Could one trust’s health and local government service integration be a model for the rest of the country to follow? Dr Chris Clayton reports on the successful pilot at Blackburn with Darwen PCT.
The debate rages about the impact the government’s health reforms will have on the NHS and how councils will adapt to their new roles in managing public health. But a handful of areas across the UK have been pioneering a radical way forward that may just provide the answer to how the NHS will integrate health and social care commissioning and manage the transition of public health into local government.
Many people’s view of healthcare is skewed. They see it as a success if they are admitted to hospital for treatment; rarely do they question the reasons why they ended up in hospital in the first place and whether the NHS and its partners might have better invested their scarce resources to act on the causes.
Our traditional approach to improving health in communities has been to allow unhealthy social, political and economic systems to generate ill health, then to seek to “buy back” lost health through expensive hospital treatment.
In its new local government role, public health will be central to mobilising both NHS and non-health sector investment against shared aspirations for health improvement. However, unless we also get to grips with the complex issue of health commissioning, the opportunities for transformational changes in health outcomes will be missed.
Locally integrated public services developing a “single public sector offer” with secondary and primary care, and aligned with “health relevant” local government services, are the only way we will effectively improve health outcomes and ensure efficiency by better integrated public service delivery.
Better value care
In Blackburn with Darwen this approach is already reaping rewards. For a range of well documented reasons, we have a high number of admissions to residential care and high usage of hospital emergency care services. This does not make the best possible use of available out of hours community-based health and social care services – the costs to local health and social care are high and some services could be better utilised.
A pilot project between the council, independent sector and care trust plus provides the links to integrate all out of hours services, giving the public a single point of access, without undue dependence on the North West Ambulance Service Trust, the emergency department or admittance to residential care. Services brought together for the purposes of the scheme include:
- out of hours social care duty team;
- district nursing and twilight nursing team;
- out of hours primary care service;
- social care staff delivering crisis care in the community;
- social care staff providing on-call cover in sheltered housing schemes in the borough;
- third sector organisations.
An integrated working steering group has been established, which has input from colleagues from the council, care trust plus and GPs, and will link closely with accident and emergency and the out of hours GP service. The aim is to cut emergency admissions to hospital and care homes.
As well as saving time and money the integrated approach offers us a once in a lifetime opportunity to tackle the health costs of environmental problems such as poor housing. Cold and damp housing can reduce mobility leading to an increased risk of falls; exacerbate chronic conditions such as asthma, chronic obstructive pulmonary disease and circulatory conditions; and lead to impaired mental health. Fuel poverty is now a well established human health risk and there is a large body of evidence showing that it is a primary contributor to morbidity and health inequalities that can be avoided if preventive measures are taken to improve the quality of people’s homes.
Blackburn with Darwen has some of the poorest housing stock in Britain and, while improvements have been seen in the condition of social housing, a third of owner-occupied and half of all private rented properties remain poor, with resultant hazards to health. Through our links with the local authority we have been able to invest in existing local authority housing support via the Decent and Safe Homes Service so, although the council will tackle the issue of poor housing through selective licensing schemes – ensuring landlords fulfil their obligations to their tenants – the NHS will have health professionals working with council staff to offer tenants physical and mental health support.
A common aim
This work is supported by a shared database and referral process removing any silos. The long term ambition is to create an integrated network of professional teams that all have the same objective – to improve the health and wellbeing of families in the borough.
Our “think family” approach has meant we have had to remove barriers that 10 years ago would have been impossible. It has required a wholesale cultural change to move from traditional commissioning models to a family approach but the result is greater service coherence as well as improved outcomes on intractable problems such as obesity. North West public health observatory statistics highlighted that schoolchildren in the borough are less overweight than their regional counterparts, despite being at higher risk.
Through our Get Our Active Lifestyles Started (GOALS) weight management programme, families attended weekly evening sessions at a high school for 18 weeks and took part in food and goal setting activities, as well as practical physical ones. The pilot evaluation showed all seven overweight children reduced their body mass index, and four out of five parents/carers reduced their BMI by the end of the programme.
We have helped children who would have, without us, become obese and would suffer in later life from all the health and social problems associated with being overweight. The challenge is to replicate this work across the whole borough – which is only possible through an integrated approach between the NHS and the council. Integration allows us to be effective in tackling the problem, avoiding duplication and saving money.
The health reforms risk creating a change in the public’s psyche as people may think their local GP can pull all the strings when it comes to healthcare provision. To ensure GPs are not constrained they must be able to get support from the NHS and local government. An integrated CCG – or iCCG as it is known in Blackburn with Darwen – offers the greatest opportunity to fulfil these demands.
GPs do have an excellent understanding of what is required to help the patient in front of them, including the wider social determinants of health. The iCCG model offers emerging CCGs a solution that not only opens up NHS services but also allows the CCG to directly influence a local authority’s policies and decisions.
This is about creating an organisation that can coordinate commissioning on behalf of the individual and that links the CCG, NHS Commissioning Board and the local authority as it strives to get the best available level of healthcare. Furthermore, crucially, it would maintain integration of management and back office functions, which could provide the basis of support for CCGs and avoid disruption and additional costs.
We suggest the government allows us to continue this work and analyses the results over the course of this parliament. We are confident this solution will convince everyone it offers the most sensible and effective approach towards integrated healthcare commissioning.