Councils would be wise to look west when they draw up their plans to integrate health and social care services. As Jeremy Dunning reports, Herefordshire is already ahead of the game
Last month’s health White Paper has massive implications for joint working between social care and the NHS. The headline outcome will be the abolition in 2013 of primary care trusts, with which councils in England have forged a range of partnerships in recent years. In their place, consortia of GPs will commission most health services, and will become councils’ new partners in the drive to integrate care.
The White Paper has a strong focus on integration, particularly through a new statutory responsibility for councils to join up health and social care locally through new health and well-being boards, and a proposed duty for GP consortia to help them do so.
However, critics have warned that the reforms could upset existing successful joint arrangements, including the removal of shared boundaries that exist between most councils and PCTs in England. Calls have been made to protect existing examples of successful joint working by the chair of the House of Commons’ health select committee, Stephen Dorrell.
One area that has gone far down the road of integration is Herefordshire.
Since 2008, Herefordshire Council and the local PCT, NHS Herefordshire, have had a joint chief executive and a single management team, a single corporate plan and shared targets. They have pooled budgets for learning disabilities, equipment and adaptations and mental health and are developing one for continuing care.
A public sector joint venture is being set up to carry out back office services for the Herefordshire Hospital Trust, the PCT and the council.
Joint working has already reaped dividends in improved outcomes and reduced savings, for instance through a specialist intermediate care service for older people with mental health problems (see case study).
But not only is Herefordshire succeeding to integrate under the current system, but it appears to have laid the foundations to do so under the new system that the White Paper will usher in.
It already has a GP consortium that carries out practice-based commissioning, the initiative introduced by the Labour government under which practices are delegated notional budgets by PCTs to purchase services. The consortium covers the whole county and thus shares the council’s boundaries. GPs are heavily involved in partnership working and sit on a commissioning board similar in character to the health and well-being boards proposed in the White Paper.
“We’re slightly ahead of the game”, says Wendy Fabbro, associate director of integrated commissioning for Herefordshire Council and NHS Herefordshire.
She says: “We already have GPs in a pivotal position. We have a health and social care commissioning board, which is chaired by the chief executive and the chair of the PBC (practice-based GP commissioning consortium).
“We then break the board into six work streams and each of these will have a GP lead commissioner as a co-lead of that group.”
Fabbro concedes there is anxiety elsewhere in England about handing so much commissioning power to GPs and concerns that some councils are not ready to lead on integrating commissioning.
But she says: “We are already working closely with primary care and GPs to look at how they will be commissioning care.”
GPs’ involvement has so far included providing dedicated support to nursing homes in Hereford, while multi-disciplinary teams are being installed in GP practices throughout the county.
Revised care pathways, shifting care to a primary setting for patients with diabetes and deep vein thrombosis have also been implemented as a result of practice-based commissioning.
These arrangements suggest joint working in Herefordshire has a certain future from 2013. However, there is uncertainty for areas that do not have such joint arrangements, as Professor Jon Glasby, an expert on joint working, spells out in his column (see right).
Other councils may well be turning to this county on the England-Wales border for advice in the coming years as they seek to build relationships with GPs and prepare for the radical changes ahead.
Case study: Marjories Shaddock, intermediate care service user, Hereford
Judith Mallett, of Hereford, gained peace of mind after signing up her 86-year-old mother to Herefordshire’s specialist intermediate care service more than nine months ago.
She believes her mother, Marjorie Shaddock, who has vascular dementia, would have been in a nursing home and in a far worse physical and mental state without it.
Shaddock received the service after a prolonged stay in hospital during which her condition deteriorated, says Mallett.
Jointly funded by the council and the primary care trust, it is aimed at helping older people with mental health problems remain in their own homes. People are referred during crisis or on hospital discharge and the council and PCT delivers the service in partnership with domiciliary care provider SureCare Services.
Service users are assessed on how they are coping when at home alone through Just Checking, an assistive technology system that tracks their movements. A care plan focused on reablement is drawn up and delivered by SureCare, while other forms of telecare, such as safe walking technology or exit sensors, are installed to manage specific risks. The service includes a roving night team, whose staff are available between 11pm and 7am to provide support for service users.
The service, set up in 2008, cost £400,000 in its first year but now costs £300,000 a year. But it saves the county an estimated £1.5m-£1.7m a year by reducing admissions to residential and nursing care. Since March this year, the council has been funding 175 placements a month for this client group, down from 232 at the end of 2007.
The care agency continues to provide support for Shaddock and Mallett can still use the Just Checking system as peace of mind to see how her mother is coping.
She says the effect of the system on her mother has been even more important, adding: “Getting her home has meant she’s much happier and is more contented as she has her own things around her.”
Exciting times but questions remain, says professor Jon Glasby
Although much of the commentary on the health White Paper has tended to focus on GP-led commissioning, one of the most exciting sections concerns an increased role for local government, writes Jon Glasby.
There are references to a greater role in tackling health inequalities, promoting public health and facilitating joint working between health and social care.
But there remains a series of questions (and many still remain even after a recent consultation document on the topic).
● Are GPs ready and willing to work in partnership with local government (and vice versa)?
● How strong are the relationships between the two? How easy a partner will the NHS be to work with as it tries to introduce significant changes, make substantial savings and reduce management costs, all at the same time?
● Above all, what practical mechanisms will there be to enable local government to achieve against its new responsibilities?
While the desire to put local democratic processes closer to the heart of the NHS is an important pledge, the corresponding risk is that councils are asked to promote joint working without the power to deliver in practice.
The formal evidence and longstanding experience on working in partnership in health and social care suggest that what doesn’t work (by itself) is structural change. Tempting though they may be, the evidence suggests that structural solutions only give a false impression of change, do not save the money expected and lead to a loss of morale and productivity. In the NHS, moreover, structures shift so often that staff quickly become change-resistant, learning that, if you keep your head down long enough, it might soon go away.
What might work is attention to the “softer” side of partnership working – to relationships, culture, values and staff and service user involvement. It is also important to be clear about the outcomes that joint working is meant to achieve, and White Paper pledges on a more outcomes-focused approach seem helpful here.
With any major reform programme, the risk is that areas like Herefordshire with strong existing relationships and good links with local GPs will hit the ground running and other areas with a less positive history of collaboration will find it significantly more difficult in the short to medium term.
Jon Glasby is professor of health and social care and director of the Health Services Management Centre, University of Birmingham.
This article is published in the 12 August issue of Community Care magazine under the heading Herefordshire has the right mix