social networks.1 Yet the weight of both funding and services continues to .... Adult Social Care Funding: 2014 State of
PLACE-BASED HEALTH A POSITION PAPER
JESSICA STUDDERT AND SARAH STOPFORTH
2
INTRODUCTION Debates about reform of our health and wellbeing systems suffer from a rare combination of action and inertia. There is widespread recognition of the wider determinants of health, as popularised by Sir Michael Marmot, that only 20 per cent of health outcomes result from clinical treatment, with the remaining 80 per cent determined by wider factors such as lifestyle choices, the physical environment and family and social networks.1 Yet the weight of both funding and services continues to be balanced the opposite way: it is overwhelmingly focussed on reaction to illness rather than the promotion of wellness, with only four per cent of health expenditure in England supporting prevention. 2 Recent years have seen no lack of action. There have been two major pieces of health and care legislation, multiple initiatives from the Department of Health and
NHS England, and a compelling case from the social care sector of the demographic timebomb we face. 3 The result of these largely top-down measures and macro analysis has been some change at the local level but so far there has been no systematic shift away from crisis management towards early intervention and prevention. NLGN and Collaborate have come together to chart a new approach, which shifts the starting point of reform from organisations to places. We have convened the Place-Based Health Commission, chaired by Lord Victor Adebowale, which brings together national and local cross-sector leaders. 4 Evidence from our early research finds a thirst for change across sector professionals, but uncovers barriers to achieving it. By starting in places and working upwards, the Commission will generate new insights into the system from the inside out. This will cast light on how professional collaboration, service integration and demand shifts can work in practice.
1 Cited in British Academy (January 2014), ‘If You Could Do One Thing’:
3 See timeline on page six.
Nine Local Actions to Reduce Health Inequalities. 2 NHS England (2013), A Call to Action, available at https://www.england. nhs.uk /wp-content/uploads/2013/07/nhs_belongs.pdf.
4 For full details of the Place-Based Health Commission and
commissioners, see http://www.nlgn.org.uk /public/2015/reimaginingplace-based-health/.
3
WHY NOW? The need for a different approach is borne out by the evidence that an unreformed health and care system is not sustainable. It is largely uncontested that the NHS, established in the mid-twentieth century, faces a series of profound challenges in the twenty-first. Demographic changes mean that people are living longer, often with multiple needs and long-term conditions. Demand pressures are changing with unresolved public health challenges and a lack of community-based care putting more pressure on acute services. This is all underpinned by funding shortages. Although experienced differently, as social care budgets have been cut and health has been relatively protected, both parts of the system face chronic funding black holes. As a result of these pressures, quality and service performance is declining and will only deepen if left unchecked. The NHS is not meeting key targets and is overspending, while the Care Quality Commission has highlighted safety concerns in some hospitals and care homes.5 5 For more details, see King’s Fund (November 2015), Statement by Dame Kate
Barker et al: Commission on the Future of Health and Social Care in England.
DEMOGRAPHIC PRESSURE LIFE EXPECTANCY6
FEMALE MALE
70 66
1948
83 79
2014
POPULATION BY AGE GROUP 7
23%
65+
17.6%
13.8%
5% 0.9% 1974
85+
2.3% 2014
2035
6 See www.ons.gov.uk /ons/rel/social-trends-rd/social...41/health-data.
xls [accessed October 2015]; Office for National Statistics (2015), National Life Tables, United Kingdom, 2012–2014. 7 Office for National Statistics (2012), Population Ageing in the United Kingdom, its Constituent Countries and the European Union.
4 LONG-TERM CONDITIONS 8
EMERGENCY ADMISSIONS
10
5.3m
condition
COSTS
3.6m
15.4m At least one 1.9m long-term Three or more
2018
= £12.5bn
+47%
2.9m
Projected rise
long-term conditions
1997
PER YEAR
2012
FUNDING PRESSURE
2014
DEMAND PRESSURE
FUNDING GAPS BY 2020 11
PUBLIC HEALTH COSTS 9
NHS
OBESITY COSTS
£5bn PER YEAR
SMOKING COSTS
£2.7bn
£22bn PER YEAR
SOCIAL CARE
£4.3bn PER YEAR
PER YEAR
10 House of Commons Committee of Public Accounts (2014), Emergency
8 See https://www.england.nhs.uk /2014/02/25/martin-mcshane-6/
[accessed October 2015]. 9 Department of Health (2015), Policy Paper: Obesity and Healthy Eating; Jeremy Hunt (2015), Personal Responsibility Speech to the LGA.
Admissions to Hospital: Forty-Sixth Report of Session 2013-14. 11 NHS England (2014), Five Year Forward View. This outlined a funding gap of £30 billion per year by 2020 and the Government have since committed £8 billion, bringing the funding gap down to £22 billion; Local Government Association and Association of Directors of Adult Social Services (2014), Adult Social Care Funding: 2014 State of the Nation Report.
5
WEAK CITIZEN ENGAGEMENT In 2014 Collaborate carried out a survey of people’s perceptions of public services. They found that: 12
66% PEOPLE EITHER NOT INTERESTED OR DO NOT HAVE TIME TO WORK WITH PROVIDERS TO IMPROVE PUBLIC SERVICES
24% 16%
PEOPLE BELIEVE PUBLIC SERVICE PROVIDERS UNDERSTAND THEIR NEEDS
FELT ORGANISATIONS REGULARLY OFFER PERSONALISED PUBLIC SERVICES
12 Collaborate (2014), The Collaborative Citizen Report 2014, 2nd Edition.
The urgency for change these demographic, demand and funding pressures create has not been lost on the policy world. Over recent years, successive waves of reforms, pilots and initiatives have been pursued, mostly introduced from the top down. So far they have been largely isolated and taken together their impact has arguably been less than the sum of their parts. They have also not fundamentally addressed the remaining challenge of weak citizen engagement.
TIMELINE TOWARDS PLACE-BASED HEALTH The concept of place-based health is not new and has been developing over recent years. The timeline on page six charts the notable steps on the route to reform taken within different parts of the health, care and wider public service system, including moves towards greater devolution.
6
TIMELINE TOWARDS PLACE-BASED HEALTH COMMUNITY BUDGETS Four ‘whole place’ and ten ‘neighbourhood’ community budget pilots pool funding across agencies to provide more effective joined-up services.
2009
on Funding of Care and Support recommends a cap on lifetime care costs and to increase means-tested support thresholds
2010
TOTAL PLACE 13 pilot areas test new freedoms to co-design public services to reduce costly duplication
COALITION GOVERNMENT
TROUBLED FAMILIES 16 local authority area pilots join up services for families with complex needs, rolled out in 2013
VANGUARD SITES
BETTER CARE FUND
DILNOT COMMISSION
A single budget totalling £3.8bn nationally pooled locally between NHS and local government to develop integrated working HEALTH AND
SOCIAL CARE ACT 2012
NHS England’s future vision warns of a £30bn annual funding gap by 2020, argues for radical upgrade in prevention and public health and reform based on specified care delivery options
Legislation creates clinical commissioning groups, health and wellbeing boards and transfers public health responsibility to local government
2011
2012
FIVE YEAR FORWARD VIEW
2014
2013
CITY DEALS
CARE ACTDEALS 2014 CITY
Between cities and central government in two waves to give greater powers and freedom around economic growth
Legislation creates new duties on local authorities to promote wellbeing, prevent care needs and integrate support with health services
INTEGRATED CARE PIONEERS 14 pilot sites chosen to develop innovative ways to deliver person-centred, co-ordinated care and support
50 sites chosen in three phases to lead development of new care models
DEVOLUTION DEALS Devolution of health budgets announced to Greater Manchester (£6bn) and Cornwall (£2bn)
CONSERVATIVE GOVERNMENT Manifesto commits to £8bn funding increase to NHS by 2020
2015 THE LONDON AGREEMENT Five new integrated care pilots
SPENDING REVIEW
Commits to investment and efficiency savings in the NHS, full integration with social care by 2020 and a 2% social care levy on council tax
7
Despite these measures, progress towards actually delivering a whole system transition towards prevention has been slow. There are several reasons for this. One is the difficulty of moving money out of hard-pressed acute services. Another is the difficulty of driving collaboration between different public service agencies. Yet another is the remaining need cited by some for watertight evidence that prevention drives savings as well as improved health outcomes. There are many reasons not to act but we reject them all. It is obvious to us that a system which prioritises prevention and coordination will provide better health outcomes for people over the longer term than one which does not. The need for change will become even more critical over the coming months and years ahead. Reforms in specific parts of the system are likely to take effect within narrow parameters. The Five Year Forward View assumes ownership for those who currently run the system. The Vanguard pilots are developing new care models in specific sites. And wholesale devolution of the health and care budget in Greater Manchester and Cornwall involves the renegotiation of relationships across both sectors within these localities.
There is a risk emerging that these separate and ambitious initiatives can’t hold the weight of what is expected of them. The wider system will not be transformed until a clear understanding of the ingredients of success emerges from the morass of initiatives. If we accept, as the complex policy landscape implies, that reform will happen in different ways in different places, how can we be sure what the common building blocks of a new system should be? Where innovation succeeds, how can this be scaled or replicated in a way that is sympathetic to local difference but does not start with a blank sheet each time? In this context, the Place-Based Health Commission must cut through the complexity and draw out some clear priorities for the future.
8
WHY PLACE-BASED HEALTH? Taking the starting point of place enables us to go to areas working within the current system boundaries and pursuing the reforms already enacted by central government. Using the lens of place will enable the Commission to interrogate what is happening as a consequence of these changes. Why are some Health and Wellbeing Boards strong and others weak? Why has the Better Care Fund been grasped in some places and side-lined in others? On a deeper level, the Commission will be able to draw out more fundamental conclusions about how transformation can be catalysed at a faster pace and on a greater scale than has been realised to date. By reimagining health as place-based, we seek a system that opens out the definition of health from clinical care to one that encompasses wider determinants. How can the services and resources that already exist in places be better aligned and utilised to contribute to better and more equal outcomes for people? Our framework for place-based health sets out a system which takes an asset-based approach,
focussing on shaping demands in the longer term and ultimately producing better health and wellbeing outcomes. Place-based health would mean reconceptualising ‘health’ from something that happens primarily within institutions, to involve all local assets and stakeholders in a shift towards something that all parts of the community, and individuals themselves, recognise and feel part of. This would mean the individual would move from being a recipient of interventions from separate institutions to being at the heart of place-based health: CURRENT SYSTEM
DEPARTMENT OF HEALTH
NHS
DEPARTMENT OF COMMUNITIES & LOCAL GOVERNMENT
PUBLIC HEALTH
PERSON
SOCIAL CARE
9
CE NT
PLACE-BASED HEALTH
NMENT VER O LG RA
NH S
AL GOVERNMENT LOC
CO M M U N
PERSON
IT Y L
OC
AL
BU
SIN E
SS
VC
S
P L AC E By definition, place-based health would mean different things to different people and places. There are certain core features of the current system which we identify as needing to move away from in a place-based health approach:
CURRENT SYSTEM
PLACE-BASED HEALTH
Closed
Open
Separate service silos
Whole system approach
Vertical top-down model
Horizontal model across places
Institution-led
Person-centred
Largely reactive
Largely preventative
Focussed on treating illhealth
Focussed on promoting wellbeing
Health in a clinical setting
Wider determinants of health in communities
Services “done to” citizens
Balance of rights and responsibilities
There is compelling international evidence that reforms built upwards and outwards from places can create system shifts from institutions to people (see Annex for details). NLGN and Collaborate’s own early evidence demonstrates that there is an appetite for such a shift amongst health, local government and other stakeholders involved in health and social care provision.
10
INSIGHTS FROM OUR EARLY RESEARCH NLGN and Collaborate carried out original research, surveying professionals in the health and care sectors and beyond about their perceptions of the challenges and opportunities involved in moving towards placebased health.13 Our findings help frame the challenge for the Commission in identifying the barriers to making reform work in practice. Our research uncovered evidence of a shared vision in principle amongst professionals for place-based health, but a degree of disconnect between this and how citizens themselves are engaged in their health. Across all sectors, we found echoes of the shape of a place-based health approach:
13 The survey was sent out to health professionals, local government
officers, and a cross-section of the private and third sectors and was in field for four weeks in June 2015. There were 231 respondents, of which 45.5 per cent were from local authorities, 29.4 per cent were from the private and third sectors (mostly charities), and 25.1 per cent were from the health sector.
“People taking responsibility and understanding what they can do to help themselves […] and increasing models for supporting people to stay at home” Local authority commissioner “Stronger emphasis on people taking responsibility for their own health and wellbeing, advice and information readily available early on” Head of adult social care “Care closer to home provided in a coordinated way by a wide range of partners who are connected and responsive. A population that is educated and informed about self-care, self-management and preventative approaches to health. A health and care system that is less complex, better organised and responsive to citizen needs” Deputy chair of a CCG “More care in the community provided in a seamless manner (no organisational boundaries) giving greater selfcare for the patient” Chair of an NHS trust “Self-managed conditions with the help of technology, personalised health pathways, health professionals out and about in the community engaging with community groups [and] more interdependence between professionals and citizens” Charity worker
11 At the heart of place-based health is an implicit, mutually beneficial pact between the rights and responsibilities of both institutions and people. Institutions will collaborate across the whole system to provide simple, accessible personcentred support and care. In return, people will take greater responsibility for their own health, by making healthier lifestyle choices and self-managing conditions to a greater degree. Perceptions of organisations being 'very engaged' or 'fairly engaged' in early intervention and prevention
FROM PATIENTS TO COLLABORATORS: if the end-goal of place-based health is a person-centred system then we need to make sure people are engaged and able to take a lead on their health. How can people collaborate with professionals to improve their own health outcomes? We asked the professionals to identify the main barriers to implementing early intervention and prevention from their organisational perspective, and the findings suggest core areas of focus for the Commission.
78.1% 72.6%
72.6%
What is the top challenge to implementing early intervention and prevention initiatives in your area? (n=136)
62.3%
43.4% CCGS
LOCAL AUTHORITY
HEALTH AND WELLBEING BOARD
50%
VOLUNTARY AND COMMUNITY SECTOR
LACK OF STRONG SYSTEMS LEADERSHIP AND VISION ACROSS SECTORS
COMMUNITY GROUPS
NHS ENGLAND
32.4%
15.8% 8.2% LOCAL BUSINESSES
GENERAL PUBLIC
Yet our research found that professionals believe the general public are one of the groups least engaged in early intervention and prevention. Only 16 per cent of respondents thought that the general public were ‘very’ or ‘fairly’ engaged.
INSUFFICIENT FUNDING/RESOURCES TO COVER UP FRONT COSTS
LACK OF ORGANISATIONAL WILL WITHIN THE NHS
INSUFFICIENT EVIDENCE OF DELIVERING COST SAVINGS DOWNSTREAM LACK OF 5.9% FINANCIAL INCENTIVES FROM CENTRAL GOVERNMENT
10.3%
9.6%
19.1%
12 The biggest barrier identified was the lack of strong systems leadership and vision across sectors. Although we found the components of a shared vision in principle, there remains in practice a perception of disconnect between the different sectors, with different expertise, structures and accountabilities. The fragility of relationships across organisational boundaries was highlighted by the third perceived barrier of lack of organisational will in the NHS, and was elaborated upon in some of the written responses:
to the opportunities presented by the devolution of health budgets. Health sector representatives were significantly more sceptical of the benefits than were local government and other stakeholders. Would the devolution of health budgets benefit the early intervention and prevention agenda in your locality? 55% 47%
54% 48%
45%
43%
“Health are more forward-thinking […] and more proactive than local authorities” Healthcare provider
41% 31%
“NHS tend to look upward not outward” Local authority representative
15% 11%
8%
“Clinicians are good at science, evidence and uncertainty whereas local government are good at engaging wider groups of people and making difficult decisions about resources” Local authority representative “Health are a lot more closed than local government” Charity chief executive This mutual disconnect between perceptions of value across sectors is further highlighted by different attitudes
2%
ALL YES
LA NO
HEALTH
OTHER
NOT SURE
Amongst those who were enthusiastic about the benefits of devolved health budgets, survey respondents suggested that it would provide an incentive to develop new models of services, enable freedom to innovate and ensure local democratic accountability. Amongst those
13 who were ‘not sure’ about the benefits of devolution, issues highlighted included a lack of evidence of success with a high potential of risk, that we are yet to see an outcome from existing devolved measures, and that it would be dependent on where decision-making powers lie, especially who holds the budget.
FROM ORGANISATIONS TO PLACES: if placebased health involves people working beyond organisational boundaries then we need to ensure the shared vision, which might exist in principle, becomes practice. Where does effective systems leadership come from? The second biggest barrier identified in our survey revealed a belief that there are insufficient resources or funding to cover upfront costs. This perception of the relative safety of the status quo compared to the risks associated with change is supported by the fourth and fifth barriers identified, which related to insufficient evidence of cost savings downstream and lack of financial incentives to implement reform. These findings indicate that despite the macro analysis of the demand gaps widening and service quality declining, there remains a reluctance amongst professionals to take a leap into the relative unknown.
It stands to reason that operating within significant financial restraints reduces the scope for experimental autonomy required to innovate and risk potential failure. But the tight focus on the bottom line within one service can produce cost consequences within other services, as costly demand is shunted around rather than sustainably reduced overall. So efficiency within one service can create inefficiencies within others. We see this through the consequences of inadequate social care provision creating greater pressures on hospitals through A&E admissions and delayed discharges.
FROM SUPPLY TO DEMAND: if place-based health means a sustainable shift away from reaction and towards prevention then we will need to better understand and manage community demand. How can we take an asset-based approach to using existing resources more effectively?14 These challenges are at once structural and individual; institutional and cultural; focussed on the present and into the future. The Commission will need to take a fresh look at deep and persistent problems in the system.
14 For more details, see http://www.hsj.co.uk /comment/new-care-
models-to-keep-up-the-nhs-must-shift-focus-in-three-ways/5089505. article [accessed November 2015].
14
THE PLACE-BASED HEALTH COMMISSION
The evidence gathered will be relayed back to key stakeholders and tested in each of the four areas through brokerage events. This is a way of understanding what the constraints are and where potential might lie to build a system of place-based health around the individual.
The Place-Based Health Commission’s inquiry will examine different models in different places. Evidence gathering sessions have been undertaken in four locations with a cross-section of stakeholders involved in place-based health participating. The four areas reflect different population-level needs, different types of geography and different approaches to achieve better outcomes. These are:
This unique methodology will enable the Commission to explore innovation in particular areas and draw out common themes relating to opportunities for - and barriers to - change. Based on the insights from NLGN and Collaborate’s early research findings, the core questions which are guiding the evidence-gathering phase of the Commission’s inquiry are:
BIRMINGHAM: collaboration across care pathways. SUFFOLK: co-location of health and wellbeing services and integrated care organisations. SUNDERLAND: using customer insight as a route to behaviour change. SUTTON: community resilience and wider social action for health.
How can we put the individual at the heart of a place-based health system?
Who or what should lead the shift towards place-based health and what skills or powers do they need to do so?
How should funding, regulation and performance management systems for key institutions in a place be altered to support the development of place-based health?
How can we create convincing evidence of the benefits of place-based and preventative health fast
15 enough to enable a rapid transition? What evidence exists already and is more needed to catalyse change?
PLACE
Can we create more collaboration between local authority and health players, and between commissioners and providers? How do we overcome the cultural and institutional barriers to this?
SYSTEM
PERSON These findings will inform the Place-Based Health Commission’s final report, to be launched in spring 2016. This will set out a series of recommendations which will resonate at an individual, local and national level. These will be geared towards shifting from strategy to action by setting out how the shared vision of place-based health in principle can be widely adopted in practice.
16
ANNEX: CASE STUDIES The demographic and financial challenges our healthcare system faces are similar to demand pressures faced in all advanced countries. We can draw lessons from international innovations where reform has sought to shift local systems to refocus resources away from acute settings and closer to people in their homes and communities. This is a snapshot of different ways place-based health has been initiated nationally and regionally: the scaling up of a successful pilot in Denmark, replication of pilots in the Netherlands or the complete redesign of services as in Sweden or Valencia in Spain. The incentives to innovate differ in different areas and countries, with a distinction between places with top-down policy change and grassroots based, bottom-up change.
SCALING UP OF A PILOT LONG-TERM CARE IN DENMARK Denmark has blazed the trail in terms of integrated community care for elderly and frail people, stemming back to a Commission on the Elderly held in the 1980s. The Skaevinge project (named for a town in Eastern Denmark) was piloted in 1984 and ran for 25 years as an innovative integrated care model. It formed the foundation of longterm care in Denmark. The pilot focused on preventative systems and self-care for elderly patients and addressed the gaps between nursing homes and home care services by integrating the services. To reduce the stigma attached, nursing homes were re-branded through a change in the law to become ‘housing for older people’ and the first 24 hour home care service was established. Older people were helped to live independently for as long as possible using their own resources whilst nursing staff were on hand and responsible for treatment, care and supervision. Monetarily, this integrated care model has been successful in decreasing service expenditure despite an increase in the elderly population.
17
REPLICATING A PILOT BUURTZORG IN THE NETHERL ANDS
REDESIGNING SERVICES THE ESTHER PROJECT IN SWEDEN
Buurtzorg (literally translated as “Neighbourhood Care”) was an initiative that begin with a group of four nurses in the Netherlands. Founded in 2006, they are committed to implementing person-centred care in the healthcare system, joining up health and social care to provide better quality services to promote individuals’ independence for longer. Teams integrate professional nurses, primary carers, the individual and their family to provide care and support packages tailored to their individual needs and, crucially, within their own homes. The Buurtzorg nurse acts as the single point of contact for the patient to most effectively provide wraparound care. Although this results in higher costs per hour because of the intensive work undertaken by the nurses, it also results in lower numbers of hours in total.
Jönköping County Council is an elected regional health authority serving 340,000 in southern Sweden. It plans, funds and provides health services for this population, working in partnership with local government in the county’s municipalities. It has considerable autonomy and tax-raising powers. The council initiated the Esther project, where staff and clinical teams were brought together to think about delivering best outcomes for a fictional elderly resident and to redesign services and systems around her.
An Ernst and Young evaluation found that the model created 40 per cent savings to the Dutch healthcare system. The Buurtzorg model has been taken all over the world and as of 2014 there were over 8000 nurses working with Buurtzorg in several different countries: the Netherlands, Sweden, Japan and the USA.
This has had the positive impact of a 20 per cent reduction in hospital admissions, a redeployment of resources to the community, a reduced length of stay for patients with heart failure and reduced waiting times to see specialists.
18
REDESIGNING SERVICES THE ALZIRA MODEL IN SPAIN The Alzira model is one of vertical integration of primary and secondary care providers which was first piloted in the Alzira region in Valencia, and has since been scaled up and replicated across the regions of Valencia and Madrid. Local government is the commissioner and there is one provider. It receives funding per resident from the local authority for the provision of universal primary care, acute and specialised health services, all free at the point of use. Data and record sharing, including a unified IT system, across primary and secondary care is crucial to the success of this vertical integration. The model is based on four principles: public ownership, public control, public financing and private management. It has proven positive outcomes of reduced emergency admissions and re-admissions to hospital and increased patient satisfaction compared with other healthcare providers.
NLGN
THE PL ACE-BASED HEALTH COMMISSION
New Local Government Network (NLGN) is an independent think tank that seeks to transform public services, revitalise local political leadership and empower local communities.
Our current model of healthcare is broken. Without radical change we will not prevent the kinds of lifestyle diseases and deal with the demographic challenges that are putting the health and social care system under so much pressure.
COLL ABORATE Collaborate is an independent social business supporting cross sector collaboration in services to the public.
NLGN and Collaborate launched the commission to imagine the future of place-based health. Chaired by Lord Victor Adebowale, the Commission will tackle the most challenging questions facing both the NHS and local councils today as they struggle with rising demand, reducing budgets and the changing demographics of their service users. Supported by:
*The Commission is supported by a funding grant from Abbvie.
