Integrated Care Boards – a new frontline in localism?

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

Collaborative management in the face of government response to COVID-19? Evidence from care home staff and stakeholder experiences in West England.

Luke Bradbury

Picture credit: https://socialvalueportal.com/support-national-effort-covid-19/resources/news/social-value-in-action/support-national-effort-covid-19/

As a student on the MSc Public Management course at INLOGOV and having worked part-time in care for a number of years, I felt my final dissertation project was an opportunity to investigate the impact of COVID-19 on adult social care and the implications of government intervention. The works of organisations such as SCIE (Social Care Institute for Excellence) have already shown that inaccurate government guidance – combined with years of underfunding – resulted in the sector being ill-prepared for dealing with a pandemic and that care policy and practices had to rapidly adapt to unforeseen circumstances with limited support.

This case study aimed to explore this in the context of two care homes in West England during the early months of the pandemic. It was also interested in the role of collaborative management between care homes and their surrounding communities including local authorities, charities, businesses etc. ‘Collaboration’, in this context, took some influence from Helen Sullivan and Chris Skelcher’s conceptualisation of a collaborative agenda governing the (often mutually) beneficial cooperation between different public bodies and community agencies. One might consider how care homes may have banded together with their own local communities to ensure they still had the means to provide quality care in the face of COVID-19. Indeed, recent research by Fiona Marshall et al. has shown that, where government support was scarce, many care homes formed resource networks with external stakeholders such as local businesses, dentists, veterinaries, and domiciliary care agencies to source vital materials including personal protective equipment (PPE), electronics, toiletries, bedding and even food.

This study used semi-structured interviews and recruited five participants via a combination of snowball and non-probability purposive sampling. This included two deputy care home managers representing two different care homes in West England as well as a carer, a local parish councillor, and a co-owner of a local chemicals firm. The latter two participants were recruited as active members of the local community for one of the two participating care homes (or ‘external stakeholders’). Thematic analysis and grounded theory-based coding was then used to interpret the data.

The analysis firstly uncovered a strong dissatisfaction with the central government response to COVID-19 amongst all participants. Care staff spoke about how the implementation of the Coronavirus Act forced them to take on extra patients from hospital without an effective COVID-19 testing system in place and that inconsistencies between government guidance and company policy led to confusion amongst managers. Practices were forced to adapt; for example, adhering to stricter infection control measures and taking on extra care duties such as virtual GP consultations. External stakeholders also spoke about how these circumstances encouraged some level of collaboration within the community and a desire to assist local care organisations; for instance, a parish council was enabled to collaborate with the local chemicals firm and local school to source PPE such as goggles and hand sanitizer which could then be distributed to care providers.

Despite this opportunity to establish a resource network, collaboration between the two care homes and their surrounding communities was not evidenced as Marshall et al. had found previously. This was attributed to two main reasons. Firstly, resource dependency was less prevalent because effective internal management within both care homes meant they already had a sufficient supply of PPE. As one of the deputy managers recalled, the manager for her home made the decision to stock up on PPE and to lockdown early, therefore minimising the spread of the virus. The second reason was down to external circumstances that aided both care homes. Since both operate within rural areas of West England, they occupy less densely populated regions than care homes within inner city locations and therefore surrounding transmission rates remained relatively low. The implication is that locality largely eliminated the need to establish support networks with external stakeholders because they were not experiencing the same level of devastation seen in many other care homes. This was corroborated by staff who felt ‘fortunate’ compared to what they were seeing on the news.

These findings indicate the importance of effective management but also the extent to which contextual circumstances may or may not have necessitated collaborative networking between care homes and their surrounding communities during the early months of the pandemic. Whilst collaboration was less necessary here, the background coordination of parish council and local actors to produce a ‘safety net’ of resources did highlight the potential of localised collaboration and intervention in times of crisis. Perhaps, had such coordinated localised governance been enabled within the surrounding communities of less fortunate care homes, they may have been spared some of the devastations of the pandemic. Regardless, there is certainly a strong call for greater support towards the care sector for government and policymakers to consider – particularly in terms of clearer guidance, increased funding, and enabling localised governance to support care organisations.

Luke Bradbury graduated from the MSc Public Management in September 2021.

How can we nurture urban transformation?

Dr. Catherine Durose

The complex, rapidly changing, increasingly precarious nature of cities has highlighted the limits of a traditional ‘top down’ master governance plan. How then can we shape and transform cities in order to address the challenges we face as a society, from sustainability to social cohesion?

Rather than attempting to discipline the urban governance environment, academics are increasingly trying to use different ways of thinking about the urban environment in order to work with its messiness, focusing on contingency, emergence and interaction. In our recent research, we have embraced this approach, but sought to develop it by also acknowledging the role of human agency in shaping and nurturing urban transformation.  Our work has given a sustained focus on how different people – those working on the front-line of public services, or in voluntary, community or social enterprise organisations, activists, and residents – can create change in urban neighbourhoods. Our new research places those working for change at the centre of debates on how cities transform.

We conducted a 30 month study in neighbourhoods in Amsterdam, Birmingham, Copenhagen and Glasgow. With local partners, we identified individuals who had a reputation for making a difference. We interviewed and observed them, and created spaces for them to come together to reflect on what they do, how they do it and why it matters. Our research discovered examples of how people made use of and nurtured four common resources:

  • Vision: a set of ideas to bring people together and offers a collective narrative for the future.
  • Relationships: ongoing engagement with a range of different people, often across cultural, economic or organisational boundaries.
  • Different ways of knowing: from professional knowledge to local.
  • Materials: from buildings to human bodies.

Living Lab in Birmingham

Examples included: how a mobile bakery in Amsterdam brought people together to take action, how historic buildings were re-purposed in Glasgow to offer a different future for the neighbourhood, how healthy lifestyle opportunities in Birmingham helped women from under-served communities realise their potential, and how resources were re-used and shared in Copenhagen to build a sustainable neighbourhood food economy. 

Seen together these examples begin to demonstrate a different way of thinking and showing how cities may be transformed:

First, how transformation may come from giving meaning to action and a pathway to a more liveable neighbourhood. 

Second, nurturing rather than extracting resources.

Third, engaging with people as community members to foster a sense of belonging and solidarity.

Finally, recognising and valuing different kinds of knowledge and harnessing them to respond creatively to social problems.

These practices did not begin with, focus upon, or end with those formal institutions that govern a city. Indeed, they often reflected institutional limits. Instead, they were guided by a belief in fostering power in communities towards a shared vision of a different future. 

The understanding of change expressed here, brings together a recognition of the role of people in catalysing urban transformation by bringing together different resources in a way that is purposeful, but also allows for a process of becoming that emerges over time. The work and resources we draw attention to here were often precarious, hidden, unvalued and yet hard to replace. Opportunities to experiment, to nurture, to fail, to reflect were all crucial, but we should acknowledge are also under severe pressure.

Our research brings together the history of different urban neighbourhoods, and their potential, and recognised the actual whilst considering the possible. We hope these insights contribute to ongoing learning and critical imagination in how we can approach the future of cities differently. Our article, ‘Working the urban assemblage: a transnational study of transforming practices’ by Catherine Durose, Mark van Ostaijen, Merlijn van Hulst, Oliver Escobar and Annika Agger has now been published in Urban Studies, and is available open access.

Catherine is Reader in Policy Sciences at INLOGOV, with a specific interest in urban governance and public policy.

Can democratic renewal help us ‘build back better’ from the COVID-19 crisis? Key recommendations from the Newham Democracy and Civic Participation Commission

Elke Loeffler and Nick Pearce

Newham has seen one of the highest rates of COVID 19 mortality in England and Wales. Being one of the 10% most deprived areas in the UK (according to 2019 deprivation indices) the crisis has exposed wider social and economic inequalities – in health, housing, access to services and income – particularly for the Black and Minority Ethnic population.

At the same time, Newham has also seen a flowering of community support and creativity in response to the crisis. The local council has pioneered new ways of working with the voluntary and community sector. A new COVID-19 Health Champions network has been launched to empower thousands of Newham residents to remain up to date on the latest advice about COVID-19, and a new digital initiative  ‘Newham Unlocked Community Broadcasts’ showcases the creativity of local artists.

Newham is also one of a relatively small number local councils in the UK which have a directly elected Mayor. In 2018 Rohksana Fiaz took over from Sir Robin Wales, after his 23 years in the post, as London’s first directly-elected female mayor. In her election manifesto Fiaz promised to hold a referendum on the direct elected mayoral system before the end of her third year as Mayor (i.e. 2021), although the impact of the COVID-19 pandemic will affect this timeline.

The Democracy and Civic Participation Commission

In this context the Mayor and the Council of Newham set up an independent Commission in autumn 2019 to examine both the Council’s current directly elected Mayor system of governance and the alternative approaches that exist in English local government, and to make recommendations on the best system of governance for Newham’s future, and to explore ways in which local residents can become more engaged and more fully involved in local decision-making and the Council’s work.

The Commission was led by Professor Nick Pearce. Extensive evidence gathering took place between November 2019 and February 2020.

A key concern of the six Commissioners was to make bold recommendations to reduce inequalities in public participation and bring citizen power into the Council to improve public services and the quality of life of local people. The COVID-19 crisis, which occurred during the latter stages of the Commission’s work, gave a dramatic glimpse of the huge potential resources in the community and the willingness of local people to make a contribution to improve the quality of life in their neighbourhood.

The “Newham Model” for more inclusive public participation

The resulting “Newham Model” aims to provide checks-and-balances to the way in which Newham is governed. It provides new participatory governance mechanisms. In particular, the Commission Report proposes the creation of a permanent Citizens’ Assembly, selected like a jury – the first of its kind in England. It suggests strengthening the accountability of the executive Mayor to local people and the main stakeholders of the Council, while also limiting the mandate of the executive Mayor to two terms, so that there is a frequent impulse for innovation and creative thinking at the centre of the Council.

Other key recommendations for strengthening public participation and co-production of public services and outcomes with local people are:

  • Extension of participatory budgeting – an increase in the resources allocated to areas or neighbourhoods for expenditure which is determined by local people from the current level of £25,000. The aim should be to spend a minimum of 20% of the Community Infrastructure Levy (CIL) resources through neighbourhood or area-based participation.
  • A new framework for area-based decision-making – allowing powers to be drawn down to the most local level – along with the piloting of an ‘urban parish council’ in one of Newham’s communities.
  • A new “Mayor’s Office for Data, Discovery and Democracy” to provide expertise and leadership on the democratic use of data, digital tools for resident engagement, and learning from digital champions such as the government of Taiwan.
  • Wider use of co-production with residents and people accessing services, including area regeneration, which means that the local council needs to become much better at mapping what local people are doing, and want to do in the future.
  • Enabling local councillors to play the increasingly important role of ‘community connectors’, mobilising local people and their enthusiasms.
  • Support for an independent, community-owned local media organisation.

The Report of the Commission was launched on 6 July 2020 in a virtual public meeting, with presentations from the Commissioners, followed by responses by the Mayor and Vice-Mayor on behalf of the Council. Newham Council’s cabinet members will formally consider the commission’s report and recommendations at a later meeting.

Clearly, councils need to adapt the ‘Newham Model’ to fit their local circumstances, while simultaneously learning from democratic innovators in the UK and internationally.  Moreover, research institutions such as INLOGOV have an important role in sharing learning on new local governance models to help local government to ‘build back better’ from the COVID-19 crisis.

 

Nick Pearce is Director of The Institute for Policy Research (IPR) and Professor of Public Policy at the University of Bath. He was formerly director of the Institute for Public Policy Research (IPPR), as well as Head of the No 10 Downing St. Policy Unit between 2008 and 2010.

Elke Loeffler is a Senior Lecturer at Strathclyde University, and INLOGOV Associate. She is author of ‘Co-Production of Public Services and Outcomes’ and co-editor of ‘Palgrave Handbook of Co-Production of Public Services and Outcomes’, both of which will be published in autumn 2020.