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

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?

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.

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.

Let’s Tackle Covid

Cllr Ketan Sheth

The ‘mass vaccination event’ at Twickenham Stadium on the Spring Bank Holiday was a proud day for the NHS and local government. The North West London NHS and Hounslow Council, supported by the Rugby Football Union, pulled off this remarkable day with less than a week to plan, following a surge in Covid cases in Hounslow.

The communications around the event included the obvious routes of national, local and social media, but also included targeted door knocking in Hounslow. During the day, as it became clear that there were likely to be some vaccines left over, the local NHS took the wise decision to open up the offer to anyone aged 18 and over and this was quickly picked up and reported by the BBC, Sky and other media outlets. The result was a huge spike in demand towards the end of the day. By the close, over 11,000 people had been vaccinated – a record for a single day at one venue in the UK. Those behind this effort are to be hugely congratulated.

There are three lessons I think we can learn from this remarkable event. First, it may be a myth that young people don’t want to get vaccinated. Most of those turning up when the offer was extended were under 30. Media reports talked of a ‘festival atmosphere’ and those who attended have confirmed to me that there was a real ‘buzz’ among the young people coming forward. A number of young people turned up with older family members, having persuaded them belatedly that they should be vaccinated. While time will tell, this does suggest that there may be more enthusiasm among younger people for getting vaccinated than had been previously suggested.

Second, and perhaps more contentiously, the quicker we open up to all age groups, the easier it will be to coordinate the vaccine effort. Had the whole day been open to anyone aged over 18, it is likely the demand would have been even higher throughout the day. While the initial targeting of older and more vulnerable people made sense, it becomes harder to justify as we move down through the age groups – and harder for the NHS to coordinate and promote vaccination. We might also want to think about vaccinating people at their convenience wherever they live – while the event was targeted at Hounslow residents and others in the NHS ‘North West London’ sector, I know people from Richmond were not turned away.

Finally, what we can learn is that if everyone pulls together and works as one team, remarkable things can be achieved, even in short space of time. This is a lesson that extends beyond Covid-19 and the vaccination programme – and bodes well for ‘integrated care systems’, in which the NHS and local authorities are expected to work in statutory partnerships in the years ahead.

Cllr Ketan Sheth is Chair of Brent Council‘s Community and Wellbeing Scrutiny Committee and Chair of NW London Joint Health Overview & Scrutiny Committee 

Help council commissioning to ‘build back better’

Jason Lowther

Local government is digging deep into its financial reserves and hiking council tax bills by double inflation, but still anticipates making further service cuts in 2021–22. The Public Accounts Committee report earlier this month shows how central government support hasn’t matched Covid-related budget reductions. More positively, at the same time, councils and partners are eyeing the improvements made to commissioning and procurement during the pandemic and asking whether these could help balance the budget. Can adding value to local government’s annual procurement spend of £100bn help improve outcomes for citizens, sustain local councils, and build a better recovery?

As NESTA’s recent report, A Catalyst for Change, evidenced, councils’ collaboration with other public sector bodies, citizens and the voluntary and private sectors was at the centre of the response to COVID-19. Local authorities ‘stepped into their role as conveners, leveraged their existing relationships and partnerships, and forged new ones to dynamically address key issues. This allowed organisations to link up volunteers with vulnerable people, support businesses, deliver food parcels or find temporary accommodation for rough sleepers’.

I’ve heard from some of the council managers on INLOGOV’s teaching programmes of the amazing agility and flexibility councils have been able to develop with partners in areas such as social care and housing. Commissioning and procurement processes that in the past were seen as inflexible, slow, risk-averse, price-obsessed and lacking innovation were transformed rapidly in response to the immediate threats of the pandemic. Data was shared in more depth and quickly, enabling better targeting of services. More flexible financial and performance management arrangements opened the door to flexible service delivery.

Now, a major research programme led by Dr. Richard Simmons at Stirling University, called Optimising Outcomes, is looking at the impact of Covid on partnering and procurement. The programme is working with key sector bodies such as CIPFA and SOLACE as well as universities and research councils, to answer key questions such as:

  • How, and how effectively, are local authorities deploying their commissioning and procurement functions to address the challenges posed by Covid-19? What are the successes to be celebrated? Where are the tensions that need to be managed? Where is the system at risk of breaking down?
  • What are the opportunities for improved procurement performance? How do local authorities optimise every aspect of procurement spend?
  • Can local authorities adopt more innovative, strategic, entrepreneurial and relational approaches to strengthen local resilience and avoid a weak and incapacitated system?
  • What role can greater data-analytic capacity play in supporting a more agile and effective response?

As part of this research, council managers have been invited to take part in a survey to capture learning from the many challenges and achievements of the sector during the last year.  The survey is aimed at all UK council managers (there is a separate survey for procurement teams) and takes around 10 minutes to complete.  The closing date for responses is 21st June.

If you are a UK council manager and haven’t yet taken part, please would you complete the survey here.    

This is a great opportunity to ‘build back better’ by applying the lessons and innovations councils and partners have developed over the last 18 months. I’ll report back on the results later this year.

Source: DHSC website

Jason Lowther is Director of the Institute for Local Government Studies (INLOGOV)

Backroom or backlit? Council meetings post-Covid

Cllr. Bryony Rudkin

This week two councillor colleagues of mine told me of meetings they’d attended, one an unusual face to face gathering, the other online. For one friend it was the first time she had been to the Town Hall in almost a year. She and her colleagues sat, each at their own table, in an echoing chamber and raised their voices in order to be heard. It was an informal meeting of councillors, officers and other public servants, called to debate sensitive issues in person so that information could be shared freely and confidentially. The issues were serious and compounded by lockdown and stretched resources, an unwelcome distraction at any time. However, this turned out to be a meeting filled with laughter, jokes and gentle teasing. There were interjections and interruptions which helped the meeting flow freely. Delight in seeing each other was tempered only by the acknowledgment of how long it had been since they had last done so.

My other friend told me of an online meeting where an argument had taken place and where one person had cried after making a very personal speech. She observed that what she called “the protection of the screen” meant others were not afraid to show their reaction to the emotions on display but equally the meeting had been stripped bare of physical comfort, an arm around a shoulder or a squeeze of the hand.

These two accounts got me thinking about what we gain and what we lose when we meet online. There’s an interesting seam of academic literature on what meetings are, their role in policy making, the artefacts they produce and of particular interest to local government practitioners, what they tell us about what councillors actually do all day (Brown, Reed & Yarrow: 2017; Freeman: 2008, 2019; Freeman & Maybin: 2011; Llewelyn: 2005). What no one has yet had the chance to explore is the terrain of the online meeting. My own research has used webcast meetings as a rich source of data. Not all UK authorities broadcast public meetings prior to the pandemic but there is now a growing nationwide archive of the formal business of local authorities open to research. What might we want to learn from a closer look? Are individual councillors more or less influenced in their decision making by what they hear from fellow politicians or officers? What of the informal behaviours in meetings – the notes passed, the interruptions, the heckling, the laughter and the eye rolls? In real life these act as lubricants to the flow of discourse and breathing space for thought and reflection. How are they replicated in an online world? If you’re busy on the WhatsApp finding out what your friends are thinking, how much attention are you giving to what is being said?

Arguably, it might not be worth the effort of exploration. The legislation that enables online meetings in English and Welsh local authorities expires in May. The roll out of the vaccine means a roadmap back to the council chamber – alongside the doorstep for local election campaigning – might just be in reach. No doubt those first few ‘real’ meetings will be different. We will have to relearn what it means to speak and listen in person, without the protection and comfort of our screens and homes. We may have gained bigger audiences. Residents, having exhausted Netflix, may be turning to council meetings for entertainment. Maybe not. Anecdotally, councils aren’t directing too much effort into collating viewing figures right now, but having turned the cameras on, it may be difficult to turn them off. We can only wait and see.

I suppose for me it’s always been what happens ‘back stage’ in politics that’s piqued my interest. Privileged access to such space has shown me there’s always so much more to meetings than first meets the eye. It might be happening online, but I’ll wager not to the extent or with the nuance of the past. Back lighting is more of an imperative than backroom dealing right now.

And so I’m reminded of another story a fellow councillor told me years ago about meetings and what goes on in them. Sadly he’s no longer around, so it’s safe to relate. He’d been sent to observe a council meeting in another authority to check on behaviour and conduct. Everything he actually saw taking place was no better or worse than in any other council, he said. The real problem was behind the scenes. The leaders of all three parties represented in that chamber actually carried out negotiations by leaving notes for each other on the top of the old Victorian cisterns in the gents toilets. They were all men. The chief executive, with whom they had disagreements was a short woman who was never going to find them there.

Cllr. Bryony Rudkin is a PhD student at INLOGOV, Deputy Leader of Ipswich Borough Council and is a member of the UK delegation to the Congress of the Council of Europe. Bryony also works with councils around the country on behalf of the Local Government Association on sector-led improvement, carrying out peer reviews and delivering training and mentoring support.

References:
Brown, H., Reed, A. & Yarrow, T., (2017), “Introduction: towards an ethnography of meeting”, Journal of the
Royal Anthropological Institute, 23:S1, 10-26
Freeman, R., (2019), “The role of the councillor and the work of the meeting”, Local Government Studies,
46:4, 564-582
Freeman, R. & Maybin, J., (2011), “Documents, practices and policy”, Evidence & Policy, 7:2, 155-170
Llewellyn, N., (2005), “Audience Participation in Political Discourse: A Study of Public Meetings”, Sociology,
39:4, 697-716