The Greater Manchester area has a lower life expectancy and a higher rate of unemployment than the rest of the UK, an increasing and ageing population and 112,000 people who are long term sick and economically inactive. Many of these challenges are not unique, but Greater Manchester (GM) are leading the way in developing truly local solutions, with devolution of funding and planning agreed as early as February 2015.
So, what makes Manchester different from other parts of the health and care system, and what have been the enabling factors that have resulted in the devolution agreement and pace at which change is being delivered.
From discussions during the recent NHS Confederation, NHS Clinical Commissioners, NHS Providers and the Local Government Association visit, it was clear that there were two main enabling factors – relationships that have developed over time and leadership from across the system.
Relationships that have developed over time
The local authorities in Manchester have been working together for over 30 years to plan and deliver council services in a coherent way to the local population. The local health organisations have been working collaboratively for around half that time. The developed nature of these relationships has meant that there is a shared and coherent view of the challenges that the system faces and how these should be addressed, coupled with a high-level of trust between colleagues and organisations. This has allowed the region to develop a single strategic plan - Taking Charge of Health and Social Care which is innovative, all-encompassing and defines a unified approach to transformation.
The developed nature of these relationships has meant that there is a shared and coherent view of the challenges that the system faces and how these should be addressed, coupled with a high-level of trust between colleagues and organisations.
Leadership across the system
A key system principle is subsidiarity, with the appropriate system partners making decisions about the delivery of services within their defined area. To do so, it is essential for leadership, both clinical and operational, to be engaged at all levels right across the system, from those making Greater Manchester-wide decision at GM partnership board level, to local neighbourhoods determining how they can collaborate to improve services for their population. Clinical leadership, and the engagement of the wider clinical community, has enabled the system to move at pace to address defined goals.
It is essential for leadership, both clinical and operational, to be engaged at all levels right across the system.
How does the system work?
The Greater Manchester health and social care partnership, brings together all NHS organisations and councils, primary care providers, NHS England, the Voluntary community and social enterprise (VCSE) sector, Healthwatch, the Greater Manchester Combined Authority, Greater Manchester Police and Greater Manchester Fire and Rescue Service. Delivery of integrated care is via 10 single commissioning functions based on local borough footprints that work across health and social care. Local single hospital services bring together providers of hospital-based services while a series of Local Care Organisations (LCOs) join up local community health services, social care, GP services, mental health services, VCSE services and private sector providers. This streamlining allows for greater clarity of purpose and the removal of duplicative transactional activity.
What is the system trying to do?
- Transform the health and social care system to help more people stay well and take better care of those who are ill.
- Align health and social care system to wider public services such as education, skills, work and housing
- Create a financially balanced and sustainable system
- Ensure that services are clinically safe throughout
The system has five specific aims relating to improving health and care:
- More GM children will reach a good level of development cognitively, socially and emotionally
- Fewer GM babies will have a low birth weight resulting in better outcomes for the baby and less cost to the health system
- More GM families will be economically active and family incomes will increase
- More people will be supported to stay well and live at home for as long as possible
- Fewer will die early from cardio-vascular disease (CVD), cancer and respiratory disease
What does this look like in practice?
Our visit included the opportunity to meet staff at organisations in Tameside and Glossop, who, through the Our Care Together programme, have developed a collective local approach to improving health and care outcomes aligned with the overall Greater Manchester Strategy. This has included the establishment of a single strategic, place-based commissioner across the CCG and Local Authority and an Integrated Care Organisation, using the Foundation Trust licence, which brings together all the service providers in an area.
The former has allowed for the pooling of financial resources to drive system change, including revised models for urgent, intermediate, residential and nursing care delivery, and the roll-out of an innovative approach designed to reduce the pressures on hospital providers - Care at Home. This incorporates improved discharge assessments, linked interventions, for example, with homelessness and housing coordinators to address individuals’ wider identified needs, and health assessments via Skype.
The commissioner and provider have started to work with general practice on a neighbourhood basis thereby planning services for local system rather than along organisation or registered list silos.
Collectively the commissioner and provider have moved towards an outcome based contractual approach and have also started to work with general practice on a neighbourhood basis thereby planning services for local system rather than along organisation or registered list silos.
What has been achieved across GM to date?
The development of effective relationships, leadership and trust across health and care and more widely with other public services and politicians, is not only an enabler for transformation, but also one of the key achievements for the system, and one which elsewhere has proved challenging to deliver.
Perhaps the biggest achievement has been demonstrating that local systems can cope and indeed outperform other areas of the country when responsibilities and budget are devolved to local areas.
For the system, current pressures mean that achieving financial balance continues to be a priority, with a surplus delivered over the last two years. Mental health has been an initial focus of transformation, with reconfiguration of acute and emergency care being developed. Cancer and mental health targets as well as RTT, are being met, but perhaps the biggest achievement has been demonstrating that local systems can cope and indeed outperform other areas of the country when responsibilities and budget are devolved to local areas, and the national supporting framework is removed.
Read our briefing series - Learning from the vanguards.