If I look at the long term plan through the lens of the West Yorkshire and Harrogate integrated care system, there are significant opportunities around enhancing community services to ensure that they are the bedrock of future health and care. Most STPs or ICSs have the same ambitions for the future – joining up primary, community, mental health and social care services, with populations of around 50,000. The fact that this is now embedded in the primary care contract is the biggest opportunity and the biggest risk that we face.
Opportunities and risks
Things look different in community services because we start in a different place. Most of the people we look after have got one or more long-term conditions, of which they’ll never be cured. Being older or having a special educational need or having chronic obstructive pulmonary disease, asthma, diabetes, dementia, means we’re going to be a partner in your care for the rest of your life. That means we start with the person and we deliver a team around the person. This plays out in the way that we structure community services in our neighbourhoods. Community services are increasingly part of an integrated neighbourhood team. That team includes social workers, community nurses, occupational therapists, speech and language therapists, social care staff and GPs – all with a tailored offer which involves the patient and their carers as partners in delivery. That’s a very different ethos from what we’ve had in the past. I think across the whole country people are embracing joined up teams across sectors in the neighbourhood.
Things look different in community services because we start in a different place. Most of the people we look after have got one or more long-term conditions, of which they’ll never be cured.
Investment in community services has suffered over recent years because of differences between the payment systems in use. Commissioners have had to pay for a tariff-based, activity-based system in the hospital sector. Once they’ve worked out what that leaves in terms of risk, they’ve been able to invest very little in real terms in community and primary care services. So the balance of investment and growth hasn’t been in favour of community services. Routing guaranteed money through an investment through primary care contracts, and having additional resources within ICSs, means there’s an opportunity to invest in the sector. It is a big opportunity to look at the mental, physical and social needs of people. This in turn will help to deliver better outcomes for people and reduce care variation.
However, there are risks for community services though the long term plan. We have been working to exploit one of the biggest potential benefits in our health and care system compared with every other country – that we have list-based general practice. General practice has a relationship with just about every member of the community and great data. What we’ve been working on for the last couple of years in West Yorkshire and Harrogate is to use that list base and population of 50,000 to develop integrated neighbourhood teams and services.
The big risk is money going straight to general practices could undermine some of that progress. People could start to look at the practice as a unit, not at that population of about 50,000, and there could be a risk of money not flowing appropriately.
There’s also a risk around staffing – we need a future workforce which is going to be sustainable, rather than just poaching staff of each other. Not having a settlement for social care or local government that’s workable in our more economically-challenged places will be a problem, with other sectors being under the cosh while the NHS looks a bit more cash rich.
Investment in community services has suffered over recent years because of differences between the payment systems in use.
A focus on places, not structures
In West Yorkshire and Harrogate, we’ve got six different 'places', each of which has a different history, different relationships, different geography and different partner services. The approach we’ve taken is to always keep the energy in the places. We’ve got 50 neighbourhoods of 50,000 people with integrated primary and community services. They come together in seven partnerships to deliver the vast majority of care in our places, commissioned by six joint commissioners – councils and the NHS – and supported by an association of acute trusts that works to deliver all the hospital care. There is also a joint committee of mental health providers who deliver all the specialist mental care.
It’s a different way of working. We start with the services, and with what service offer we want to build around the population, recognising that one in four people has a long-term condition, the majority of emergency admissions to hospital are for older people and a significant proportion have five or more long-term conditions. We’ve got to change the model – national solutions will not work – you’ve got to have a local approach where people decide what’s right for them.
We’ve got to change the model – national solutions will not work – you’ve got to have a local approach where people decide what’s right for them.
Tackling health inequalities from a community perspective
We know some populations get a bad deal. if you’re a man in West Yorkshire and Harrogate and you’ve been in touch with secondary mental health services, you will die 18.6 years sooner on average. If you have a learning disability, you might die between 14-20 years sooner – a learning disability is not a health condition. If you live in a poorer part of society, you will have a shorter, unhealthier life. We know these things – what we need are models of primary and community services that can work with these populations differently.
In the secondary prevention area, we know poorer people are more likely to smoke, to drink, to have mental health issues and long-term conditions, and are less likely to access services. We’re looking at how to change that by having better models that people can access more easily. Secondary prevention work around people who we already know have an issue will reduce health inequalities. Beyond that, there is a primary prevention agenda about community resilience and the dividend we get from having community-based services.
A simplified commissioning approach
My direct experience as a mental health and community trust chief executive is that we’ve had the most competition and the most tendering to deal with. If you provide services in the community, you have constant tendering and competition. That is energy-sapping, takes up a lot of capacity and leads to fragmentation of services in my view, and that’s where we’ve ended up. What I think will happen, and what’s started happening, is that commissioners will simplify a set of arrangements which provide a uniform offer at certain points. This will include intensive home-based treatment and crisis services in mental health, specialist community teams operating as an interface between home and hospital and effective urgent care teams that focus on delivering care at the point of need.
If you provide services in the community, you have constant tendering and competition. That is energy-sapping, takes up a lot of capacity and leads to fragmentation of services in my view, and that’s where we’ve ended up.
This means a simplified offer in community with consistent standards which focus on outcomes and providers working in partnerships of GP federations and the community providers, working together to deliver simpler, better, more effective, joined-up care. That’s got to be better than what we’ve got at the moment. In West Yorkshire and Harrogate, five out of six systems have aligned incentive contracts with their acute trusts which manage risk. We can build on this approach and have a contract with a focus on outcomes, population-based and with some degree of risk in it – a cap and collar, some fixed costs, some variable costs, a quality premium. You can use a lead provider arrangement, an alliance arrangement or a single contractual arrangement, but that will be horses for courses, I think. You work in partnership to deliver outcomes. Ultimately that is about relationships as much as contracts.