experiencing.
In my recent blog on health inequalities and how Integrated Care Systems are using or misusing funds to tackle inequalities it was concerning that many readers complimented me on doing what is a comparatively simple piece of work – sending some Freedom of Information Requests and analysing the responses.
What was apparent was that many players in the local health and care system were:
- Not aware of the existence of these funds
- Did not know how to get access to this information
- May have known what was happening but felt unable to challenge or question decisions that had been taken.
This is worrying, not least because it is areas such as health inequalities and public voice that need informed scrutiny and public debate. If they don’t have this they risk continuing to being treated as marginal issues at best.
What can be done?
Here are some thoughts.
A high performing organisation must create mechanisms that challenge what it is doing both internally and externally. That is a key driver for improvement and excellence. Sweeping issues under the carpet will disillusion staff and reduce public trust.
Empower Staff
Organisations such as the Integrated Care Boards need to have internal structures that empower officers who are responsible for engagement, involvement and tackling inequality.
In Sheffield the Clinical Commissioning Group established a separate committee as part of its constitution where all decisions that required public consultation or involvement were sent. This committee considered the approach being taken by the commissioner – for example how were views being sought? Who should be involved? What actions needed to be taken to be inclusive etc. It was not about ‘marking the homework’ it was concerned with empowering the commissioner to make the best decision possible by ensuring that the views of key stakeholders were heard and understood. The Committee membership included public voice members (recruited through open open recruitment) Healthwatch, the local authority and as importantly Directors from the CCG, GP members and members of the involvement, equality and communications teams.
Empathetic learning
Integrated Care Systems need to establish inclusive action learning sets that create a safe and empathetic place for decision makers to honestly share the challenges that they are facing tackling difficult issues and be constructively challenged by peers.
Trusted relationships
There needs to be trusted relationships with different communities and stakeholders.
During the pandemic Sheffield CCG funded at least 20 voluntary organisations who worked with or came from specific communities – learning disabilities, BME communities etc to regularly share their concerns and challenges – with the ‘gold command’ in the city. There was a clear view from decision makers that this assertive relationship building helped Sheffield’s vaccine rollout be one of the best compared to other Core Cities. This approach is similar to the small grant programme run by Healthwatch in Sheffield.
Another great example is how Birley Health Centre have used simple mechanisms such as Facebook to create a platform for the honest sharing of criticism and praise. Most importantly it creates an ongoing relationship with patients at the practice, approximately 10% of patients are members of this group.
Building Capability in communities
Understanding and influencing complex short lived health systems is really hard! In Sheffield there is a long standing Introduction to Community Development and Health course – aimed at citizens from easily ignored Communities. In 2023 this course celebrates its 25th anniversary! Frankly any ICS that is serious about local accountability and transparency should be investing in these sort of local initiatives and taking advice from national organisations such as Citizens UK.
Scrutiny and Challenge
Local Authority health scrutiny committees have an important role here. However, I think that they can be significantly helped by partnerships with organisations who are independent and have the skills and expertise to analyse data quickly. A practical partnership with a university could help here – so long as they understand that they are using their skills to produce fast analysis that helps systems in real time!
Finally – of course there will always be a few old bureaucrats like me with a glass of wine and a computer who will write blogs sharing their opinions – but surely we can do better than that!
WHAT DO YOU THINK?
What do you do when you are allocated a tiny amount of funding to tackle a long standing and complex problem? There must be a temptation to spend it on other pressing challenges … on the basis that the funding would not make a great deal of difference anyway.
I think that this is one the dilemmas that integrated care systems faced when each received some funding specifically to address inequalities.
This spreadsheet shows the funding allocated to each integrated care system in England for 2022 – 2023, page two shows the specific funding allocated to address health inequalities.
The thinking behind this funding is set out in this document.
In Yorkshire the total funding to specifically tackle health inequalities was just over £22 million in 22/23. This sounds a lot – but equates to just under a quarter of one percent of total NHS spend.
Just to note I might have misinterpreted some figures – but I think my data is broadly correct – get in touch if you know better!
More positively this is recurrent funding with quite broad criteria with regard to how it is used, this could provide an opportunity to develop strategic levers for system change.
So, lets have a look at how each of the three Integrated care systems decided to use their allocation. I have had responses to a Freedom of information request from each ICB in Yorkshire.
The full response for each ICB can be read below, I recommend reading the West Yorkshire one in particular because it is the most considered and comprehensive.
I have tried to summarise these responses in the table below
Summary for each ICB
West Yorkshire
Have well established structures, active involvement of a range of stakeholders including the local NHS, Local Government and the VCSE. Their actions are consistent with the Core20plus5 NHSE model. They have a decentralised model which balances local actions with sub regional activity when this is more appropriate.
Humber and North Yorkshire
Half of the funding has been used to underpin their financial plan. I interpret this as contributing to addressing the financial security (deficits) within the system. While I do not agree with using this funding in this way – I do welcome their honesty in declaring this. The approach they are taking with the remaining funding is consistent with some of the priorities within Core20plus5 but is quite narrow.
South Yorkshire
As the table above shows, South Yorkshire ICB approach feels vague. They are not able to identify their spending plans for this year – and now have less than 3 months to commit. It is hard to see how they will get the money out of the door. From the response it looks as though they are more focussed on next year. Unlike the other two ICBs it is hard to see what specific structures they have in place to drive this work forward.
Actions
Read this
Given the significant variation in actions across the three ICB in Yorkshire it is very likely that this inconsistency is reflected across England as a whole. This muddled approach is consistent with the findings of a piece of work by Olivera et al which flags up that work in local health care systems on inequalities is characterised by vagueness, lack of clarity and lack of commitment to action. This report is a must read for NHSEI and for integrated care boards.
More accountablity
It is very concerning that Integrated Care Boards are able to use this funding to address wider system funding problems by in effect raiding a tiny fund which is specifically allocated to develop actions to improve the health of the most disadvantaged. This is precisely the sort of behaviour that creates and deepens inequality. NHSEI need to establish clearer requirements to ensure that ICBs are held to account for decisions they take both locally and nationally.
Theory of Change
As the Olivera paper notes there is a real lack of clarity about what actions will have the greatest strategic impact and indeed what is meant by health inequalities. It does feel as though there is a lack of rigour here. There should be a clear requirement for Integrated Care Boards to each develop a 5 year theory of change which should underpin their health inequalities strategies.
What do you think?
Fading away? NHS Yorkshire action on financial insecurity
In my previous blog I looked at the response of the three Integrated Care Systems (ICS) in Yorkshire to the growing financial insecurity faced by many people in this region. Each Integrated Care Board (ICB) received a paper which set out the context, rationale and in the case of two ICS made a number of recommendations for action.
As I said in the blog – it is so important to come up with quick practical actions that will make a material impact on people who are most effected by a toxic combination of poor health, financial insecurity and a reliance on NHS services between now and the next two years at least.
It is important that ICBs recognise that local government and the VCS are under terrible financial pressure and their situation is likely to get worse. So just referring more people through social prescribing to welfare rights and debt advice is worse than passing the buck – it is irresponsible unless funding for these services is found.
I have now looked at the minutes of each ICS which captures the discussions in response to the papers. A summary of all the minutes is available here
The big danger is that after an initial flurry the financial insecurity crisis will be largely ignored as NHS systems default to focussing on the very real demand and quality issues in the health system – ignoring the feedback loop between health and poverty and forgetting their ambitions to take a ‘population health management’ approach in an ‘integrated care system’.
There is a tendency to default having ‘interesting’ discussions but failing to agree practical strategic actions. If any board is commissioning work try to understand the problem’ or is hunting for ‘evidence of what works’, it’s a sign that they have avoided taking action.
West Yorkshire minutes
Chair reminded the ICB that the Integrated Care Partnership (WYPB) asked for a response in relation to alleviating poverty.
Recognition that the ICB had two potential roles – for staff and for citizens in West Yorkshire.
Practical examples such as Winter warmth investment and link to tackling inequalities.
Call for development session for ICB
Recognition that work was going ahead in each place and it would be helpful to have oversight and assurance for this work
Actions
Board members invited to contact the Chair and Chief Executive to join a Task and Finish Group to take forward actions identified in recommendations.
Humber and North Yorkshire
Actions
A letter has been drafted by the Chair and Vice Chair (not in public domain) which will describe actions that are taking place and setting out best practice with regard to impact.
The ICB is looking to secure clear evidence in terms of impact and is working with local universities with regard to this.
It is expediting the approach to social prescribing and work with regard to workforce and recruitment.
South Yorkshire
Noted a fast change environment and worsening situation with regard to inflation. Concerns raised with regard to impact on cost of prescriptions, need for signposting to debt advice by NHS, impact on winter planning.
Concerns re NHS workforce impact with 40,000 earning less than £25k, focus on areas of deprivation not sufficient – eg people with learning disability, impact on local economy.
Concern that leadership on this is not clear – view expressed that ICB role is not about dictating or providing answers but contributing to solutions. Important to learn from COVID. Importance of working in collaboration with VCS.
Actions
Place directors to consider practical responses and report to October development meeting – I think this means a private meeting.
My conclusions
ICS responses to the growth of financial insecurity in their populations is unclear. There is a real risk that instead of meaningful strategic actions we will see a default to traditional pathways that appear to involve action but make little difference to population health.
The red RAG ratings to watch out for are – an over emphasis on:
- Role of NHS as Economic Anchor
- Focus on staff pay and conditions rather than wider population actions
- Focus on Social Prescribing to the exclusion of welfare rights services
- The awful OHID guidance aimed at making NHS staff more poverty aware
Actions we need to see
First, identifying populations who are using the NHS and at risk of financial insecurity and commissioning integrated welfare rights/debt advice to run alongside clinical services for example:
- Major Trauma
- Head Injuries
- Motor Neurone Disease
- Cancer
- Muscular Dystrophy
- Multiple Sclerosis
- People with acute mental illness
Second, commissioning of sessional welfare rights/debt advice services to run alongside GPs serving the most deprived populations in each place.
What do you think?
We are in for a very tough time over the next couple of years … and it will be the poorest who carry the greatest personal burden.
This is the time when the NHS needs to be looking hard at how it provides services so that they are delivered in a way that recognises the terrible financial pressures that people face.
I have had a look at the three Integrated Care Boards (ICB) in Yorkshire and was heartened to see that each had a paper which is specifically about the impact of financial insecurity on the health of the populations they serve.
Actions
Two of the papers – WYICP alleviating poverty report and Humber and North Yorkshire ICS had been discussed at the wider Integrated Care Partnership (ICP) too – this feels right, because the wider voluntary and community sector and local government already have a track record here.
The South Yorkshire paper has only been to the ICB so far – it’s more of a discussion paper – without specific recommended actions.
The other two papers suggest actions that include:
- We need to better at bringing population based data that is relevant to the ICS specifically on inequality and financial insecurity.
- NHS and care staff need to be provided with training and support about the impact of financial insecurity on their patients so that they can signpost and advise.
- Thought needs to be given to how access to welfare advice and support is given within key pathways.
- The role of the NHS providers as key economic anchors needs to be utilised
- NHS and Social Care staff who are experiencing financial insecurity need to be helped
Leadership
West Yorkshire and Humber and North Yorkshire recommend establishing strategic groups to keep a grip on this agenda and to be accountable for a response. Humber and North Yorkshire ICB has used their helicopter view to provide an appendix summarising approaches being taken in each place and by each NHS organisation. This is helpful although there is no overarching analysis of this.
What do I think?
The papers help, although they default too easily to rather grand system change ideas rather than focussing on actions that address the immediate crisis. For example talking about the role of the NHS as an economic anchor is fine but ain’t going to address current challenges. The reasons why the NHS needs to step up here is better explained by organisations outside the NHS such as Macmillan and the Money and Mental Health Policy Institute.
I think the NHS needs to focus primarily on practical actions that health systems can take now that will improve peoples financial insecurity and benefit the NHS. This will require cultural change and modernising what we think good clinical practice is.
Calls for more work on understanding population data better is probably a distraction. It is perfectly possible to establish a framework based on health impact/need for NHS services/financial vulnerability that can play to the strength of NHS clinical delivery models – by focussing on particular conditions and defined populations. The generally rather bland Kings Fund think piece has a good example of this below. I have written extensively on this using examples such as the Cancer, Major Trauma, Mental Health, Progressive Illnesses etc.
There is money
There is funding out there available to help people. The online advice service ‘entitledto’ produce a yearly analysis of how much benefits are unclaimed each year. Their estimate for 2022 is £15bn across the UK. This equates to roughly £1.2bn available for people in Yorkshire. I challenge any NHS ICS to propose an alternative course of action that would help people as significantly as enabling people to access these unclaimed benefits.
The reality is that vulnerable people experiencing traumatic health conditions need expert help to access the benefits they are entitled to.
I think that the NHS has a key role to play in helping get this money into peoples pockets by funding dedicated welfare rights services. There are too few examples of this – in Sheffield the NHS funds a welfare rights service specifically for people experiencing acute mental health problems.
Actions
We need an action plan which:
- is informed by services on the front line who are tackling financial insecurity and health. Such as national ones like Macmillan and the Money and Mental Health Policy Institute and local ones such as Local Citizens Advice.
- is about impact over the next 2 years
- invests NHS funding directly into welfare rights services that are integrated into key clinical services – not distractions such as social prescribing
- focuses on areas where the toxic combination of a significant health problem and financial insecurity impact on NHS utilisation and personal recovery.
- What do you think?
Disclosure – I am Chair of Citizens Advice Sheffield
Waiting for the South Yorkshire Integrated Care Partnership
UPDATE – 24th October 2022
Since I published this blog on the 3rd of October the original South Yorkshire and Bassetlaw ICS website has been updated. It now appears to be the platform for the new Integrated Care Partnership.
3 months after the NHS restructured we are still waiting for the South Yorkshire Integrated Care Partnership to be formally launched.
Quick Explainer
Since July 2022 Integrated Care Systems (ICS) are the way the NHS is organised. England has been divided into 42 sub regions each with an Integrated Care Board (ICB) – mainly focussed on the NHS and an Integrated Care Partnership (ICP) – with a broader strategic remit including local government and the voluntary sector.
ICPs are responsible for producing the Integrated Care Strategy for the ICS.
It’s the Integrated Care Partnerships that puts the ‘I’ in ‘ICS’
Integrated Care Partnerships are important, but there seems to be significant variation in the progress being made to establish this basic infrastructure that is part of Integrated Care Systems.
Lets have a look at Yorkshire (population 5.4 million)
In Yorkshire there are 3 ICS. Two appear to have an Integrated Care Partnership up and running with clear links to it via the Integrated Care Board these are West Yorkshire and Humber and North Yorkshire.
3 months into the creation of the new health structures the only mention that I can see of the South Yorkshire Integrated Care Partnership is an announcement that the South Yorkshire Mayor has been appointed Chair. There appears to have nothing up at the moment that the public can see – not even a note on the website saying that this is a work in progress, watch this space etc etc.
I think the resources and responsibility to establish the partnership rest with the Integrated Care Board not the Mayoral Combined Authority (MCA) … although it would be refreshing if the SYICB were to pass the resources for coordinating the Integrated Care Partnership over to the MCA.
Here are the screenshots from the three Integrated Care Boards showing how we can find out what the Integrated Care Partnership is doing, who is on it etc.
West Yorkshire
Humber and North Yorkshire
South Yorkshire
Meanwhile in South Yorkshire
I have heard informally it that the South Yorkshire Integrated Care Partnership had a private meeting in the week starting the 28th of September, and that Oliver Coppard the Mayor for South Yorkshire has been confirmed as Chair
However, at the moment it is not possible to know:
- Who is on this partnership
- What its agenda is
- What its forward plan for meetings are
Does any of this matter?
The government guidance is clear:
“The integrated care partnership MUST involve in the preparation of the integrated care strategy: local Healthwatch …. and people who live and work in the area.”
“In order to influence the first 5 year joint forward plans the integrated care partnership would have to published an initial strategy by December 2022”
In South Yorkshire we have less than two months for the public and communities to get there head around what an Integrated Care Partnership is let alone to then engage and comment on the strategy.
Current Position
This is how I rank the three Integrated Care Systems with regard to how they publicise the role of the Integrated Care Partnership
First – West Yorkshire
- a clear accessible website – that shouts their values.
- The website also makes it easy to click on the ICP pages – one click away!
- There are also clear links to the agendas and minutes of previous meetings. It is easy to find out who the partners are – with logos to each organisation that click through to the relevant website.
Second – Humber and North Yorkshire
- website nice & friendly
- it does take 2 clicks to get to the ICP pages
- the ICP link is a bit hidden in the Integrated Care Board Page.
Third – South Yorkshire
- nothing to see here!
I would be very interested to hear from people living in other ICS areas outside Yorkshire. How easy is information about your Integrated Care Partnership to find? Who is on it?
What do you think?
As a resident of Sheffield I was keen to have a look at the newly launched “Start With People” strategy, which was approved at the first public meeting South Yorkshire Integrated Care Board (ICB). It sets out how the ICB will work with people and communities . Here are some thoughts.
The strategy is strong on principles – particularly with regard to the aspirations that the ICB has with regard to developing strong and trusted relationships with the public in South Yorkshire.
I was surprised but pleased to see a photograph of Dean in the strategy. Dean is the butcher I go to every Saturday down at the Moor Market. So when I popped down for some home cured bacon (which I strong recommend) and a couple of Barnsley Chops I showed Dean his photograph. Both Dean and his wife were surprised to see him in the strategy – they knew nothing about it and had not been approached for their permission. To be honest as I said to him, I was surprised too – I know that he has an excellent reputation for a finely cut piece of sirloin – but I was not aware that he had strong views on collaboration and co-design in the NHS.
There is a serious point here – if you say that your NHS strategy puts the relationship with the public at the heart of your work then you need to live by that. The photographs in this strategy are of real South Yorkshire people – yet it feels as though they have been used as stock images to bring a bit of local colour to give the report authenticity. That is not right.
Moving on….to inequalities
The strategy identifies a range of areas that the ICB will be focussing on here and references the NHSE Core20PLUS5 framework. However it is not possible to understand how the actions that are set out here relate to these. It is also hard to understand the relative ambition with regard to scale and impact here. These feel like a disparate collection of projects that have been hoovered up into this space.
What is lacking is an analysis that tells us what the problem is, its scale and the actions that the NHS will be taking to address it.
I think part of the reason for this deficit lies in the very simplistic “Theory of Change’ that the ICB is using – this is listed on page 38 of the report – and I show it below.
Most theories of change start by analysing the problem that needs solving – and then considering what the goal should be with regard to addressing this problem. Many – particularly when addressing complex whole systems problems also recognise that a key early step is to consider who needs to be involved, influenced or engaged in order to take effective action.
The (uncredited) theory of change in this strategy does none of these things. Sadly, I do think the NHS has history here – tending to default to project delivery planning tools when trying to achieve system change.
There are more appropriate theories of change – check out the United Nations one or closer to home – NESTA. Both have an upfront analysis of what the problem is – which for a new organisation with ambitions to be accountable and transparent would seem like an essential thing to do.
Finally! … a real problem
For me the most important paragraph in the whole document is tucked away at the end of the section on the Voluntary and Community Sector – page 9 – which states:
When I read this paragraph my thought were:
- Is this really the case?
- Why do communities distrust the NHS?
- Which communities distrust the NHS?
- What does this mean for the health of populations?
- What does this mean for the way that NHS are provided?
- What actions need to be taken to change this perception?
- And most importantly has the lack of trust maybe got something to do with inequalities?
So, coming full circle – yes, it is really important to be upfront about principles – but communities will not trust us if they feel that we are just playing lip service to how we represent and involve them and present unconvincing strategies to address the real problems they and the health systems faces.
WHAT DO YOU THINK?
Talking about Community Anchor Organisations
At Leeds Beckett University we undertook a piece of work called Space to Connect which was funded by the department for Digital Culture Media and Sport and the CooP Foundation.
The programme was meant to look at how community anchor organisations could develop physical spaces to improve sustainability and services.
We had just started work when the Pandemic hit!
So instead we worked with these organisations looking at what they did during the pandemic to respond to the needs of isolated and vulnerable people in their communities. Many of us saw how community anchors pivoted and were among the first organisations to respond to need.
At the time there was a lot of hopeful talk about how this experience would represent a shift (some say a ‘left shift’) in how the local voluntary sector was perceived, funded and collaborated with by the NHS in particular. I think it is fair to say that there is still some way to go!
One of the products we produced was a discussion tool that can be used in a meeting or a workshop to begin an action focussed conversation within NHS organisations or an ICS about Community Anchor Organisations. The idea being that just having a conversation in a meeting would represent a useful step forward.
There is a blog on the Leeds Beckett website about this – which you can access here
If you would like to look at the discussion tool the link is here – ignore the first page – it is just the standard format used by Leeds Beckett when reports are stored on the website – it is much more attractive than that!
Finally, what was really important was our joint work with Locality which is the national organisation representing Community Anchors. The link to the Locality website is here
Do feel free to get in touch if you would like to know more.
Inequality and Left Behind Neighbourhoods
I recently spoke at the All Party Parliamentary Group Inquiry into Levelling Up which is focussing on ‘left behind neighbourhoods and feeds into the development of the Governments Levelling Up White Paper.
Here are a three things I learnt.
Unclear Actions
The best analysis I have seen is the one done by they Institute for Government, it’s nice and short and concludes ‘broad ambitions but … lacks focus’.
Money – this won’t touch the sides on the way down!
The Levelling Up white paper is full of commitments to funding and some of it sounds like quite big sums but its really hard to work out how real any of it is.
When I try to understand funding I ask the following:
- Is it new funding?
- Is it recurrent or one off?
- How much is it worth once it has been divided up into 151 unitary local authorities in England?
- How does the funding match up with what has been cut from local authorities in the last 10 years
- How does it compare to current local authority budgets
An example – the White Paper refers the creation of the £2.6bn UK Shared Prosperity Fund to be used to ‘restore local pride across the UK focusing on investment in improving communities and place, people and skills and supporting local business’.
£2.6bn sounds like a real statement of intent – this feels like big money! But when we look at the allocations we can see how small this fund actually is. Over the three years of the fund South Yorkshire will receive £46,132439.
If this fund were divided by population for the four local authority areas this equates to approximately £6.4m per year for Sheffield – for 3 years.
This still sounds like a tidy sum – but Sheffield Council is now spending £211m less every year due to government cuts over the last 10 years.
Despite the paper talking about the importance of local decision making even this small fund is not in the gift of local decision makers. 16% has already been allocated to the Department for Educations Multiply Programme which focusses on on local skill development for adults – specifically numeracy. The remainder then has to be allocated across three huge areas:
- Community and Place,
- Supporting Local Business
- People and Skills.
This funding is barely going to touch the sides on the way down!
Local Context and Decision making
One of the biggest challenges that the White Paper and the focus on ‘left behind neighbourhoods’ does not acknowledge is the local context. If we are going to create fairer places we need those with resources to behave more fairly and maybe even give up some of their funding to help hard pressed communities.
The problem is that those who are relatively better resourced are also under pressure! Look at the NHS – which is usually a bit better off than Local Government.
Dentistry – in some parts of the country it is increasingly difficult to access NHS dentists.
Here is what Healthwatch England and CQC say.
General Practice faces an increase in demand and a decline in recruitment and retention – here is what the BMA says.
Waiting Times for elective services have increased – here is what the BMA says.
What this means for inequalities and levelling up
We are in a position where about 30% of the population experience substantial health inequalities. If we are to take action at a local level this means reallocating resources within an area because the funding made available through the levelling up white paper is not sufficient.
If the whole of the local system is under pressure it will be extremely difficult to persuade key stakeholders within the local NHS such as GPs, Dentists and Hospitals to reallocate some of the general ‘whole population’ resources to focus on those experiencing the greatest degree of health inequality.
What can we do?
This might feel a bit wet – but I think it is really important that we ensure that local decision makers are honest and describe clearly how much resources are actually available for ‘levelling up’ this means using frameworks such as my 5 questions above – this particularly applies to the NHS commissioners and Integrated Care Systems.
What do you think?
The NHS Operational and Planning Guidance for 2022/3 sets out a significant target for the system level roll out of virtual wards.
Here is the target
“By December 2023 to have completed the comprehensive development of virtual wards towards a national ambition of 40-50 virtual beds per 100,000 population.”
According to my maths – England has a population of 56 million which equates to (560*45) the creation of a minimum of 25,200 virtual beds in England. According to the Kings Fund, England has experienced a significant decline in acute hospital beds and currently has just over 100,000.
So this proposal equates to a 20% increase in beds – assuming that actual hospital beds are not reduced further.
Here is the money
NHSEI has allocated a total of £200m in 2022/3 and £250m in 2023/4 subject to targets being met (pp23/4 of operational planning guidance).
This £450m is transition funding only, and the second tranche of £250m has to be match funded by local systems in order to be released. This means that after 2023/4 local health systems will have to manage costs of running 20% plus beds from within their own resources.
The implementation costs equate to £450m/25200 = £17,900 per new virtual bed.
What is a virtual ward?
According to the NHS Supporting Information virtual wards:
“Support patients who would otherwise be in hospital to receive the acute care, remote monitoring they need in their own home or usual place of residence (I assume this means a care home).
..provide acute clinical care at home for a short duration (up to 14 days) as an alternative to care in hospital.
…are suitable for …. People with respiratory problems, COVID-19, heart failure or acute exacerbations of a frailty led condition”
What’s not to like?
I think there are two areas to be concerned about – which need more thought and action.
Inequality and Equality
The supporting information document I mention above is prefaced by a standard NHS statement – see below.
However the subsequent document makes no mention of why equality and inequality are relevant to this agenda and what actions might need to be taken with regard to the implementation of virtual wards.
Here are some suggestions:
The government has an ambition that 20% of acute beds will be provided at home in Communities. We know that:
- people with multi-morbidities are over represented in poorer areas
- Many people who experience health inequalities (core20plus5 group are more likely to live in poor quality housing, have low income and experience greater financial security
- The virtual ward model places a strong emphasis on digital connectivity -yet there is good evidence that disadvantaged communities lag behind with regard to access to digital technologies.
If we are to develop virtual wards in a way that does not widen inequality we need to consider how these will impact on people whose ‘virtual ward’ experience may be significantly worse than someone with a secure income, decent housing and good digital connectivity.
This leads me on to my second point…..
Integrated Health and Care systems
The current proposal feels like lifting and shifting a clinical model from a hospital to a community setting. Just because it is not in a hospital does not make it any more of a community based service – unless it is integrated into the local voluntary and community sector.
The ‘virtual ward’ patient is likely to require greater support from family or other carers, may require access to welfare rights and housing assessments etc. All of these can be addressed through a stronger funded connection with local voluntary organisations and local government etc.
What needs to happen
The NHS talks about the need to have a stronger focus on inequality and about shifting investment towards community and the voluntary sector, the virtual ward process needs to have:
- robust measures to understand the impact on inequalities
- have an explicit focus on capturing examples of good practice that address inequality and involve collaboration with the voluntary sector – this Leeds example looks interesting
- Costed plans to address the needs of patients living in poor conditions with fragile incomes
- Costed plans to ensure that the potential of the local formal and informal voluntary and community sector is utilised.
What do you think?
Talking and Learning about Patient Experience
In November last year I gave a lecture on Patient Experience to District Nurses, Health Visitors and School Nurses who are training at the Leeds Beckett School of Health.
I was lucky enough to be able to develop this in collaboration with the excellent Sarah Neill who heads up patient experience at Sheffield Clinical Commissioning Group.
Here are some of the things that I learnt and some information about a symposium we are planning for the 2nd of March this year.
We need to be clearer about what we mean by patient experience and why it is useful.
Finding out about how people feel about a service they received is generally seen to be a ‘good thing’. In the wider world of e-commerce leaving comments is increasingly understood as being useful. For businesses it can help them improve and promote their products, for customers it helps them avoid a bad service, find good ones and provides a way to ‘give something back’.
Yet, in the world of the NHS the use of patient experience feedback still feels to be inconsistent and its role poorly understood. I think this is for a number of reasons:
Top down
Many of the official or statutory methods for capturing patient experience feel as though they have little relevance to front line provision. In a number of cases this is because the perception is that these measures are really there to assure distant decision makers at the top of organisations or government that they know what is going on. Further, the relatively low number of respondents at a service or GP level can lead front line staff to feel that these are merely the views of an unrepresentative minority.
Resources
Health and care services are under unprecedented demand and have experienced real reductions in funding and a reduction in the rate of growth ever since the austerity imposed by the Coalition Government in 2008. For many clinicians there is a view that there is insufficient time and resource to develop patient experience while they are struggling to provide front line services.
Clinical training
I do think that some clinicians feel (after devoting years to professional training and ongoing CPD) that the reported experience of patients provides little added value to their practice.
The added value of patient experience
Despite the above challenges I think that systematically listening to the experience of patients is really important for the following reasons:
Validation and empowerment
Getting feedback on a specific action can be empowering. Most feedback to the NHS is positive. In the tough times we are experiencing with the pandemic, made worse by the actions of some of the press and government ministers it is so important that front line practitioners get to hear a different and often more positive view from people who actually use their services
Understanding the pressures that people face.
This quote is from a manager in an NHS Care Trust
“Can we look at the more social side of peoples lives – housing, isolation which may be the cause of or at least exacerbate a mental health problem. To understand experience properly do we need to understand it in the context of peoples lives?”
As we move to yet another reorganisation of the NHS one of the key words is integration – if we are to move to an integrated approach to service provision we need people to help us to understand how the social determinants of health impact on their health and there ability to use services.
The two quotes below come from a piece of work that Macmillan initiated to try to better understand what people with cancer were most concerned about.
Advocacy
Many NHS front line staff are working with defined populations of people (parents, a geographic community, people with a specific condition such as HIV or motor neurone disease etc). Understanding how this population collectively experience services and how these fit into the context of their lives can empower clinicians by providing them real stories of their patients. Clinicians can use these to advocate for service improvement and development in their organisations and with colleagues.
Join us!
As part of a wider piece of work Leeds Beckett are collaborating with the Patient Experience Library, with the support of NHS England and NHS Improvement to develop more training and support for people responsible for Engagement and Experience in the NHS and local Health and Care Systems. We are starting this work with a national symposium on the 2nd of March.