Government and NHS integration in Richmond upon Thames

London Borough of Richmond upon Thames and the CCG are moving jointly towards an integrated outcomes-based adult community health and social care service. This aspiration now also includes mental health services and early thinking has started for children’s services.The accountability to residents and service users is the explicit driver for partners and integration is a means to achieving the outcomes that Richmond people say matter to them most. The concept of place plays an important role for integrated services, a significant number of which are based around community localities. These localities are not always congruent across the health and care sectors, but being able to work with the ‘messy reality’ is an important part of integration.

How public health became involved

Public health has been treated as a senior partner in the council and the skills that public health specialists bring to the integration agenda are highly valued. The public health team is part of adult community services: DPH reports to the director of adult services but also has a seat at the council’s executive table.

It was timely that when public health became a function of the local authority, Richmond upon Thames Council had made a decision to become a more systematic commissioning organisation.

This meant that the intelligence skills of the public health team were immediately useful, assisting in turning a procurement-driven system into one driven more by outcomes; for example a re-tendering exercise for an integrated drugs and alcohol service acted as a learning exercise in moving away from a medical treatment model to a recovery model. This model involves not only the NHS and social services, but is also linked to education and employment and the relevant agencies, with which the council already had links.

Public health contribution to integration

What others say – Councillor David Marlow, Cabinet Lead for Health and Social Care:

Richmond residents tell us they want ‘joinedup’ health and social care services; that is why the council is clear on its priority for health and social care integration. Our public health team has played an important role in supporting our HWB in the development of our borough strategy for health and wellbeing, and in championing integration. Work of our public health team has included: working with older people to better understand and tackle loneliness and isolation; work with carers to inform our needs assessment and increase support for carers across the whole health and care system; and setting up a vibrant Dementia Action Alliance (DAA) which brings together a wide variety of local organisations working together to make Richmond a dementia friendly borough.

Strategic leadership

Public health, adult services and Richmond CCG are co-located in the council offices on the same floor. The DPH and her staff are seen as honest brokers between local government and the NHS. Along with the chief officer of the CCG, the director of adult services and the director of children’s services, the DPH is a member of the strategic partnership group where potential areas for integrating services are first broached. The local NHS and the council have established a number of other important joint groups that bring together senior officers from each to ensure that integration becomes ‘hard wired’ into how business is done. The DPH and her team act as a conduit within and between all these groups.

One of the first actions of the public health team was to demonstrate how data and statistics could be turned into intelligence about the whole population of Richmond. The first JSNA and Joint Health and Wellbeing Strategy (JHWS) identified a number of ‘cracks’ in the system that mattered most to local people, specifically between:

• health and social care – multiple points of access and care assessments, lack of care coordination sometimes leading to increased costs, confusion about social care and NHS funding arrangements and eligibility
• services for mental and physical health – co-morbidity
• children’s to adult services transition
• the transition between hospital and home – the need for greater collaboration between the local NHS and the council on managing care for people with long-term conditions in a community setting.

Each of these priorities requires more integrated services. Key outcomes which the partners, including public health, have developed are:

• an integrated health and social care commissioning strategy
• a joint collaborative commissioning team for health and social care
• reconfiguration of services into a local outcomes-based model of care that includes primary care, community care, some social care and links to hospital services.

The JHWS is now being refreshed. Joined up services continue to be one of the major planks, but in addition there is a wider remit that also explicitly adds in prevention. Both are adopted across the life course around the three themes of ‘starting well,’ ‘living well’ and ‘ageing well,’ with integration the golden thread.

Representatives of public health were also key partners round the table in planning and developing Richmond’s use of the BCF. In particular, public health provided intelligence about the population and its health and care needs, current performance, metrics and performance management tools and identified high-impact interventions for which the BCF could be used. Public health specialists continue to lead on the metrics and monitoring aspects of the BCF. A review of the BCF has been scheduled and the public health team will be involved in considering how children’s services can be included and how the BCF can take account of the wider prevention agenda while freeing up partners from some of the complex administrative demands that attended its first year.

What others say – Cathy Kerr, Director of Adult Services Public health colleagues helped us define the problem and focus on clear definitions and evidence. For example, they helped us look very closely at precisely which hospital admissions are avoidable, why and what can be done to avoid them. We will also be involving them in Richmond Response and Recovery, our programme for effective discharge from hospital. They will look at the numbers of people who need support on discharge, what is the evidence of effective interventions and what outcomes we should aim for. 18 Public health’s role in local government and NHS integration They will take a granular look at ‘softer’ outcomes, such as patients’ and service users’ perceptions and how we can capture these and use them to measure our performance. Evidence, outcomes and evaluation The strategic partners involved in developing integrated services in Richmond are all committed to the idea of integration as ‘a marker of people’s experience’ of services and the extent to which they are perceived as seamless and centred on the way they want to live their lives. The public health team has contributed valuable expertise to developing an outcomes-based approach to integration which focuses closely on community services. What others say – Kathryn Magson, Chief Officer, Richmond CCG Our DPH provides an overall perspective on outcomes-based commissioning. She has been heavily involved in the design of all our outcomes, in relation to both physical and mental health. She has helped us to focus not just on shifting care into the community, but also on including the prevention agenda – bringing prevention closer to home. Public health colleagues bring more than just content, (ie their specialist knowledge) they also bring discipline and rigour to the planning and commissioning process. The outcomes-based approach began with a really intensive piece of community engagement to find out what the outcomes are that people want. This has brought all the partners together and helped develop clear objectives for a new integrated (seven to 10 year) contract for adult out of hospital health and social care services to be let in April 2016. Further work is under way to develop an outcomes framework for mental health community services and it is intended that this will also be in place by April 2017. The community engagement exercise made it clear that a place-based approach should be taken to services. The council has developed ‘village planning’ as a tool to work with selfdefined communities with a common identity. More recently, the public health team has used this tool with the health and wellbeing board. Public health staff sit on the village planning board and steering group and are able to bring their intelligence function to good use in helping identify where services need to be brought more closely together. For example, the DPH chairs the DAA, which consists of a wide variety of local organisations working together to make Richmond a dementia friendly borough. Recently the DAA has embraced the concept of dementia-friendly villages, identifying important local community assets, including not only dementia specific care services but local pharmacies, shops, schools, faith groups, heritage sites etc that define a locality and engaging them in the dementia friendly work. The public health team recognises that the reality of a place-based approach is not as neat as the village concept might suggest. For example, in addition to the village model, there has been a long history of four locality based health and social care teams, the voluntary sector-run independent living service is organised around four community locations and the Richmond GP alliance has recently established four locality based multidisciplinary primary care hubs, using the money they have won from the Prime Minister’s Challenge Fund to offer extended access. These geographical units are not all completely congruent. The public health team, colleagues and partners in the NHS acknowledge that it is important to work with this ‘messy reality’ rather than pursue an ideal of co-terminosity that is unreachable, and jeopardises success. Being honest and recognising this reality is seen as part of Richmond’s success in its integration work. The cross-council prevention strategy developed jointly with the CCG in response to the Care Act 2014, was led by public health. Public health’s role in local government and NHS integration 19 It provided an opportunity to define prevention around the idea of place and connected, resilient communities and to embed the concept of prevention in a wide range of council and NHS activities. For example, the MECC programme was used in relation to topics across the life course that are specific to Richmond, such as loneliness and isolation among older people; winter warmth; active travel and accessing new technologies. A 45 minute web-based training programme has been developed for staff to help them to understand why certain issues are specific to Richmond. This programme, along with other web-based training is also available to staff in other agencies including voluntary sector staff. Further initiatives include the development of dementia friendly parks, ensuring the accessibility of parks and open spaces and training frontline staff, such as the safer cycling team (who train people in schools, workplaces and other settings on safe cycling) to champion and support the wider community inclusivity. Integrated transport is an important component of our approach, making explicit links between strategies and programmes such as the cycling, air quality and healthy workplaces programme (community intervention) as well as road infrastructure and cycle routes (place-level intervention). Public health skills have also been helpful in commissioning a community independent living service from the voluntary sector. The public health team has assisted in identifying people at risk of loneliness and of hospital admission, understanding the burden of morbidity and level of need in each of the four Richmond health hubs and helped in developing a service specification and performance management framework. What others say – Cathy Kerr, Director of Adult Services Public health has been predominantly involved in providing us with intelligence, helping us to shape strategies and take an outcomes-based approach to commissioning. They have also done some very helpful work around risk stratification, working very successfully with CCG and GP colleagues, identifying high risk population groups and what interventions are most likely to be effective in meeting their needs. They bring rigour, discipline and the sort of evidence that takes clinicians along with us. They can talk clinicians’ language and act as a bridge to them. Integration is often just thought about in the context of adult health and social care. However, in Richmond the refreshed HWB strategy theme ‘starting well’ explicitly looks at prevention and joined-up services at the beginning of life, focusing on joint working in areas of high impact. For example, health visiting (commissioned by public health) and children’s centres are working to achieve the internationally recognised standards (developed by UNICEF) that mean services are ‘baby friendly’. For women suffering from mental health problems during and after pregnancy, a joined-up pathway is being developed which will involve local authority health visitors as well as specialist NHS mental health services. A new transformation plan is the start of a five year emotional wellbeing and mental health programme for children and young people. This plan is focused on improving outcomes through a whole-system approach, involving families, communities, schools and services. It centres on promoting resilience and early help, particularly through schools and community settings, and improving access to specialist mental health support. The school nursing service (commissioned by public health) will develop its role in promoting emotional wellbeing and mental health. Outreach school and community-based clinics will be piloted by the emotional health service to provide timely access to psychological therapies. Achieving for Children, the social enterprise company providing children’s services for the London Boroughs of Richmond and the Royal Borough of Kingston upon Thames, is taking forward Phase 2 of its Strengthening Families programme – a five year programme begun in 2015/16. 20 Public health’s role in local government and NHS integration This involves a multi-agency approach to ensure families are identified as early as possible and that there is a comprehensive response to their needs. A form of risk stratification developed by the public health team will support the process. What others say – Robert Henderson, Deputy Chief Executive, Achieving for Children Our public health team has a very coherent and clear understanding of prevention, integration and of how commissioning can be used to move them forward. The team has a strong understanding of our locality model of working with teams, built around the school and the community. In drawing up the specification for our school nursing service, public health has captured exactly what we want to achieve and is doing the same for health visiting. They have done significant work around services to mitigate risky behaviour of children and young people, making it very clear that separate services will not be helpful. They have also gathered some good analysis and produced evidence on suicide and self harm which means that we have put more resources into supporting emotional health. We are very excited about having a fullyintegrated health and social care service for children aged nought to five and their parents. In designing this service, our public health colleagues have embraced what matters to us and given us a clear steer on what is likely to help us meet our objective of delivering for children. In general, the public health team is seen as a facilitator that can bring partners together around need, outcomes and evaluation. The team recognises the importance of understanding partners’ agendas to find common ground and of being open to what matters to residents. In return, partners trust and use public health expertise to play an important role in the joint endeavour of integration. Contact Dr Dagmar Zeuner Director of Public Health [email protected] Anna Raleigh Consultant in Public Health [email protected]