social care

Forging an alliance with the NHS

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Cllr Ketan Sheth

If local councils and the NHS do not work together as trusted equal partners, our residents are the ones that lose out.

In Brent, our local communities were among those most affected by the first and second waves of the Covid-19 pandemic, with the local hospital, Northwick Park, making the national headlines having been caught in the eye of the storm, which acutely demonstrated the terrible impact of health inequalities on real lives.

We are, of course, particularly reliant on our NHS partners to provide emergency services, planned elective care, and a full and complex mix of outpatient and specialist services, including mental health and community services.

Likewise, NHS staff are reliant on local councils (and other local partners) playing their part in delivering a seamless patient pathway, that can go from a first GP visit right through to a tailored social care package.

Delivering high quality, equitable health services take detailed planning and a solid grasp on the needs of local communities.

In Brent, we have seen increasing levels of partnership working with the local NHS trust. Collaboration is made easier because London North West University Healthcare NHS Trust (LNWH) shows a refreshingly genuine commitment to gaining a deep appreciation of the views, concerns, and perspectives of our local populations. This is reflected in the development of the trust’s new five-year strategy. 

In addition to undertaking vast analysis of public health, demographic and other data relating to our communities, LNWH sought engagement right from the start. The trust co-created a strategy with the help of almost 900 local community members and 40 representatives from local authority and partner organisations. Over 2,300 staff also contributed, many of who live locally and reflect the diverse population of our local communities and are frontline NHS staff who know all too well the importance of good partnership working.

I hosted one of the open forums for the trust where the local residents had an opportunity to say what they felt should be the trust’s priorities. Working in partnership with local communities and improving the quality of care came out as key themes.

This is not surprising. In Brent, our communities experience significant health inequalities when compared with regional and national levels. Local councils like Brent can only provide so much support to address these issues, so we must work with NHS partners to combat health inequalities right across our health and social care system. Indeed, we are now seeing an increased trust present at place-based and neighbourhood meetings.

One of the biggest challenges facing LNWH is the level of emergency activity. As a local council, we must work collaboratively to address systemic issues like this that the trust cannot resolve alone. Indeed, the emergency pathway is a key touchpoint for the most deprived people in Brent and partnership working presents us with a real opportunity to connect them earlier with more appropriate support in the community.

The trust’s discharge processes are perhaps the most reliant on partnership working — the NHS isn’t just its hospitals. It’s vital that we work collaboratively across organisations — the rest of the local NHS like GPs, district nursing, mental health and social care — to help the trust improve the flow of patients through its hospitals.

LNWH has called its new five-year strategy ‘Our Way Forward’. It sets out a welcome commitment to local authorities, communities, and people. We must take joint responsibility for Our Way Forward, because by working together we will forge a far better health outcomes for our residents than we can alone.

Cllr Ketan Sheth is Chair of North West London Join Health Scrutiny Committee

Mission Possible? 

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Jason Lowther

With under 700 days to the next UK general election, political parties are busy developing their manifesto documents.  In February, Labour leader Keir Starmer made a major speech laying out his “five missions for a better Britain”.   How do these five missions relate to local government?  And is the turn to “mission driven” government likely to work?

The five missions vary in their level of specificity and challenge.  Securing “the highest sustained growth in the G7, with good jobs and productivity growth in every part of the country…” is a little vague but likely to be difficult, especially given we are currently ranked 6 out of 7 in terms of output per worker.  Mission #2, “make Britain a clean energy superpower”, accelerating the move to zero-carbon electricity from 2035 to 2030, is specific but very challenging.  Mission #3, reform of health and social care and reducing health inequalities, will require a re-focus from secondary (hospital) care to social care and addressing the social determinants of health.  Mission #4 is about community safety, and likely to involve more community policing.  Finally, mission #5 is to “break down the barriers to opportunity at every stage” through reform to the childcare and education systems.

Local government potentially has important roles in each of the five missions.  Local education, skills and economic development functions will be critical to improving productivity.  On energy, Net Zero requires at least a doubling of electricity generation by 2050, from decarbonised sources.  Decarbonisation strategies need to be place-based, taking account of the geography, building types, energy infrastructure, energy demand, resources and urban growth plans.   We’ve recently argued here for the key roles of councils in this area. 

Turning to health and care services, local government clearly has leading roles – including ensuring place-based planning to address the social and behavioural causes of health inequalities.  Analysis by the Liverpool and Lancaster Universities Collaboration for Public Health Research in 2021 concluded: “investment across the whole of local government is needed to level up health including investment in housing, children’s, leisure, cultural, environmental, and planning services”.  Similarly community safety, child care and education are areas where local government could be enabled to have much greater positive impact.

Perhaps as important as the specific “missions” is the approach to governing which the party is proposing.   Labour’s document characterises this as a move from top-down, target-led, short-term, siloed approaches, to government which is more “agile, empowering and catalytic”, working across the public and private sectors, and civil society.  This, it argues, requires organising government around a shared vision, focusing on real world outcomes, concentrating on ends with flexibility and innovation concerning means, devolving decision making from Westminster, increasing accountability including central and local data transparency, and adopting long-term preventative approaches including greater financial certainty for local areas. 

In some ways the idea of mission-driven government echoes the 1990s thinking of Ted Gaebler and David Osborne’s book “reinventing government”, which argued for a more entrepreneurial approach to the delivery of government.  Their work pointed to entrepreneurial companies setting overall missions and goals, and then leaving managers to figure out how best to deliver these – for example, by providing an overall budget for a service rather than detailed line-by-line budgets which disappear if not spent by year end.  The focus on managers rather than considering the perspective of politicians is one of the problems identified in subsequent evaluations of the reinventing government model, together with difficulties in sustaining the approach.

Mission-driven policies addressing ‘grand challenges’ of society are increasingly common, for example in the UN Sustainable Development Goals and various EU policies.  Mazzucato et al recently argued that addressing such challenges requires strategic thinking about: the desired direction of travel, the structure and capacity of public sector organisations, the way in which policy is assessed, and the incentive structure for the private, public (and I would add community) sectors. Labour’s paper makes a start (albeit at a very high level) on thinking through these areas. The litmus test, though, will be in developing the detail and how far this engages with local areas.   

Over the next few months, we will be contributing to the debate on the upcoming party manifestos with some research-informed thoughts on a variety of local government related policy areas.  If you would like to be involved in developing these, please get in touch. 

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: BBC

Integrated Care Boards – a new frontline in localism?

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Jason Lowther

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

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

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

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

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

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

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

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

Picture credit: National Audit Office

Can drama “Help” social care?

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Jason Lowther

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

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

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

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

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

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

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

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

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

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

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

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

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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.

After austerity, comes the reckoning

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Jason Lowther

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

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

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

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

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

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

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

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