Work at our level, don’t ask us to work at yours

Giles Piercy, who is part of Power to Change’s Community of Practice looking at health and social care, shares his thoughts on how integrated care delivery could work with community businesses

I recently attended an Integrated Care Champions (ICCs) meeting for the London Borough of Hammersmith and Fulham (LBHF), which has a population of around 180,000. Around 30 people were in the room – including GPs, voluntary sector workers, community nurses, hospital workers – all keen to see greater integration and to champion better care. The idea of ICCs is for people to become champions across the borough’s public services, to make sure care standards are improved and service delivery is integrated. So far, so good.

But this aspiration is unfortunately rarely turning into action. The statutory providers in the borough have an annual health and social care budget of around half a billion pounds to employ staff and deliver services. Looking at GPs alone, there are 30 GP practices probably employing in total over 150 GPs.  In terms of people involved directly in health and social care, in LBHF, there will be around 5,000 full-time staff and many, many more if you consider services that may have an impact on the wider determinants of good health like community businesses, housing associations, libraries. When you look at it like that, the aspiration to “integrate care champions” across an area the size of LBHF is optimistic to say the least. Unsurprisingly, twenty or so people gather every few months to have a good natter, and not as much progress is made as those participating would hope.

The missing links

Power to Change’s Health & Social Care Community of Practice (CoP) has been thinking about this issue. This is a group of community businesses across the country that are involved in health and wellbeing services in their local areas. We have an emerging consensus that, whilst much is made of integrating the voluntary sector into the health and wellbeing services, the system is, in reality, set up to ignore and marginalise the capabilities of local people and local third sector organisations.  One of the main reasons is because statutory health and wellbeing services generally operate at a geographical footprint that we struggle to align ourselves to. Most of the organisations in the CoP are small – typically they run small community centres or charities from which they deliver health and wellbeing services. They are, for the most part, geared up to serve a hyper-local population maybe around 10,000 or fewer people.  There are thousands of these types of organisations up and down the country; unfortunately, the current structure of the health and care system starves them of the oxygen they need improve their local population’s wellbeing.

There are, however, some signs of an emerging recognition of this within the NHS, as demonstrated by the appetite to see some services coalesce around GP networks (population size between 30,000 and 50,000).  In the area where my charity operates this would be a population of 50,000 people. Whilst this is obviously an improvement to trying to arrange matters across the whole of Hammersmith and Fulham, trying to bring together networks at this level still presents enormous challenges. In the recently published NHS 10-year forward plan, there is a commitment to employ 1,000 Link Workers across England. Whilst welcomed, the question is whether one (full-time equivalent) person can really shift the dial and “link” across an area with 50,000 population? Operating at this level and across such a geography, I would argue that it will be impossible for one Link Worker (particularly if employed by, and based in, GP surgeries within the Primary Care Network), to understand and build productive relationships across the health and wellbeing being landscape.

What will probably happen is that they will gravitate to the organisations that they know or are aware of that cover the same (or larger) footprint and, in doing so, risk ignoring or marginalising the majority of small(er) hyper-local VCSE organisations like community businesses – the ones that are really connected to local people and also really connect local people.

Also, does a budget for 1,000 Link Workers really represent a meaningful commitment to support local organisations contributing positively to the wider determinants of health? It’s a start but truly lacks ambition and commitment.  In our Primary Care Network, it’s around £35,000 from an overall health budget of about £150m – less than 0.025%!

Bigger isn’t better

There are such huge barriers within the health system that prevent it from being able to operate effectively at a locality or neighbourhood level, especially when it comes to health maintenance and ill-health prevention. These must be challenged.

Economies of scale can work for some parts of the care system: such as undertaking specific operations, procurement, training, etc. And they do make it easier to audit, monitor, compare and control different health care provisions across the country. But in our view, this approach fundamentally weakens two core aspects of improving health and wellbeing.

Firstly, much of what improves people’s health is one-to-one care, being a part of their community and engaged with meaningful activities.  Layers of supervisory management and quality audit add pretty much nothing to the moment of care being delivered by a dedicated professional (whether from the statutory, private or voluntary sector).  Perversely, a Community Nurse, who is on the frontline of care delivery, whether taking blood pressure or dressing a wound, is probably paid less than corporate care staff who have added little to the moment of care.

Secondly, health is improved by encouraging people to be resilient; to look after their own health and be supported to do so by those around them, those from their own community. The current deficit-based ‘health’ system is extraordinarily weak in terms of building personal resilience and stronger, better connected, healthier communities.

Co-design, co-budgeting

Our plea is that local people and local organisations need to have a greater say in the way that local services are delivered; for this to be realised we need to be co-producing and co-designing new systems that involve local people and organisations in meaningful and sustained ways, integrating and creating links across the health and wellbeing sector for populations closer to 10,000 or lower, rather than 50,000 or greater.

We also need a radical rethink about the way that budgets are managed and shared.  If we see value in local people having agency and control over the way that health services are designed, commissioned and delivered then the system also needs to give them greater control over the budget.  In doing so people’s health and wellbeing will be improved, stronger more resilient communities will be created and critically, communities will emerge that place less demand on statutory services.