Public performance and delivery

Integrated Care Boards – a new frontline in localism?

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Jason Lowther

As the government once again kicks down the road decisions on vital reforms and funding for social care, local areas are establishing the Integrated Care Boards which will lead the new Integrated Care Systems (ICS), bringing together the NHS, local government and partners to plan and deliver integrated services to improve the health of the local population.  Building on the progress made since many public health responsibilities transferred back to local government in 2013, this is a great opportunity to address the determinants of health and issues around health inequality.  Might ICSs at last lead to an effective local voice in our over-centralised, top-down healthcare system?

Each ICS is supposed to plan at three levels: the neighbourhood (an area of around 40,000 people), the ‘place’ (often a LA area), and the (ICS) system (covering around 2 million people).  Working at the neighbourhood level is likely to be somewhat informal, often using a social prescribing approach and developing multi-disciplinary teams including third sector partners.  The approach to ‘place’ looks set to vary between areas, with some ICSs devolving significant responsibility (and funding) whilst others centralise these at ‘system’ level.  Meanwhile at ‘ICS system’ level, Integrated Care Partnerships (joint LA and health committees) will develop an Integrated Care Strategy to meet the assessed health and social care needs of their population identified in the Joint Strategic Needs Assessments and Wellbeing Strategies prepared by local Health and Wellbeing Boards.

Beyond the formal planning process, the success of local ICSs will partly depend on the quality of local collaborative (managerial and political) leadership – across statutory partners and with the third sector.  It will be a tough job to balance the priorities of the national health service and issues of local places, but many local authorities will be able to offer helpful experience , for example from moves to more networked governance approaches.

The National Audit Office recognises the potential but appears dubious on current prospects.  Last month it published a review, Introducing Integrated Care Systems: joining up local services to improve health outcomes, finding:

“NHSE has a detailed regime to monitor performance against core NHS objectives but … it is less clear who will monitor the overall performance of local systems, and particularly how well partners are working together and what difference this new model makes…“

The report notes that, whilst government is asking ICSs to set out local priorities and make progress against them, there is no protected funding and few mechanisms to ensure this happens.  This leads, as the NAO politely puts it, to “a risk that national priorities, and the rigorous oversight mechanisms in place to ensure they are delivered, crowd out attempts at progress on local issues”.  The report also identifies five “high risk” elements of effective integration: clarity of objectives, resourcing, governance and accountability (such as how ICSs will function alongside existing local government Health and Wellbeing Boards and how accountability differences between NHS and local authority bodies will be resolved), and the capacity to balance priorities other than national NHS targets. These urgently need to be addressed if ICSs are to begin to meet their potential.

At one of Inlogov’s “Brown Bag Lunch” discussions earlier this month we agreed on the importance of issues around how ICSs develop, particularly in terms of developing effective system leadership and planning, collaborating with community organisations, and links to wider devolution processes. I’d be interested to hear about experiences in local areas as these develop. 

Jason Lowther is the Director of INLOGOV. His research focuses on public service reform and the use of “evidence” by public agencies.  Previously he worked with West Midlands Combined Authority, led Birmingham City Council’s corporate strategy function, worked for the Audit Commission as national value for money lead, for HSBC in credit and risk management, and for the Metropolitan Police as an internal management consultant. He tweets as @jasonlowther

Picture credit: National Audit Office

Is Government Giving Value For Money?

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Jason Lowther

When money is short, how we spend it becomes even more important. As central government reheats its arguments for austerity following the chaos of the last few weeks, I’ve been reflecting on the contents of the 2021 budget (just a year ago).  The 2021 budget set out not just spending plans, but also a souped up approach to measuring outcomes and cost-effectiveness of government spending. How are these playing out, and will they survive the No 10 merry-go-round?

Rishi Sunak, then eight months into the job as Chancellor, noted that government borrowing was relatively high after the pandemic, warned of the public finances’ exposure to rises in interest rates, and outlined how spending was being linked to the delivery of outcomes alongside across the board ‘efficiency savings’:

The fiscal impact of a one percentage point rise in interest rates in the next year would be six times greater than it was just before the financial crisis, and almost twice what it was before the pandemic…

Decisions have been based on how spending will contribute to the delivery of each department’s priority outcomes, underpinned by high-quality evidence. The government has also taken further action to drive out inefficiency; SR21 confirms savings of 5% against day-to-day central departmental budgets in 2024-25. (page 2)

The “priority outcomes” are the latest in a long line of attempts to prod government spending into delivering effectively on political priorities, rather than blindly increasing/decreasing by x % compared to last year.  A 2019 report from the Institute for Government helpfully outlines many of these earlier initiatives (summary from the House of Commons Library) including:

  • “Scrutiny programmes” and the Financial Management Initiative (FMI), introduced under Thatcher.
  • The Cabinet Office and Treasury set up the Financial Management Unit (FMU) in 1982 to help with creating plans under the FMI.
  • The “Next Steps” report, published in 1988, which recommended the establishment of executive agencies to carry out the executive functions of government.
  • Tony Blair’s administration developed a greater focus on performance targets and Public Service Agreements (PSAs) which put these targets on a formal basis.
  • In 2001, Blair’s government also set up the Prime Minister’s Delivery Unit (PMDU), which was intended to coordinate PSAs and bring them under more central control.
  • Under the coalition government in 2010-15, PSAs were abolished and replaced with Departmental Business Plans (DBPs). These shifted the focus from targets to actions – in other words, they listed what each department would do and by when, rather than what they sought to achieve.
  • Under the Conservative government in 2016, DBPs were renamed to Single Departmental Plans (SDPs), which were themselves renamed to Outcome Delivery Plans (ODPs) in 2021. According to the NAO, SDPs (and by extension, ODPs) are supposed to be “comprehensive, costed business plans”.

As well as having to write down what outcomes they want to achieve, and how they will know whether that is happening, under the SDP system departments were also required “to assess progress in delivering their priority outcomes [and] … share regular performance reports with HM Treasury and the Cabinet Office”. 

In the 2021 spending review, the departmental outcomes were spruced up to reflect the (now last-but-one) PM’s five priorities of levelling up; net zero; education, jobs and skills; recovering the NHS; and reducing the volume and harm of crime.  

This blog’s audience may be interested in “Where does local government fit in this compendium of key priorities?”  The answer is a little depressing: on the last line of the last page (page 30 of 33), just before the devolved government departments. The relevant outcome is inspiring enough: “A sustainable and resilient local government sector that delivers priority services and helps build more empowered and integrated communities”, albeit with the reassuringly non-SMART measure that “the department will provide narrative reporting on progress for this outcome”.  Of course I exaggerate, because local government has critical inputs to very many of the earlier outcomes too, but it’s hard not to conclude that local services and communities were not yet at the top of the ministerial attention list.

Will the “priority outcomes” survive the whirlwind of ministerial movements and unforced economic missteps?  After the last seven weeks, I’m not going to make predictions – but we should know in the next month, and alongside the financial figures they could be our best hint yet on where a Sunak government is heading.

Picture credit: https://www.youtube.com/watch?v=Du_6mRV8Hm8

Jason Lowther is the Director of INLOGOV. His research focuses on public service reform and the use of “evidence” by public agencies.  Previously he worked with West Midlands Combined Authority, led Birmingham City Council’s corporate strategy function, worked for the Audit Commission as national value for money lead, for HSBC in credit and risk management, and for the Metropolitan Police as an internal management consultant. He tweets as @jasonlowther

Black History Month

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Picture source: https://www.evertonfreeschool.com/2020/10/06/black-history-month-2/

Cllr Ketan Sheth

Black History Month creates a moment when we can step back and reflect together, as well as individually, on  the immense contribution of Black, Asian and minority ethnic communities whose rich history, culture, and experiences, have shaped Brent and beyond.

The NW London Joint Health Scrutiny Committee comprises 8 NW London boroughs. As Chair, I know we simply could not function without the dedication, the skills, and above all, the compassion that thousands of people from our diverse communities contribute to the NHS, day in and day out.

The difference this makes to all our lives, is immeasurable. Black History Month affords us an opportunity to acknowledge and thank them for the important work they do: their continuing contribution to the care, the culture, the shaping, and well-being of Brent.

The colour of someone’s skin should not determine how they are perceived, considered, and treated – positively or negatively – but the impact of the pandemic has highlighted many disturbing features of inequality in our communities. Many of these problems are not new. They have existed for far too long.

Black, Asian and minority ethnic communities are more likely to be affected by life-changing diseases like diabetes, prostate cancer, and sickle cell than people from other backgrounds.  Living  in less-affluent areas, they are more  greatly affected by poor housing as well as poor air quality from the busy urban roads that run through their neighbourhoods. There is a big gap in life expectancy between richer and poorer areas irrespective of race, but these communities are disproportionately affected. 

To tackle these inequalities, the North West London Integrated Care System is launching a  joint initiative between the local NHS and NW London boroughs, which will seek to build real understanding of what matters to our residents, how we can work with them to remove barriers to health equality to deliver healthier neighbourhoods and better outcomes. 

This initiative is the first tangible benefit I have seen emerge from the  new Integrated Care System, which has health services and local authorities coming together to address many of the challenges that impact our well-being. That is, health and care services, employment, education, housing, and the environment we live in.

We might perhaps reflect for a moment on the work of the great poet, James Berry OBE, who never avoided the difficult issues of injustice in history, or in the present, but always sought for mutual understanding. His poem, “Benediction,” stresses the need for us truly to hear one another, and truly to see, and through so doing, to understand. He said:

Thanks to the ear that someone may hear

Thanks to seeing

that someone may see

Thanks to feeling

that someone may feel

Thanks to touch

that one may be touched…

Black History Month is a reminder to us to truly hear and see one another, to celebrate our heroes and tell the stories that, for so long, have been hidden or forgotten. It is also a reminder that the evils of the past have resonance today, reflected in the impact of poverty and institutional racism that many in our communities experience as part of their daily lives. Ultimately, it is an opportunity to continue to learn, understand and come together to pull down these barriers and build healthier and fairer neighbourhoods.

Cllr Ketan Sheth is Chair of Brent Council’s Community and Wellbeing Scrutiny Committee

The role of scrutiny in navigating our new health and care economy

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Picture credit: https://www.gponline.com/deadline-extended-gp-access-cover-england-brought-forward/article/1456385

Cllr Ketan Sheth

Mortality rates during the pandemic laid bare the health inequalities that exist across the country. Behind these figures lie human stories and grieving families that should remind us of the urgency and importance of understanding and addressing these inequalities.

In Brent, an ethnically diverse North West London borough, we recently set out to do just that.

Systems thinking

We know that Brent residents, who are from ethnic minority communities, disabled, or who are in poverty, experience significant health inequalities; but what does that look like in practice? How are our healthcare systems contributing to and/or compounding inequality? And what can be done to resolve this challenge?

Usually, GPs are the first point of call when someone is not feeling quite right. They ought to help everyone to access timely and safe healthcare. Therefore, reviewing access to GP services is critical and we decided to focus a dedicated scrutiny task group for eight months to report.

By giving ourselves time to understand this complex area in detail, we developed a deep comprehension of the landscape we were going to scrutinise. Patient voices are at the heart of our work, and we worked closely with Brent Healthwatch to ensure those from communities that have been under-represented in these conversations in the past, as well as those experiencing the worst health outcomes, were able to articulate and share their experiences.

Also, the task group held a number of evidence sessions over the course of six months, which were attended by stakeholders across Brent’s health economy. This included council officers, local commissioners and service providers.

All of this enabled the team to make a number of practical recommendations to  Brent Council and NHS partners.

Our work focused on three pivotal areas: Demand, Access and Barriers

With the dynamics of our healthcare and well-being landscape changing locally as well as nationally, it is more vital than ever to ensure all our residents have equality of access and consumption of healthcare services.

We found repeatedly that some groups of patients experience significant, and unnecessary, barriers, specifically:

• Patients of low-income

• Patients with a disability

• Older patients

• Patients whose first language is not English

• Children and young people

• Refugees and asylum seekers

• Patients who cannot access digital technology

Knowing this, GP services must seek to reduce and resolve the barriers experienced by patients, with a focus on deprivation, ethnicity, disability, and other protected characteristics as described in the Equalities Act 2010, if we are to execute our duties under the Act.

We recognise that rising demand, changing patient expectations and workforce retention issues continue to place pressures on primary care. Therefore, it is essential that the NHS continues to plan for this and uses the expertise of healthcare professionals across the system.

The digital transformation to healthcare, brought about by the pandemic, although helpful to some, introduced additional barriers for other people and communities.

In acknowledging the varying levels of ease in which patients access GP service, we strongly believe an access and treatment standard ought to be developed. This will ensure that Brent residents experience consistent and high levels of service: whether their requests are routine or urgent, focused on physical or mental wellness; or made via the telephone, online or in-person.

Our work has been conducted in the spirit of cooperation and partnership, and particularly, we look forward to continuing our dialogue and work with our partners across Brent’s health economy to evolve our shared vision of GP access across Brent.

Cllr Ketan Sheth is Chair of Brent Council’s Community and Wellbeing Scrutiny Committee

Can drama “Help” social care?

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Jason Lowther

Photo credit: https://www.youtube.com/watch?v=5Z2ufAl2lko

Fresh from winning the Grand Jury Prize at the Banff Rockie Awards on Monday, Channel Four’s drama Help was yesterday nominated for Best Drama in the Edinburgh TV awards, with its lead actor Jodie Cromer also nominated for Best Actor.  The drama was one of the most watched on the channel, bringing to millions of viewers the plight of care homes and their residents during the pandemic.  Whilst the Help storyline is fictional, it is based on hard and devastating facts.

In my view, Help could be criticised for its farfetched ending and sometimes unsympathetic rendering of the care home manager, however its characterisation of care home staff and residents is both caring and revealing.  Clearly emotionally affected researching the programme, writer Jack Thorn said: “hearing the stories of those at the frontline, having people break down in tears on zoom in front of us has been incredibly moving and galling”.   

My two favourite parts of the programme (no spoilers) are the endless recorded message of a hopelessly over-run “NHS 111” call centre in the background for several minutes, and Jodie Cromer’s wrenching speech to camera (1:34 on the video) demanding “…underlying health conditions, eh?  When did all lives stop being worth the same?”  The programme ends highlighting some stunning research findings: 40% of Covid deaths in the early pandemic (from March to June 2020) were in care homes; the average wage of a care home worker is £8.50 per hour; whilst government provided 80% of PPE needs for the NHS, it only met 10% of adult social care’s needs. 

This last claim is based on the National Audit Office analysis published in November 2020, which found that the adult social care sector received approximately 331 million items of PPE from central government between March and July (10% of their estimated need) whereas NHS trusts received 1,900 million items sent to NHS trusts (80% of estimated need).  Whilst both fell significantly short of what was required, there is an apparent imbalance here.  Data collected by the Care Quality Commission (CQC) showed that, throughout April and May 2020, more than a fifth of domiciliary care providers had no more than a week’s supply of PPE. 

This situation was well known to the Secretary of State, not least because the LGA and the Association of Directors of Adult Social Services wrote stating “we continue to receive daily reports from colleagues that essential supplies are not getting through to the social care front-line. Furthermore, national reporting that equipment has been delivered to providers on the CQC-registered list does not tally with colleagues’ experience on the ground”.  Nevertheless, in a scene included in Help, during a Downing Street press conference on 15 May, 2020, Mr Hancock said: “right from the start, it’s been clear that this horrible virus affects older people most. So right from the start, we’ve tried to throw a protective ring around our care homes”, repeating in the House of Commons on 18 May that “we absolutely did throw a protective ring around social care”. 

Understanding the human costs of these central government failures is difficult, with the effects on staff, residents and their family impossible to measure objectively.  Help does a good job in illustrating some of the pressures on care staff and the pain of relatives unable to visit dying residents, made all the more poignant now that we know some of the behaviour during the pandemic of senior central government actors such as Hancock’s affair and Johnson’s multiple parties forensically examined in Sue Gray’s recent report. 

Perhaps the most basic measure is in human lives.  Last year researchers used the national death registry of all adult (aged ≥18 years) deaths in England and Wales between January 1, 2014, and June 30, 2020 to compare daily deaths during the COVID-19 pandemic against the expected daily deaths.  They estimated that during the early pandemic, about 26,000 excess deaths (almost half of the total excess deaths) occurred in care homes and hospices.  This is likely to be an underestimate since early in the pandemic, testing of suspected cases was available only in the hospital, whereas routine testing of staff and residents in care homes was not implemented until May 2020.

The latest ONS statistics, issued in February 2022, suggest that since the beginning of the coronavirus (COVID-19) pandemic, there have been over 274,000 deaths of care home residents (wherever the death occurred) registered in England and Wales; of these, 45,632 involved COVID-19 accounting for 17% of all deaths of care home residents. 

Intriguingly, The Lancet reported in March that “COVID-19 has had a disproportionate impact on the mortality of care home residents in England compared to older residents of private homes, but only in the first wave. This may be explained by a degree of acquired immunity, improved protective measures or changes in the underlying frailty of the populations.” Meanwhile, last month the Care Quality Commission finally published data on deaths in each care home during the first year of the pandemic (April 2020 to March 2021).

Whatever the precise figures, it’s clear that adult social care residents and staff were badly let down by central government, far from the Secretary of State’s “protective ring” narrative. This despite the best efforts of care managers, local commissioners and councils discussed in Luke Bradbury’s blog here last week.  Help does a fantastic job of showing the impact of these critical central failures – and recognising the incredible work care staff did in such difficult circumstances with so little financial reward.

After austerity, comes the reckoning

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Jason Lowther

The publication last month of the Institute for Government’s report on the impact of cuts in local services during the decade of austerity has revealed to the public what has been obvious in the sector for years – austerity was hugely unfair and hit the poorest hardest. 

Neighbourhood services under strain is written in IfG’s usual forensic style, and its conclusion is all the more brutal because of it: the most deprived areas received the biggest grant cuts, resulting in bigger reductions in local services such as libraries and recycling.  Central government grants were cut more in deprived areas because of the way cuts to grant funding were distributed ignoring councils’ different degree of dependency on this income source.  Because of the central cuts and pressures such as the increasing demand for social services, councils have been forced to cut preventative and universal services like children’s centres and housing programmes to help vulnerable people to live independently.

The report’s detailed analysis of changes in spending reported to DHCLG concludes that most councils chose to protect similar services.  ‘Relatively protected’ services included environment and regulatory services, homelessness and public transport.  At the other extreme, most councils applied higher than average spending cuts in housing, cultural, and planning services (figure 1 below).  This mirrors earlier analysis by the National Audit Office (which also highlighted the protection of social care services).

Figure 1: Local authorities that disproportionately cut, relatively protected, or increased neighbourhood services spending between 2009/10 and 2019/20, by category

Source: Institute for Government analysis of DLUHC, Local authority revenue expenditure and financing in England: individual local authority data – revenue outturn 2009/10 and 2019/20.

The IfG report hints at the innovative ways different councils responded to these pressures, from contract renegotiation and the use of new technology, to service redesign and rationalisation.  For a more detailed exploration of this, I recommend Alison Gardner’s excellent thesis on how local councils responded to austerity – including strategic asset management, shared services, commercialisation, co-production and demand management.  Whatever methods were used, however, it’s clear that by the second half of the decade of austerity the cuts were no longer into ‘fat’ but into ‘flesh’.

These new findings add to a growing library of research on the effects of the UK government choice to pursue austerity policies, including a BMJ study in October 2021 which suggested that the constraints on health and social care spend during this period of ‘austerity’ have been associated with 57,550 more deaths than would have been expected had the growth in spend followed trends before 2010.  Considering cuts to local government funding specifically, a July 2021 study in The Lancet estimated that cuts in funding were associated with an increase in the gap in life expectancy between the most and least deprived quintiles by 3% for men and 4% for women between 2013 and 2017. Overall reductions in local government funding during this period were associated with an additional 9,600 deaths in people younger than 75 years in England. Well before the pandemic, the UK was seeing a rapid slowdown in life expectancy gains in the 2010s and, although a number of other high income countries also saw such slowdowns, of large populations only the USA experienced a more severe slowdown/reversal and the magnitude of the slowdown in the UK was more severe than other large European populations.

Perhaps the most damning finding of the IfG report is that central government lacks the information to know what the impact of its spending cuts are on local services.  This echoes the assessment of the Nuffield Trust and Health Foundation back in 2014 which warned government was making decisions with ‘no comprehensive way to quantify the impact that social care cuts are having on their health and wellbeing’ and were therefore effectively ‘flying blind’.  Having abolished the Audit Commission in 2010, the government was left with no comparable performance statistics for two-thirds of local services.  Some may believe that this was quite convenient, given what we are now learning about the effects of that government’s spending policies.