This case study describes North East Lincolnshire’s progress developing integrated care arrangements. It is part of an evidence review commissioned from the Institute of Public Care.
The NHS and local government in North East Lincolnshire have been working together for more than ten years with a common aim to improve health and care outcomes for their population.
North East Lincolnshire is a geographically remote area that has historically been characterised by economic decline and significant health inequalities associated with poverty and poor living standards, leading to a dependency on services. Early commitment to addressing these challenges has centred on a vision to integrate around the whole person, from cradle to grave, to promote healthy living, self-care and prevention. As well as adult health and social care, the integration agenda includes the 0-19 age group, and the broader determinants of health and wellbeing such as public health, housing, education and skills.
A shared vision for their ‘place’, owned across political parties, and led by the ‘Union’ of the Council and CCG has driven a joint approach to commissioning, service delivery and financing to the point that integrated working is seen as business as usual. This case study offers an example of an advanced whole system approach which has weathered the many changes in the NHS and local government, remaining committed to their core principle that integration is the best vehicle for advancing health and wellbeing.
Formal arrangements between the Council and what is now the CCG began in 2004 with mental health service commissioning; provision was expanded in 2007 to include adult social care, public health, and children’s services, underpinned by a section 75 agreement. Between 2009 and 2014, to implement the national direction of travel towards commissioner/provider split, three social enterprises were formed to provide services to adults (mental health services, community health services and social work functions), commissioned by what is now the CCG. The framework for further integration introduced by the Better Care Fund in 2013 largely reflects North East Lincolnshire’s existing and ongoing plans for joint working.
Historically, joint working has focused on a ‘lead commissioner’ model (delegation of functions by each partner to the other, with a transfer of funds). For example, as lead commissioner, the CCG buys all residential and nursing care on behalf of itself and the Council. The arrangements in place have permitted the pooling of funding to enable integrated services to be commissioned from providers. Although technically there are detailed arrangements for the governance of pooled funds with the section 75 agreement, in practice budgets and contracts are fully operationally integrated. It is the responsibility of the lead commissioner to ensure that funds are used appropriately and that the under and overspends are managed. More recently, an integrated care partnership has been created via which providers have come together as a single legal entity ‘Together Ltd’ to reshape pathways, redesign delivery models and realign resources to ensure people receive responsive, consistent, high quality care; Together Ltd will eventually be funded through a capitated budget operating under a single contract. The next stage of the journey for the Council and CCG as joint strategic commissioners was the formation of an enhanced partnership called the Union, which went live in September 2017 with a joint chief executive.
Governance, leadership and commitment
The Union’s Partnership Board provides single strategic leadership across the CCG and the Council’s people related functions, and delivery of Section 75 health and social care arrangements. The Union is a relatively lean and uncomplicated model driven by a common purpose and commitment that has evolved over the years. Each statutory organisation (CCG and Council) continues to discharge their retained responsibilities and decision making powers through their governing bodies (Cabinet and Scrutiny Committee for the Council and Governing Body for the CCG), but delegates delivery to the Partnership Board and joint executive team. No new organisation has been created.
The Health and Wellbeing Board plays no direct role in the new governance arrangements beyond the signing off of the Better Care Fund element of the pooled fund. However, it fulfils an important role in terms of its sponsorship of the Health and Wellbeing Strategy and Joint Strategic Needs Assessment and as a forum for aligning collective efforts from a wide range of stakeholders.
The Union will oversee all spend on health and adult social care, the 0-19 agenda, and the broader determinants of health and wellbeing such as public health, housing, education, and skills.
- the benefits of the Union model include:
- whole system approach to health, wellbeing and planning across the life course
- more efficient use of estate
- more effective use of combined workforce and skill set
- improved access to key levers and decision makers across the system, to allow more proactive and informed decision making.
The model will deliver the local vision and approach to health and social care integration, described as being:
“To deliver the right care, in the right place, by the right people, as close to home as possible, releasing the capacity and innovation which exists within our community to promote healthy living, self care and prevention”
This aligns with the broader place based approach which all partners in North East Lincolnshire have signed up to. These are that all people will:
- enjoy and benefit from a strong economy
- feel safe and are safe
- enjoy good health and wellbeing
- benefit from sustainable communities
- fulfil their potential through skills and learning.
Delivering integrated care
Single point of access
The SPA provides a single, 24/7 route for accessing care and support. The telephone triage system offers a streamlined multi-agency approach to ensure callers reach the right person at the right time. The SPA was originally developed as a demand management model for adult social care in 2008. In 2010 it was merged with the existing GP out of hours health triage service. It was extended again in 2012 to include an in hours health triage and community occupational and physiotherapy access functions. More recently, a SPA Facebook page has been developed, through which SPA staff are accessible 24/7, including clinical support to care homes and other professionals.
The SPA delivers:
- integrated multi-disciplinary triage across health and care, inclusive of mental health
- the ability for providers to co-operate rather than simply competing
- reduced delays and duplication, creating efficiencies in the wider system e
- asier identification of the most vulnerable and frequent users of health and social care through integrated case record systems
- promotion of self-care and independence
- improved user experience and easier access to information and advice – a Govmetric system enables callers to leave instant feedback, and feedback is consistently good.
Currently approximately 12,000 calls per month are received into the SPA.
A single database system for adult social care, community health and primary care was introduced in 2010, enabling the sharing of health and social care information and electronic transfer of referrals. This was the first integrated system in England and involved joint development with TPP (the developers of SYSTM 1) to create the first adult social care unit for SYSTM 1. The integrated case record has been pivotal in the success of the SPA, facilitating robust and auditable decision making at the first point of contact. Currently, 80 per cent of GP practices, all of adult social care (including adult safeguarding and deprivations of liberty details) and community nursing utilise SYSTM 1 as their primary case recording system. Adult mental health will also transfer during 2018.
The main challenges in implementing SYSTM 1 included consent to share and access records between health and social care. This was resolved by embedding private areas of case records, public engagement and reinforcing data protection principles within user groups. Transfer of data from existing systems was also a short term but considerable workforce implication. Any initial concerns were quickly alleviated once the system became operational and the benefits realised.
Preventative services market development board
Prevention and wellbeing have been long-standing aims for North East Lincolnshire. The shared aspiration is for: “people to be informed, capable of living independent lives, self-supporting and resilient in maintaining/improving their own health. By feeling valued through their lives, people will be in control of their wellbeing, have opportunities to be fulfilled and are able to actively engage in life in an environment that promotes health and protects people from avoidable harm”.
North East Lincolnshire has established a Preventative Services Market Development Board, attended by community, adult social care, and CCG representatives. Investment offered via the Board is provided using Council/CCG pooled funds. Specialist advice is provided to the Board by an external consultancy, which exists to provide practical support to the social enterprise, voluntary and community sector. Gaps within community resources are analysed, and third sector community organisations and charities are offered the opportunity to bid for non-recurrent seed funding. There is a strong emphasis on sustainability, so successful tenders must be able to demonstrate a sustainable model. Find out about the Board offers.
Examples of Board success stories are as follows:
A lack of affordable chiropody services for older people prompted a decision to commission a new service. A tender was written, put out to the market and awarded to a small social enterprise. “Seed” funding enabled the new service to get up and running. In time the service has become self-sustaining through a charging model. This initiative is contributing to a reduction in falls amongst the elderly.
A review of meal provision found that some people needed more than traditional meals delivery services. A local church was awarded seed funding to develop a new approach, offering meals and care. Delivered primarily by volunteers, the scheme offers users a meal delivery service along with help in other areas to support independent living, for example a shopping service or signposting to other organisations. This model benefits both users and the volunteer workforce. As a result of this approach it has been possible to de-commission the former service whilst at the same time ensuring that the community has access to a range of affordable meals services with the added value of social interaction. This has significantly reduced the call on adult social care budgets.
Carers' support service
There are approximately 16,000 carers in North East Lincolnshire, each contributing to their share of the £356 million they save the North East Lincolnshire economy every year. The Carers’ Support Service offers a range of support to carers of all ages, including ongoing one to one emotional and practical support, benefits advice, carers’ groups as well as regular workshops and training covering issues such as confidence building, assertiveness, stress management and First Aid.
The CCG and Council jointly fund the Carers’ Support Service. Feedback from carers has been extremely positive. The latest annual carers’ survey (2016-17) shows that as a result of using the Carers’ Support Service, carers feel: more in control of their situation and are able to make decisions (90 per cent), more able to cope (94 per cent) and supported in their caring role (90 per cent). Example free text from responders to the survey includes “The carers system is one of the best in the area, the help and support they give is tremendous, I couldn’t ask for more” and “Finding this service at this time is the single most important thing I have discovered, ever”.
The success of the Carers’ Support Service reflects that it has been designed by and for carers’. Prior to each retender of the service, a draft vision for the future of the service is circulated amongst carers’ and professionals to invite feedback. A tendering project group is created, comprising representatives from the CCG, Council children’s services and drug and alcohol action teams, and local carers’. This group develops the service specification, tender questionnaire and evaluation documents. One section of the tender questionnaire is evaluated by carers’ only. Carers’ receive training to enable their participation in all phases of the tender, including evaluating bids and interviewing bidders. The same carer-focused process will be followed when the service is retendered in 2018.
North East Lincolnshire has been operating pooled budget arrangements under a Section 75 agreement for a considerable time. Initially a three year rolling renewal was in operation. This then became an annual negotiation which considers factors such as inflation, efficiency pressures, needs, and any new statutory requirements. The discussion results in an ‘agreed value’ and the CCG commits to managing within that value. There is no formal risk/ benefit sharing agreement beyond this. The CCG can request a change to the ‘agreed value’ should this be necessary. Because the Council has representatives on the Boards of the integrated care providers, they are aware of any pressures that may be arising and need to be factored in. A high level of transparency between the Council and CCG underpins this unusually informal approach that has worked well for eleven years, illustrating the maturity of the relationship and ability to make financial decisions based on what is ‘best for the system’ rather than organisational self-interest.
In the past two years, the Council and CCG moved away from the national ‘client/contractor’ split by appointing a joint director of adult services (DASS). This role is broader than the traditional DASS role and includes oversight of some housing functions and the housing related support programme. The DASS is employed by the Council but is located within the CCG and has oversight of all adult services commissioning functions. This has enabled further development of the relationship between health services and Council functions and the exploration of new opportunities to join up commissioning, for example the CAMHS pathway and development of the extra care housing strategy. The DASS is a key member of the Council’s housing delivery board, and as such, is able to influence the delivery of specialist and supported housing.
The dynamic has been supported over time by three key elements:
- cross party political support
- leadership by example and expectation setting
- a sensible balance between good and trusting relationships between key individuals on one hand and pragmatic and relatively simple governance arrangements on the other.
Integrated teams of health and social care staff have become the norm in North East Lincolnshire. The focus now is to develop shared principles that govern how they deliver care. This has been happening through a programme of joint training to foster value driven practice based on understanding of public law principles and rights based approaches, underpinned by legislation such as the Human Rights Act 1998, and the Mental Capacity Act 2005. Work is also underway to ensure cohesion between children and adult service teams, with a focus on consistent adoption of strength or asset based social work practice.
Example 1 – taking a pragmatic and ethical approach when making micro-commissioning decisions (decisions about packages of care for individuals) is challenging for staff across health and social care. A framework for decision making has been created for use by social care, mental health, and continuing healthcare professionals. The framework is designed to a) ensure provision of the best possible quality of care distributed on a transparent, equitable and affordable basis and b) improve consistency and quality of decision making across micro-commissioned provision, through knowledge and application of public law principles. The framework is supported by staff practice development tools to enable embedding. The framework can be found at (the last policy on the list): http://www.northeastlincolnshireccg.nhs.uk/publications/
Example 2 – lawful approaches to deprivation of liberty is another area where knowledge and understanding can vary between staff from different professional backgrounds. As far as the law allows, a shared approach to identifying and authorising deprivations of liberty has been devised to cover health, care and community settings. As part of the authorisation process, both health and social care staff act as ‘best interest assessors’ (BIAs), who contribute to a cross-provider BIA rota alongside their separately based ‘day jobs’. BIAs attend bi-monthly practice forums which enables them to share experience and further develop expertise; BIAs then act as champions of rights-based care within their own organisations. The shared MCA policy and BIA Framework can be found at (around one third of the way down the list).
In common with most areas, North East Lincolnshire lacks an adequate supply of suitably trained and qualified health and social care workers. Being geographically remote from larger centres of population, it is hard to get staff to come to and to stay in North East Lincolnshire; this is one of the top priorities for the Union. A strategic approach to workforce recruitment and development has been put in place, drawing on the Council’s Outcomes Framework Lead for Skills and Learning and a local website promoting the benefits to living and working in health and social care in the area ‘work smart live well’.
Building on the firm foundation of joint working for many years the next stage for North East Lincolnshire is described as a movement towards a more complete and comprehensive set of combined NHS and Council responses to their population. It is hoped that Union will make more efficient use of estate, more effective use of combined workforce and skill set and enhance the whole system approach to health, wellbeing and planning across the life course. Encouraging provider to provider collaboration including the GP Federations and the community benefit society, Together Ltd will be an important feature of the integration landscape. More than anything, change has started to be reflected in the attitude of people working on the ground whose focus is increasingly on the person they work with rather than on the organisation they represent.