“There’s not enough community power within ICSs” Donna Hall on NHS reforms

April 12, 2022   By Donna Hall, New Local & Bolton NHS Trust

The NHS is embarking on the biggest reforms of a generation – creating an integrated system that should usher in joined-up care and improved outcomes for patients. As a new paper on local partnerships is published, Prof Donna Hall diagnoses both opportunities and blindspots of the reforms.

There have been countless NHS reorganisations over the years, but this one has the potential to be different.

Everybody touched by health and care will soon be part of the Integrated Care System (ICS). This will include a duty for the NHS, local government and other partners to work together to make sure that care is integrated at the point of delivery, that we share intelligence about people and their families, and work together on prevention. That’s what makes these reforms so important to get right.

My biggest concern is that we use this as an opportunity to really shift power relationships within systems. So rather than it just being about NHS reorganisation, it’s a long-term shift in the power dynamics within localities.

Instead of focusing on who’s on which board and who’s got a seat around the table, the focus should be on prevention

At the moment there’s a preoccupation with governance, which is understandable, because the ICSs are setting themselves up. But ultimately it’s about culture: that’s the thing that we need to shift. Instead of focusing on who’s on which board and who’s got a seat around the table, the focus should be on prevention, how we work with the community and voluntary sector in each local area. And how we can deeply listen to citizens and patients and use their experiences to transform and to integrate more effectively. 

For this to happen, there has got to be willingness from the key leaders in the system. If we just reorganise the deckchairs in the NHS and social care it’s not going to make a significant change. The real change comes with that shifting of power – service design with citizens at the centre, it’s not just us dreaming up new patient pathways.

There’s not enough work being done on community power within ICSs currently. Every ICS has to do a five-year strategy in July. I would say that a key plank of that strategy should be local communities. How are they going to be involved? How are we going to listen to their citizen voice? How are they going to build it into the ICS?

The real change comes with that shifting of power – service design with citizens at the centre, it’s not just us dreaming up new patient pathways.

We need to embed community power within governance structures. So having things like patient assemblies, citizens assemblies and regular involvement panels within an ICS. As well as using patient advocacy liaison services, involving Healthwatch, involving the governors of foundation trusts, etc.

This means building on the routes to ‘patient engagement’ we already have in place and expanding them. Quite often things like patient advisory groups are not entirely representative of the communities they serve; they tend to be made up of older, mostly white people. We need to make sure there’s much more diversity and ensure there are other ways of getting involved rather than going to a meeting – that’s not everyone’s idea of fun. This might mean tapping into neighbourhood and community groups that are already in existence; things like carers’ groups, which are fantastic and are able to articulate where we’re going wrong with health and care from their own family experience.

Of course greater collaboration between councils and the NHS will pose challenges. From sitting on both sides of the fence I’ve seen there’s a danger we can caricature each other. Local government can caricature the NHS as having lots of money, as being quite bureaucratic and top down. The NHS can caricature local government as being disorganised, or not having a common voice. We need to take off our organisational lanyards, and work together as a team, for the people. After all we’re all public servants, we’re all people, we’re all accountable to the people that we serve; to the communities that we serve. It’s about reminding ourselves of that.

I’ve seen there’s a danger that [the NHS and local government] can caricature each other.

I think it’s vital to put some money into prevention as well, so we create systems that can address things like social isolation, loneliness; improve physical activity, improve social connection, improve healthy eating, and address things like mental health issues before they arise.

As Foundation Trusts, we should be funding that, not just relying on the government to form separate funding streams. This is what Bolton NHS Trust is doing at the moment – we are looking at diverting money into social care to help people leave our hospitals. At the moment we have five wards that are full of beds of people who are ready to leave but cannot because the social care system is so underfunded and understaffed.  

we have five wards that are full of beds of people who are ready to leave but cannot because the social care system is so underfunded and understaffed 

The creation of the ICS has been quite unusual for the NHS. It’s not been a set of rules, it’s been guidance. It’s almost a test of the maturity of your local partnership. I was involved in some of the workshops, helping to put the guidance together, and what we said very clearly was, ‘don’t over prescribe’. Don’t make it so heavy on guidance that you squeeze any innovation out of it” We don’t want long, complicated vision documents that don’t make sense to people. And we shouldn’t be asking people, What do you think of this that we’ve already prepared? It would start with: Look, we’ve got a problem. We’ve got a huge rise in demand, we’ve got reducing resources in real terms, we’ve got pressures on the workforce. How can we work differently with you?

The new ICP engagement paper reinforces the vital role of Integrated Care Partnerships, which will sit at the local level within each ICS. In the spirit of flexibility and co-production, the paper does not dictate how each ICP should work, but reflects on conversations across local government and the NHS about the reforms’ expectations and whether they are being met so far.

Key to this is a discussion around the expectation that ICPs will involve local people and communities in their work, particularly in the development of their new integrated care strategies. The paper finds strong support for this, along with questions about quite how this would be done, by whom, and whether bodies like local Healthwatch organisations would be resourced enough to fulfill a greater collaborative role.

What would healthcare under the ICS look like, if these reforms meant a real shift towards collaboration, prevention and community power? There would be fewer handoffs between different bits of the system. More seamless care and support. Patients would be more listened to. There would be more focus on prevention. There would be lots of community activities to take part in, making sure people are not isolated and are keeping themselves physically and mentally well. They would get seen sooner by their GP, and they would get quicker referrals. And there would be better clinical outcomes.

The ICP engagement summary was published on 23 March. It seeks to inform and shape conversations taking place across England, aiding local areas to find the arrangements that suit their populations and circumstances. It forms part of an ongoing process of engaging, listening and supporting which will continue up until the establishment of integrated care partnerships and beyond.

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