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

Black History Month

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

Pushing experts under a big red bus?

Picture source: https://paulcairney.wordpress.com/2020/07/08/covid-19-policy-in-the-uk-did-the-uk-government-follow-the-science-reflections-on-sage-meetings/
Jason Lowther


Politicians have a complex relationship with experts and the evidence the latter provide.  Back in May 2020, I reflected in the Municipal Journal on how Michael Gove’s statement in the Brexit campaign that ‘people in this country have had enough of experts’ had turned 180-degrees.  With the arrival of Covid, the PM told his 9th March 2020 press conference ‘we are doing everything we can to combat this outbreak, based on the very latest scientific and medical advice’ and this line was consistently reiterated by other ministers.  Thirty months on, Rishi Sunak (Chancellor in 2020) railed against the government’s main Science Advisory Group for Emergencies expert group (SAGE) saying ‘If you empower all these independent people, you’re screwed’. 

Sunak’s argument, presented in an interview with the right-leaning Spectator magazine, seems to be that the SAGE experts failed to consider any non-health impacts of Covid control measures (particularly lockdowns) and refused to show politicians their workings.  In the article he’s quoted as saying ’I was like: “Summarise for me the key assumptions, on one page, with a bunch of sensitivities and rationale for each one”, in the first year I could never get this’.  This doesn’t seem to match with the published SAGE ‘consensus statement’ on school closures issued in February 2020, which very clearly sets out its assumptions and explicitly states:

As well as the large economic and educational costs of school closures, including increased levels of workforce absence in the health and care system and elsewhere, school closures could have adverse consequences: As infections appear to be more severe in older people, putting children in the care of their grandparents may result in a higher number of severe cases. Once schools are reopened, the number of cases may increase again, with the overall attack rate not being reduced.
(SPI-M-O: Consensus view on the impact of mass school closures on 2019 Novel Coronavirus, Feb 2020)

Later, when facing the December 2021 Omicron variant, Sunak is said to have used his own alumni and private sector analyses to challenge SAGE advice for further lockdowns with the PM and in cabinet.  He argues that the scientific evidence failed to provide a balanced analysis of lockdown decisions, saying ‘I would just have had a more grown-up conversation with the country’.  Sunak also claimed that dissenting voices in SAGE discussions were edited out of the minutes, an assertion he supported by describing a Treasury official sitting in on the discussions and reporting disagreements and uncertainties back to him. 

SAGE scientists see this differently.  Former SAGE member Prof Ian Boyd from the University of St Andrews commented: ‘It is nonsense to suggest that Sage was insensitive to the issue of the long-term effects of lockdowns – a whole subgroup dedicated itself to trying to understand what this might look like. Sage was discussing the topic of excess deaths in detail in April 2020.  Those who attended Sage meetings were acutely aware of the trade-offs associated with implementing specific actions, such as closing schools. To the extent that it was possible with the information available at the time, these deals were included within the uncertainty expressed in the advice provided to politicians. It is simply unacceptable to rewrite history, by blaming scientists, to save a political class that has systematically failed to respond to the messages that scientists have been providing to them for many, many years’.

There are valid reasons to criticise elements of the advice system the government put in place during the pandemic.  The limitations of ‘a model in which a specialist committee produces consensus statements that spare policy makers any requirement to make choices on matters in which they have no competence’ have been demonstrated in analysis by Lawrence Freedman of the intelligence failings relating to the UK entry to war with Iraq as well as the Covid pandemic.   His analysis recommends a model with more opportunities for policy makers to engage with the experts as both the advice and the policy is developed.   The editor of the Lancet, Richard Horton, argued that expertise around public health and intensive medical care should have been in the SAGE discussions.  I argued in the MJ piece that having practical knowledge from local councils and emergency planners could help avoid recommendations that prove impossible to implement effectively, since esteemed experts can still make recommendations which are impossible to implement in practice.  But it’s simply wrong to suggest that SAGE ignored key evidence on non-health effects of Covid control measures or sought to silence dissenting views.  If the trade-offs and assumptions were not considered by the Cabinet, the blame for that lies not with the scientists but with the politicians.

This article appeared in the Local Area Research Intelligence Association newsletter on 27 Sept 2022

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

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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.