health

Let’s Tackle Covid

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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 

Big changes to the NHS

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Cllr Ketan Sheth

Big changes come into effect this month in the way our local health services are managed. Eight clinical commissioning groups (CCGs), including Brent, have merged into a single North West London CCG. This CCG  will also be working with every hospital, mental health trust, community trust and local authority in North West London as part of an ‘integrated care system’ (ICS).

People often ask if such changes really matter. My sense is that they really do and that they can be both a risk and an opportunity.

NHS doctors and managers tell me that the benefit to patients is that a single organisation and system can drive a consistent approach to high quality services, using data on population health to target improvements and tackle health inequalities. There are huge inequalities across our patch, with outcomes and life expectancy varying widely between the poorest and more affluent areas. We saw this play out tragically during the Covid pandemic, where the least well off, including many people in Brent, were disproportionately affected.

The role of local authorities in the ICS – which is expected to become a statutory body in April 2022 – is also important, as it means we can better join up health and social care services, building them around the needs of our communities by working as a single system.

We also have to recognise the risks. A bigger system across eight London boroughs – North West London will be the biggest CCG and ICS in the country – could easily become far removed from local needs and concerns in each area. We know public input to both health and local council services improve those services. So ensuring a strong resident voice, at both borough and North West London level, is going to be critically important.

So too is local decision-making. I am pleased that the single CCG will have strong borough-based teams – and particularly, that the intention is to create a local ‘integrated care partnership’ (ICP) between all part of the NHS and the council in each borough. While this may sound like lots of new jargon and bureaucracy, it is important. The balance of power between the ICS and the local ICPs will be important: ICPs should be setting the local agenda with their residents while the ICS steers the overall direction of travel for the system.

On balance, the changes feel like the right thing to do – residents often complain that services don’t work together closely enough. But the success of this latest NHS reform will really depend on all of us. If we can ensure that the local systems work and play their part in driving down health inequalities across the whole area, there should  be huge benefits for North West London. If we lose local voice and influence in a sprawling, centralised bureaucracy, we will have failed.

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

NHS that involves and listens to local people is in all our interests

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Cllr Ketan Sheth

Readers may be aware that the way in which the local NHS is run is likely to see big changes in the months ahead. Part of the NHS Long Term Plan is for local NHS bodies in each area to work in partnership with local councils as part of an ‘Integrated Care System’ (ICS). In North West London, this will mean a huge partnership across eight boroughs, including Brent – my Local borough. It may also mean a merger of the eight clinical commissioning groups (CCGs) across these areas into a single CCG for North West London (subject to a vote of GPs in each borough).

NHS leaders assure us that this is not a change to services, but to how their staff are organised. They say that any changes that are proposed under the new working arrangements will be subject to the same – or more – consultation and scrutiny. We need to hold them to this promise. The biggest concern for me, as a Brent councillor, is that the voice of Brent residents is not lost in a new system covering a huge geographical area (the North West London ICS and the single CCG would be the biggest in the country).

At a recent Joint Overview and Scrutiny Committee, we had the chance to question managers and GPs about the single CCG merger. There were certainly encouraging words about their future approach to involving local people in shaping health services. They have put in place a new programme, rather grandly called ‘EPIC’ (Engage, Participate, Involve, Collaborate), which they say is a direct response to the challenge of maintaining the voices of local residents in a much bigger system.

Working with local patient groups and Healthwatch organisations, they are co-producing an ‘Involvement Charter’ setting out how the public can get involved and setting standards we can hold them to. They have expressed a commitment to strengthening the current approach and involving more people, reaching deeper into our communities than ever before. They have promised to work with councillors and others to reach the most vulnerable and isolated people, who the NHS does not have a good track record of engaging. And alongside this ‘qualitative’ engagement, they have set up a 4,000-strong Citizens’ Panel, representative of local communities, allowing them to test public opinion through surveys and focus groups on a range of issues.

The programme is ambitious and no one could argue with its stated objectives. But as ever, the proof of the pudding is in the eating. The NHS is facing big challenges right now, not least in getting services up and running again in the wake of Covid-19. Getting public engagement right is going to be more important than ever. If this programme really does see a step change in how the local NHS works with our residents – and most importantly, if it acts on what people tell them – it will have my support. My message to NHS colleagues is simple: the goals you have set out are welcome, but we will need swift and tangible evidence that things are really changing for the better. The National Health Service that involves and listens to local people is in all our interests.

 

ketan

Cllr Ketan Sheth

Chair, Brent Council Community and Wellbeing Scrutiny Committee

Social care reform – comprehensive is good, but comprehensible vital

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Chris Game

Cllr Ketan Sheth’s recent blog on ‘Local Government and the NHS Integrated Care System’ was, as he explained, timely for him personally – as an elected London borough councillor about to take on a novel scrutiny role in a new ICS.

For us Midlands readers it was timely too, for reasons most easily conveyed by the King’s Fund’s recent highly colourful Map 1 of ICSs so far established – highly colourful, that is, for some parts of England, including Cllr Sheth’s London, but bleak grey for others, like the whole of the Midlands, with merely our at least slightly more localised Sustainability and Transformation Partnerships (STPs).

This blog is not directly about either STPs or ICSs, which have only a late walk-on role. It is, though, about the future of social care and local government’s involvement in, or marginalisation from, that future, and it opens with one of Boris Johnson’s first Prime Ministerial broken pledges, in his very first speech as PM, to “fix the crisis in social care once and for all with a clear plan we have prepared”.

The ‘clear prepared plan’ bit was obvious fiction, and confirmed as such in the Conservatives’ December election manifesto.  60 pages, nearly 1,000 days working on a promised but still undelivered Green Paper, and no sniff of a plan.  One un-costed pre-condition (p.23) – that nobody should have to sell their home to pay for care – and a slightly desperate hope to build cross-party consensus on reform.

But last week, just eight months on, jostling with daily lockdown bulletins and courtesy mainly of The Guardian newspaper, saw a sudden small flurry of tantalising leaks. First came Ministers’ “radical plans for everyone over 40 to contribute towards the cost of social care in later life” – paying more in tax or national insurance, or insuring themselves against “hefty care bills when they are older”.

Broadly resembling the German and Japanese funding systems, it is variously labelled a ‘comprehensive’ and ‘compulsory’ insurance model, both of which, to be effective, it surely has to be.

But an even bigger question, I suggest in the blog’s title, is surely whether it can become a comprehensible and comprehended model, and pretty quickly – because the evidence is that our collective understanding of even the existing system is worryingly low.

With coincidental but near-perfect timing, the New Statesman magazine recently commissioned a poll by Redfield & Wilton Strategies asking a sample of 2,000 GB adults about their awareness of how social care is currently funded and organised. Its findings, for a topic dominating news headlines for several months now, were concerning.

Fewer than one in eight felt they were “significantly aware”, under half even “moderately aware”, and nearly a quarter “not aware at all”. They were then asked which of (1) the NHS, (2) private operators, and (3) my local council, they thought were currently providing community care in their locality.  Being a GB-wide sample, there are no precisely right or wrong answers, and ‘providing’ makes it almost a trick question – which personally I’d have opposed phrasing in this way. Still, there are better and worse guesses.

“My local council”, chosen by 55%, is a decent pick – if, by providing, you mean paying for.  But not, for decades now, if you mean actual care home beds.  As Covid has tragically demonstrated, funding is nowadays effectively separated from extremely fragmented provision, with only some 3% of beds directly provided by councils and at least 80% in over 11,000 homes by for-profit private companies, local organisations and charities.

As for payment – roughly £600 per week here in the West Midlands – just over one-third of residents have their fees met by their local authority; one in eight pay top-up fees, but the biggest fraction must find the full fees themselves.  Which, given our apparently limited understanding of the present-day system, must frequently come as a serious shock.

Exactly half the poll respondents ticked the “private operators” option. However, virtually as many (48%) nominated the NHS, which, note the authors, is nowadays “a very small player” indeed in providing social care.  It’s not totally wrong, but close – and that, in the proverbial nutshell, is Ministers’ social care problem.

The public generally have low understanding of how even the present care home system works, of how literally dis-integrated it has become, with home care provision twice as fragmented and considerably more expensive. But they love, clap for, and think they know ‘their’ NHS.

It was even more starkly highlighted in the crunch question: “Which of three options for the future of social care comes closest to your own view?”  Exactly half the respondents selected the ‘NHS model’ that many had just demonstrated they seriously misperceived: “Social care should be free at the point of use, regardless of whether individuals contributed taxation into the system during their working lives”.

Just over one-third preferred the ‘pension’ or ‘compulsory insurance’ model referenced in the Guardian story – or, rather, first story.  For, the following day, it reported Government plans to in effect merge health and social care services, taking the latter away from local councils altogether and handing them and their £22.5 billion annual funding over to the NHS.

The Department of Health and Social Care issued a routine denial, but the PM’s long awaited ‘plan’ appears, currently, to be that care services would be commissioned by, and funded through, the new NHS regional Integrated Care Systems (ICSs) gradually unrolling across England – although not, as yet, the Midlands, where we’re still in the Sustainability and Transformation Partnership phase.

I conclude with what seems a bit of a personal dilemma. Having worked for over half my life for an ‘Institute of Local Government Studies’, I instinctively deprecate both the fact and implications of elected and accountable local authorities losing a major function for so long integral to their existence.

On the other hand, if that’s what most people reckon they want, and the Government fundamentally misunderstands, distrusts, and already wants to diminish and/or abolish local councils ….   The question is: would the public be prepared to pay the cost of NHS-style “social care, free at the point of use”, largely unaddressed in the New Statesman questionnaire?  But that’s for another blog.

 

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Chris Game is an INLOGOV Associate, and Visiting Professor at Kwansei Gakuin University, Osaka, Japan.  He is joint-author (with Professor David Wilson) of the successive editions of Local Government in the United Kingdom, and a regular columnist for The Birmingham Post.

Local Government and the NHS Integrated Care System

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Cllr Ketan Sheth

For those councillors in local government who scrutinise the NHS, it seems to have become an expectation that as one great change ends in our local health services, another begins.

A good few years ago in north-west London we saw the start of the Sustainability and Transformation Plans (later rebranded as Sustainability and Transformation Partnerships) or STPs as they were widely called. Now it seems another change is on the way. By April 2021 an Integrated Care System (ICS) will have been introduced, taking forward much of what was developed by the STPs. And, they are coming at a time of incredible change for the NHS and local government as a result of dealing with the Covid-19 pandemic.

I’m sure many of you are familiar with an ICS. If I had to summarise, I would say they are in essence bringing together health providers and commissioners, along with local government, to plan healthcare based on local population health needs in a defined geographical area. I’ve noticed the term ‘place’ features frequently in the NHS documentation and published reports. I should say as well, that the underpinning and thinking for them is all set out in the NHS Long Term Plan. In a few areas such as Greater Manchester, they started in 2018, and more have been set up to the point where around half of England’s population is now covered by an ICS.

As for my local proposed ICS, this will be cover around 2.3million residents across eight London boroughs in north-west London stretching from Westminster out to Hillingdon, with multiple providers, and community healthcare Trusts as well, and not to forget, the local authorities. At the moment, each borough has its own clinical commissioning group (CCG), but the plan is for one CCG to cover the whole area as well (but that development is best discussed at another time) across the eight boroughs.

So, what I want to address here is this – how does an elected member sitting on an overview and scrutiny start to grips with effectively reviewing and holding to account the development of a ‘system’ of such complexity, and in the constraints of the time and resources we all know elected members face? What should our starting principles be? It’s not easy to answer, but I have a few suggestions.

As an elected member, I don’t necessarily need to worry about being a ‘systems thinker’ but I do like to test the local ICS thinking constructively. I would perhaps ask this – thinking about the ordinary residents in my ward what will it deliver for them? What will an ICS do to make them and their families and children healthier, and be able to live longer and with a better quality of life? Ultimately, for me that’s what organisational systems in our public services should be about. Simply, a means to an end of delivering something better for ordinary people and our communities.

Also, while we talk about ‘systems’ in health services, let’s not forget that when we refer to hospitals in particular we are talking often about important local institutions which command a lot of local pride and attachment; not just because of the services they provide, but because of the outstanding research they do. Also, in my home borough of Brent, they are important local employers. I think this way of looking at the world from the grassroots should not be lost in these changes.

So that’s a few ways we can start to get to grips with such a big change, and complexity. Then it might be time to prepare for the next one, whatever that may be.

 

ketan

Cllr Ketan Sheth

Chair, Brent Council Community and Wellbeing Scrutiny Committee

England’s over-centralisation – Part 2: It IS instinctive

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Chris Game

There was much in Jessica Studdert’s recent blog to agree with and applaud, but one sentence particularly struck me – the one opening her fourth paragraph: “The centralised response isn’t just structural, at times it has felt deeply instinctive.”.

So, equally instinctively, I did what even an erstwhile academic does during a lockdown – some heavyweight research, naturally. Like re-watching and content analysing the first 69 Government Covid-19 daily press conferences – one of those crisis features that, like the Thursday evening clapping, lives on because no one knows quite how to stop it.

I exaggerated with the ‘heavyweight’ bit, but I did count – sorry, totalise – the press conferences. So, first question: Which minister, Johnson excepted, was the first to front one?

No, not Foreign Secretary Dominic Raab. As First Secretary of State, he stood in while Johnson was hospitalised, but was actually eighth minister to feature. Surely, then, Health and Social Care Secretary, Matt Hancock. Nope, though he and his permanent pink tie have currently clocked up more appearances than Johnson himself.

Struggling? Chancellor of the Exchequer, Rishi Sunak? Hardly Robert Jenrick, Secretary of State for Housing, Communities and Local Government – for all the considerations touched on in Studdert’s blog. Surely not Home Secretary Priti Patel, despite being apparently the only woman minister capable of reading from a lectern.

They’ve done four, five and three respectively, but the shooting star we are looking for is Environment, FOOD and Rural Affairs Secretary, George Eustice. How short are our memories. His brief includes the so-called food supply chain, and this was late March – panic-buying, pasta-hoarding weekend.

Now the seriously tricky question. How many winning elections to serve as a plain local government councillor – not London Mayor – have all 12 featured Ministers fought between them? Maybe not a huge number? One!

One four-year term of elected local government experience between the lot of them. It was served by then 24-year old Gavin Williamson, now Education Secretary, giving English primary schools his considered judgement on when they should reopen.

It’s easy to mock – really easy – but there are archive pictures of Williamson doing his thing as North Yorkshire County Council’s ‘Champion of Youth Issues’ . Making him, I believe, alone among that TV-trusted Cabinet dozen to have even minimal first-hand insight into how local government operates in the policy field for which he is responsible.

The others can tell you lots, variously, about banking (Hancock), hedge fund management (Sunak), litigation (Raab), corporate finance (Alok Sharma), corporate law (Jenrick), public relations (Eustice, Patel), journalism (Johnson, Gove), marketing (Grant Shapps), Conservative Central Office (Patel, Oliver Dowden).

But actually experiencing what they presumably aspired to do – campaigning, meeting constituents, getting elected, representing people, learning about the provision and funding of public services, the whole government and public administration thing – for some reason never grabbed them or even struck them as career-relevant.

Which today means they know virtually nothing at first-hand about some of the vital stuff local governments do, often to the unawareness of even their own publics: emergency contingency planning, air quality monitoring, water testing, pest control, health and safety at work inspection – oh yes, and communicable disease investigation and outbreak control.

Time for a brief digression on the changing meaning of the word ‘nuisance’. It was one of my mother’s favourite words, applied frequently to my sister and myself, but to almost any usually minor upset to her daily life routine. Mask-wearing and disinfecting supermarket trolley handles would be a ‘nuisance’, not the wretched pandemic itself.

Yet the etymology of ‘nuisance’ is the Latin ‘nocere’ – to harm – and its original 15th Century meaning could quite conceivably be applied to Covid-19 and its capacity to inflict serious and even fatal harm.

The mid-19th Century predecessor of today’s Director of Public Health in Birmingham, Dr Justin Varney, would therefore have boasted the title of Nuisance Inspector – his nuisance agenda including factory air pollution, small-pox and cholera outbreaks, and sanitation, with the first generation of public urinals.

Nuisance Inspectors could not by themselves transform towns and cities, but they played a huge part. As do their modern-day successors – Public or Environmental Health Inspectors. Those successors, however – the ones that have survived the past decade of local government funding and employment cuts – could and should, as Studdert noted, have been doing even more.

The Chartered Institute of Environmental Health reckons there are some 5,000 Environmental Health Officers (EHOs) working in UK local councils. All have job descriptions including responsibilities like “investigating outbreaks of infectious diseases and preventing them spreading further.”

That’s what they do – test, track, trace and treat people with anything from salmonella to sexually transmitted diseases – in areas, moreover, with which they are totally familiar and have networks of contacts. ‘Shoe-leather epidemiology’ is the technical term – seriously.

So presumably, as in other countries – South Korea, Singapore, Germany, Ireland – these EHOs will have been reassigned from other work and spent their time contact tracing?

Rhetorical question – we all know the answers. From early March, contrary to World Health Organisation guidelines, our Government’s big ideas were to ‘delay’ the spread of Covid-19, then develop vital (now less vital) smartphone apps.

This enabled the consequently limited scale of contact-tracing to be undertaken centrally by staff newly recruited by Public Health England – the executive agency of Matt Hancock’s Health and Social Care Department created in the ill-conceived NHS upheaval in 2012.

Insufficient, inexperienced staff doing a job crying out for the skills, knowledge and contacts of council EHOs, who instead were monitoring social distancing rules in pubs, clubs and restaurants.

There are almost always costs in ‘keeping it central’, but, as we have seen, for so many ministers, it must be instinctive. It’s all they and most of their civil servants know at first hand. The alternative would be funding and at least sharing data with pesky local authorities, thereby losing some of their precious control.

Finally, last weekend, all other options exhausted, the Government did allocate a ring-fenced £300 million to English councils to play a leading role, starting immediately, in tracking and tracing people suspected of being at risk of Covid-19.

This time, tragically, the cost of blinkered, prejudiced, self-protective government was paid in lives.