building a sustainable future for health and social care · the key barriers to change across...

Building a sustainable future for health and social careAn independent reviewProfessor Lord Patel of Bradford OBEThe Rt. Hon Hazel Blears Dr Jon Bashford

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Contents Page

Executive Summary 2Recommendations 8

Introduction 10

The Vision 11

Background 12

Methods 13

Contributors to the review 13

Context 14The barriers to change 14Changing patterns of health and social care needs 14

The fifth wave of public health 15NHS Five Year Forward View 17Cities and local government devolution 19One Public Estate 20

The NHS Estate 21Social investment and impact 22New technology 24

Building a sustainable future – a model for integration and innovation 26Collaboration 26Integration 27Innovation 28

1. Shared Estates and Infrastructure 301.1 Designing and delivering a future estate footprint 311.2 Managing services for the future 37Framework for actions on shared estates and infrastructure 42

2. Workforce development 422.1 New ways of working 422.2 The Apprenticeship Levy 442.3 Competency based learning 462.4 Inclusive leadership 48Framework for actions on workforce development 50

3. Financial and budgetary alignment 503.1 Devolved budgets for health and social care 513.2 Devolution of health and social care - Greater Manchester 523.3 Public health financing 553.4 Creating a unified health and social care budgetary framework 56Framework for actions on financial and budgetary alignment 57

4. Whole system integration and innovation 584.1 New ways of doing business 584.2 Understanding innovations as part of strategic change 604.3 Social investment as a tool for integration and innovation 654.4 Alliance Contracting 674.5 Regulation and inspection 68Framework for actions on whole system leadership – integration and innovation 69

Conclusion 70

Recommendations 71

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IntroductionThe aim of this report is to present a new modelfor integration and innovation in health andsocial care that uses collaboration to create aunified, cross sector strategy for estates andinfrastructure as the catalyst for change to meetthe current financial and service demandchallenges. The model is not intended to be aone size fits all solution, in fact it is very firmlybased within the context and opportunitiesprovided by devolution and the need torecognise that place and people must be thedeterminants of future sustainability.

The model has been developed from a review ofthe key barriers to change across system,financial, outcomes, workforce and infrastructurelevels for the health and social care system. Theprocess for developing the model has beeninformed by a wide range of expert stakeholdersfrom across the public, private and socialsectors and includes examples of new ways ofworking that demonstrate the power ofcollaboration, integration and innovation forimproving lives, reducing costs and raisingquality and outcome thresholds.

The model demonstrates how a framework foractions taken in four areas: shared estates andinfrastructure; workforce development; financialand budgetary alignment and whole systemleadership can provide a sustainable future forhealth and social care.

Shared Estates andInfrastructureThe combined NHS and local authority estatesfor health and social care represent one of themost significant areas for releasing capitalassets that can achieve significant cost savingsand generate new revenue for integrated healthand social care impact investment. However, todate there has been insufficient collaboration onthe strategy at local and national levels to fullyrealise these benefits. The model proposes anapproach to establishing collaboration forshared estates and infrastructure i.e. facilitiesmanagement, IT and property development andmanagement that will enable:

• the use of estates planning as a lever forchange that can address wider system andservice transformation;

• increased efficiency and cost savings thatcan support alternative revenue streams i.e.social investment;

• new thinking and strategy for place andpeople based change that will create thefoundation for integration and innovation inhealth and social care.

The framework for actions on shared estates andinfrastructure is as follows:

Executive Summary

02 Executive Summary10 Introduction11 The Vision13 Methods14 Context26 Building a sustainable future – a model for integration and innovation70 Conclusion

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Workforce developmentThe rapidly changing needs and demands forhealth and social care requires new skill sets,competencies and learning pathways for thehealth and social care workforce. Currentprofessional divisions will need to be brokendown so that workforce development can be

planned and delivered on a cross professionaland competency basis. The model proposesmeeting these new requirements through:

• stronger and more effective leverage of theApprenticeship Levy at local area levelsthrough the development of integrated healthand social care apprenticeships development;

• Disparateestate footprint

• Complex and ineffici-ent management anddesign

• Lack of capital• Legacy sites• Antipathy to previous

PFI models

CollaborationIntegrationInnovation

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• Integration of estates rationalisation via OPE• Integrated property strategy at national level• Integrated service delivery pathways supporting strategic outcomes• cost savings

Barriers

• Collaboration across heath & social care commissioners and providers• Accountability and responsibility for strategy aligned• Innovation in design, funding and technology across multiple partners• Shared FM management

• Align estates strategy across the NHS and localgovernment

• Establish a national Property Centre of Excellence• Application of Public Service Hub model• Create area based FM frameworks

Shared Estates and Infrastructure

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• the introduction of Competency BasedLearning into course development andtraining across further and higher educationin order to better meet the needs of learnersand employers in developing skills andcompetencies that service users require;

• development of inclusive leadership forcross sector and cross organisational and

professional boundary leadership that will a)provide leaders who can operate and taskacross organisational and professionalboundaries and b) ensure that the talentsand value of a diverse health and social careworkforce are realised

The framework for actions on workforcedevelopment is as follows:

Executive Summary


• Skills gap• Professional divisions• Underdeveloped career

pathways• Disparate workforce


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• Development of new roles in workforce• Improvements in student progression and outcomes• More diverse workforce and improvements in BME staff

progression and retention

Barriers

• Maximising resource benefits at local level• Development of skills escalator for workforce• Development of executive and Board leadership for inclusion

• Cross sector arrangements for shared use of theApprenticeship Levy

• Introduction of Competency Based Learning• Improved use of WRES data to support inclusion

leadership

Workforce Development

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Financial and budgetaryalignmentOne of the biggest barriers to collaboration,integration and innovation across health andsocial care is the lack of alignment in financialand budgetary accountability. However,increasing devolution of health and social carefinancial and budgetary responsibilities is

inevitable. As these developments continue,national and local health and social care leaderswill need to prepare for a unified framework bywhich pooled budgets and financial controls canbe shared across local areas. The modelproposes that the opportunities provided bydevolution should be escalated so that:

• local areas can take advantage of the new

• Existingfinancial deficits

in the NHS and localgovernment

• Focus on short-termefficiency savings

• Silo mentalities andstructures

• Inadequate incentivesat local and

national level


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• Resources matched to local area priorities• no of devolved authorities able to integrate local health &

social care• Better planning to support shift from acute care to prevention

Barriers

• Lead accountability for integration• Removal of barriers to collaboration and integration at government level• Alignment of primary and community health care with social care and

public health

• Unified health and social care budgets via mayoralcombined authority powers

• Combining of resources and accountability in onedepartment and cross-Cabinet levers for collaboration

• NHS England and LGA to agree framework to devolvecontrol of primary and community services

Financial & Budgetary Alignment

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powers enabled by devolution to establishalignment of health and social care budgetsas part of an integrated strategy forprosperity and growth;

• the integration of health and social carefinancing can help break down silo mentalitiesand structures thus enabling health and socialcare leaders to lift their sight fromorganisational and sovereign boundaries;

• Government Departments, Cabinet andnational regulatory and commissioningagencies can collaborate and fully supportdevolution of health and social care finances;

• the capacity and capability of local healthand wellbeing boards and combinedauthorities can be developed and supportedto effectively manage and control anintegrated health and social care budget;

• the shift in revenue from central to localgovernment in public health through localrates needs to be aligned with an equal shiftin moving the focus of health and social careexpenditure from acute care and managingdemand for long term illness and disabilityto prevention and early identification.

The framework for actions on financial andbudgetary alignment is on page 5.

Whole systemintegration andinnovationNew system wide business models and

leadership at executive and elected levels isneeded to move from collaboration andalignment to full system integration andinnovation. This means re thinking health andcare services so that they act now on preventionneeds and early identification as part of anintegrated, area and people based system. Whatis needed is a new strategy for disruptiveinnovation in health and social care that fits withthe changing business models and will supportnew ways of working and delivering services aspart of broader structural change. In order toachieve this there needs to be:

• disruptive innovation in business deliverymodels to transform the health and socialcare system in line with the Fifth Wavethinking on health promotion;

• intelligent use of technologies for innovationin practice and interventions that are able toprevent chronic illness and thus stemdemand;

• leverage of social investment that can enablenew structural forms of integration andinnovation;

• adopting legal frameworks that will supportnew ways of contracting for integrated healthand social care e.g. Alliance Contracts;

• integration of regulatory and qualityinspection regimes at local area levels.

The framework for actions on whole systemintegration and innovation is as follows:

Executive Summary


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The model for integration and innovation ofhealth and social care services attempts to meetthe critical and urgent demands of the changingneeds and patterns of health and social careproblems and the increasingly restricted financialresources that are available. It is not intended tobe a one size fits all but rather to generate debate

and encourage NHS and Local Authority leadersalongside government and national regulatoryand commissioning agencies to come together -to collaborate – so that an integrated system canbe created that supports the right kind ofinnovations for improving lives and building asustainable future for health and social care.

• Outdatedbusiness models

• Restrictive legalframework

• Top down regulation andrestrictions

• Lack of single, unifiedframeworks

• Technology not imbeddedinto service delivery

models


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• Individual leaders and practitioners able to task others forintegrated outcomes

• New service delivery models and interventions result in improvedoutcomes

• Benefits of social investment realised as part of integrated systems• Cross sector, multi-agency partnerships• Quality and standards measured and maintained on basis of an

integrated system

Barriers

• Alignment of executive and elected officers accountability• Appropriate innovations as vehicles for improved outcomes• Strengthening of private and social sector partnerships• Legal framework for contracting supports integration

and innovation• Quality thresholds and regulations aligned with local

area strategy

• Establish whole systems leadership for delivery• Develop strategies for innovation that support new

ways of working, including technology• Leveraging of social investment programmes• Develop use of Alliance Contracting for commissioning

integrated delivery• Establish local area frameworks for regulation and inspection

Whole System Integration and Innovation

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RecommendationsRecommendation oneCollaboration needs to be strengthened betweennational and local leaders including between theNHS and local authorities and between theDepartment of Health and the Department forCommunities and Local Government.

Recommendation twoFinancial accountability and budgets for healthand social care need to be aligned as part of aunified system under the direction and control ofa single government department. This couldpotentially be, for example, through a newDepartment for Communities and Wellbeing.Cabinet level collaboration needs to befacilitated through the use of shared fundingarrangements as part of a common pooledresource for health and social care. This needsto be replicated at local levels through singlecommissioning authorities covering both localauthority and health services.

Recommendation threeCollaboration between providers andcommissioners needs to be supported throughnew legal frameworks such as AllianceContracting. A legal contracting framework isrequired that drives and incentivises collaborationrather than competition, based on a no disputeculture that provides parity for public, private andsocial sector organisations – an Alliance Contractcan provide this essential foundation.

Recommendation fourWhole system leadership is needed at executiveand elected levels with political and executivedecision making power over the whole system.An elected Mayor with powers beyond health

and social care including policing, justice, skills,transport, economic regeneration and housingcan bring unified budgets, coherence anddemocratic legitimacy to the system.

This should sit within combined authoritystructures under the newly mandated powers forelected mayors and be replicated in cross sectorAccountable Care Organisation frameworks. Inorder to realise this there needs to be support forboth elected officials and officers so that they areable to work across systems and professionaldisciplines, able to task others and develop amulti-skilled, competent and inclusive workforce.

Recommendation fiveWorkforce development needs to be alignedacross health and social care, taking account ofthe new apprenticeship levy system and usingCompetency Based Learning modules as part ofa skills escalator.

Recommendation sixA distributed service delivery model is requiredbased on the gradual development of multi-servicehubs. These could be focused on specific carepathways or service user cohorts, e.g. diabetes,dementia care etc. As these multi-service hubs aredeveloped, the local hospital provision can beadapted with the release of hospital estates aspart of a joined up OPE strategy between NHS andlocal authority partners. NHS England shouldensure that local providers and commissionershave incorporated these approaches inTransformation and Sustainability Plans.

Recommendation sevenInspection and regulatory regimes need to bealigned on an outcome basis at local rather thannational levels.

Executive Summary


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Recommendation eightThere needs to be a national and localcommitment to long term outcomecommissioning – beyond existing politicalhorizons. This should include recognition thatsignificant system change is being undertakenwith longer timeframes for improvementaccording to the scale and pace of change, e.g.over 5 and 10 year timeframes.

Recommendation nineDevelopment of integrated health and socialcare services should include parity amongstpartners from across the public, private andsocial sector with an explicit aim of usingtransformation in service models to help buildthe social sector.

Recommendation tenThere needs to be acceptance and understandingacross the system that willingness to innovateand make effective change means learning fromnew ways of working and that in the process ofchange some things will work and some will not.To better support the process of change thereneeds to be resources for research, developmentand evaluation, including local area feasibilitystudies.

Recommendation elevenLocal change programmes need to harness theimpact of digital innovation on services andoutcomes as part of a strategic drive towardsprevention and public health improvement.

Recommendation twelveLocal area change and transformation plansneed to maximise the possibilities and potentialprovided by social investment to help drivetransformation.

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This report is the result of a review of the keybarriers to building a sustainable future forhealth and social care. The review wasundertaken by Professor Lord Patel of BradfordOBE and the Rt. Hon Hazel Blears and took placebetween February and June 2016. A wide rangeof individuals were consulted for the reviewincluding leaders, practitioners, clinicians andmanagers from across the public, private andsocial sectors. In particular the review focusedon four principal barriers:

• EEssttaatteess aanndd ffaacciilliittiieess e.g. how theinfrastructure and locations for servicedelivery are costly and no longer fit forpurpose.

• WWoorrkkffoorrccee e.g. how professional barriers canimpede joint working and prevent wholesystem practitioner and leadershipdevelopment;

• FFiinnaanncciiaall bbaarrrriieerrss e.g. the way in which healthand social care budgets are separated;

• SSyysstteemm bbaarrrriieerrss e.g. the way in which healthand social care systems are currently governed,structured, organised and inspected;

The report explores the current context anddrivers for change, including the NHS Five YearForward View, the Fifth Wave of public health,regional devolution and the One Public Estatestrategy, and how technological advances andnew models for social investment are providingopportunities for transforming care andimproving lives.

A model for integration and innovation ispresented that addresses the current context

and barriers to change, including case examplesof how different ways of working can contributeto building a sustainable future for health andsocial care. The model demonstrates howccoollllaabboorraattiioonn,, iinntteeggrraattiioonn aanndd iinnnnoovvaattiioonn can beused to overcome barriers to change andsupport local area plans and strategies forsustainability and transformation. The modelalso highlights the need for greater collaborationand integration at government levels includingCabinet, if health and social care budgets are tobe aligned in a way that would be effective forthe challenges faced by the system.

The final section of the report includesrecommendations on how improvements can bemade that will enable a whole system approachto building a sustainable future for health andsocial care.

We hope the report will be a catalyst for widerdebate and change.

Introduction


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OOuurr vviissiioonn is for an integrated health and socialcare system that uses its estates and infrastructurewisely and collectively within a single, unifiedfinancial and budgetary framework at local andnational levels. This requires a workforce that isskilled and competent to deliver services on thebasis of need rather than professional status orrole, and whole system leadership at both electedand executive levels that can operate effectivelyacross the public, private and social sectors.

This vision can be realised if we accept thatthere is a crisis and we have the political andmoral courage to do something about it. Inparticular, we need:

• to ensure that we have the right incentivesfor collaboration, supported and encouragedby government and regulatory agencies;

• to have joint strategies for NHS and localauthority estates, so that the sale of assetscan be used to support change anddevelopment rather than as a short termplug for revenue funding gaps;

• to be less concerned with individual andorganisational sovereignty and more focusedon positive outcomes for people and places;

• a commitment to overcome professionaldifferences and interests, so that we canbuild a workforce equipped and competentto address the health and social caredemands for today and in the future;

• to shift the focus and investment for healthand social care to prevention and earlyidentification in order to reduce the demandfor hospital and residential services;

• to start working now for the health andwellbeing of all, so that we can improve livesand build a sustainable future for health andsocial care.

The Vision

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This is a critical time for the provision of healthand social care. The NHS faces a funding gap of£30 billion1 and there is a £700 million gap, andrising, in the provision of social care2. At thesame time demand for higher quality and moreresponsive services is growing for a populationthat is at one end increasingly older, with morelong term conditions and more complex needs,while at the other end, consists of growingnumbers of young people who are building upfuture serious health needs through lifestylefactors that are likely to result in long termconditions such as obesity.

Too many organisations are trying to do toomuch with too little and there is an urgent needfor change. But people are tired of top down,wholesale reform in the NHS and many localauthorities are struggling to keep basic servicesoperational. In the climate of austerity, budgetcuts and a slower than expected economicrecovery it is hard for those who lead and deliverservices to think long term. The NHS is rightlyheld in high esteem and is widely regarded asone of the greatest achievements of the lastcentury. And despite the current challenges it isstill regarded as one of the most cost effectivehealth systems in the world.

However, it is also clear that the NHS and localauthorities will not be able to continue to meetrising demands for health and social care withincurrent resources without transforming the waythat services are delivered. Debates continueabout the best way to structure, organise andfund a national health and social care systemand whether there should be a unified way ofproviding this.

The history of reform of the NHS has not beenwidely welcomed or perceived as successful inaddressing the basic issues. Top down, wholesystem transformation is not the way forward.What are needed are alternative delivery modelsthat come from the ground up, are ppllaaccee bbaasseeddas opposed to ssyysstteemm bbaasseedd and providerealistic, practical and replicable solutions thatput people and those who use and deliverservices at the heart.

Now is the right time for a new approach thatwill put those who use services at the centre andbuild a sustainable future for health and socialcare. Barriers will need to be broken in order toachieve this and this can be done throughcollaboration, integration and innovation.

“Success will require us all to thinkbeyond our statutory and organisationalborders to meet the needs of the peoplewe serve.” (NHS Five year Forward View: Time to deliver)

Background


1. NHS England, ‘NHS Five year Forward View’, 20142. Local Government Association, ‘Adult social care, health and wellbeing: A Shared Commitment’ SpendingReview Submission, 2015

Methods

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The review was conducted in two stages. Afocused inquiry first explored the barriers anddrivers for change in integration of health andsocial care, including a number of site visits todemonstration projects where new ways ofcollaborating and managing infrastructure,services, estates and IT were being practiced.The second stage of the review involveddeveloping a model for integration andinnovation and testing its potential value andapplicability amongst a number of keystakeholders from across the public, private andsocial sectors. These interviews were conductedon a confidential basis and where quotations areused in the report these are signified only by thesector from which the speaker came i.e. public,private or social sector stakeholder.

Contributors to the reviewAsian Media Group Big Lottery Fund Cabinet OfficeChiltington LandDeloitte Touche Tohmatsu LimitedDragonGate ENGIEGovernment Property UnitGPs and other primary care cliniciansRoyal HaskoningDHVHeath Education EnglandKPMGLocal authority officers and elected membersLocal Government AssociationMcLaren Group London Legacy Development CorporationMJ Mapp NHS Confederation NHS EnglandNHS Property ServicesNHS Trust Directors, managers and leadcliniciansPA ConsultingPublic Health EnglandRoyal Society of Public Health Sopra Steria The Mid Yorkshire Hospitals NHS TrustUniversity of East London (UEL) Westminster City College

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The barriers to changeThere are always barriers to change; people fearthe unknown and ‘better the devil we know’attitudes prevail. For those tasked with leadingand delivering change on the ground the scale ofthe task can seem daunting and the challengesinsurmountable. Engrossed in the day to daydelivery of an increasingly complex system whereliterally lives are held in the balance, NHS andsocial care leaders and practitioners have too fewopportunities to raise their sights and see thehorizon. History becomes a barrier as previousattempts at change are viewed as having failed todeliver their promise or are regarded withnegativity and hostility, for example:

• Public Finance Initiative (PFI)

• The purchaser/provider split

• Health Action Zones

• Community Care

Organisational structures have been re-organised, re-structured, reformed, abolishedand re-built again – Area Health Authorities,Strategic Health Authorities, Primary Care Trusts,Health and Social Care Trusts. The pace ofchange has been breathless and at timesagonising and yet still we need to think beyondthe current statutory and organisationalboundaries.

Barriers to change in the context of health andsocial care are also political. In recent debateson the devolution of health and social carepowers Lord Warner questioned whether the ‘N’was being removed from the NHS.

There remains an antipathy to closer workingpartnerships with the private sector despite thefact that there are clear skills and expertise deficitsthat could best be met by the private sector e.g.estates management, facilities, propertydevelopment and Information Technology. Wherepositive changes are made, they often remain localand ‘what works’ is not readily shared with othercouncils and health agencies.

There are skills deficits too in the workforce.Change doesn’t just happen; it needs skilledstaff who are equipped to deliver new ways ofworking. But staff also need to be engaged inthe process of change and to feel that they havea firm stake in the future. As do patients andpublic who too often feel that they have beenunable to participate in the process or feel theyhave not been adequately and effectivelyinvolved in decision making.

Changing patterns ofhealth and social careneedsThe patterns of health and social care needs arechanging rapidly and are significantly different towhen the NHS was first conceived. The NHS is nolonger primarily about curing illnesses: forexample, nearly three quarters (70%) of the healthservice budget is taken up by long-term healthconditions. In fact, the demands being placed onhealth services are increasingly social in nature orcausation – lifestyle factors such as obesity andsmoking, risk behaviours such as those associatedwith alcohol or drugs - deprivation, poverty, poorhousing, low educational achievement - are allincreasingly recognised as principal causes of illhealth or contributing factors.

Context


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GGeenneerraall PPrraaccttiittiioonneerrss ((GGPPss)) ssppeenndd aarroouunndd 4400 ppeerrcceenntt ooff tthheeiirr ttiimmee ddeeaalliinngg wwiitthh nnoonn--mmeeddiiccaall

iissssuueess..

At the same time the demands being made onsocial care are more complex – rising numbersof infirm, frail elderly require higher levels ofsupport, including medical assistance to remainat home or in the community. Increasingnumbers of vulnerable children and adultsincluding those with mental health and learningdisabilities are being cared for in localcommunities rather than in hospital.

There is an urgent need to shift the emphasis ofcare from treatment to prevention:

• one in five adults still smoke - smoking ratesduring pregnancy range from 2% in westLondon to 28% in Blackpool;

• a third of people drink too much alcohol;

• a third of men and half of women don’t getenough exercise;

• almost two thirds of adults are overweight orobese - fewer than one-in-ten children areobese when they enter reception class but bythe time they’re in Year Six, nearly one-in-fiveare then obese3.

These figures on obesity and lack of exercise,especially amongst children and young peopledemonstrates starkly why a radical step changein health promotion is needed to tackle theunderlying causes and not just the symptoms:

“If diabetes was a country it would be thefifth largest country in the world. That’s how

many people across the globe are affected”. (USA Federal Assistant Minister for Health,Ken Wyatt)

“Put bluntly, as the nation’s waistlinekeeps piling on the pounds, we’re pilingon billions of pounds in future taxes justto pay for preventable illnesses.” (NHS Five Year Forward View)

The fifth wave of public healthPublic health has been characterised as havingdeveloped in four waves:

11sstt WWaavvee:: formed the origins of public healthwith programmes to provide clean water andsanitation in response to rapid urbanisation ofpopulations.

22nndd WWaavvee:: concerned the development ofmedicine as a science associated with thedevelopment of hospitals and new approachesto combat diseases with medical treatments.

33rrdd WWaavvee:: saw the development of large socialprogrammes such as the establishment of thewelfare state and the NHS with a focus onpopulation health.

44tthh WWaavvee:: recognition of the social determinantsof ill health and factors associated with lifestylechoices such as alcohol, drugs and obesity.

It is now being suggested that we are at thepoint of a FFiifftthh WWaavvee of public health4 wheregreater emphasis needs to be placed onindividuals making decisions about maintainingtheir own health in cooperation with health andsocial care professionals. Public healthoutcomes from the Fifth Wave will be determined

3. NHS England, ‘NHS Five year Forward View’, 20144. Lyon, A. ‘The Fifth Wave’, Scottish Council Foundation, Edinburgh, 2003

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by enabling government and collaborationacross the health and social care sectors.

The Fifth Wave of public health takes greateraccount of the changing nature of health andsocial needs and demands. It also pointstowards the need for a new way to think aboutservice delivery i.e. integration of health andsocial care and greater use of innovations thatgive the service user greater control of theirhealth care. The Fifth Wave of public health hasbeen characterised in various ways but some ofthe key aspects that will influence health andsocial care systems include:

• more complex care pathways that canfacilitate multiple entry and exit points ratherthan one linear path;

• health and social care outcomes will benegotiated between practitioners, serviceusers and carers;

• the lived experience of service users will bemore central to service planning and delivery;

• the pace of change for innovations will bemore rapid and services will need to be moreadaptive and forward looking to take accountof this.

Context


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The Fifth Wave of public health is about culturechange, where healthy behaviours are supportedand sustained through collaboration andintegration across the physical, social andeconomic environment.5

NHS Five Year ForwardViewThe NHS Five Year Forward View sets out a sharedvision for the future of the NHS based around newmodels of care. It was developed by NHS Englandand the partner organisations that deliver andoversee health and care services including theCare Quality Commission, Public Health Englandand NHS Improvement (previously Monitor andNational Trust Development Authority). The FiveYear Forward View presents three criticalarguments for developing the future of health care:

FFiirrssttllyy – future health, sustainability of the NHSand thus economic prosperity will rest upon aradical upgrade in prevention and public health;

SSeeccoonnddllyy – patients need greater control overtheir care and the NHS needs to be a betterpartner with voluntary sector agencies and localcommunities;

TThhiirrddllyy – decisive steps must be taken to breakdown the barriers to care including betweenprimary and acute care, between health and socialcare and between mental and physical health.

There is recognition that ‘one size does not fit’all – and that there will need to be a range ofsolutions across different health communities.At the same time this does not mean that ‘athousand flowers should bloom’ but rather thereshould be a small number of radical new care

delivery options that are supported by the NHS’national leadership so that a selected numbercan be given the resources and support forimplementation where that makes sense.

Some of the options that are being consideredinclude:

• MMuullttiissppeecciiaallttyy CCoommmmuunniittyy PPrroovviiddeerrss -consisting of GPs, nurses, other communityhealth services, hospital specialists andmental health and social care providers, thesenew provider models can create integratedout-of-hospital care. This could result in directemployment of hospital consultants, havingadmitting rights to hospital beds, runningcommunity hospitals or taking delegatedcontrol of the NHS budget.

• AAccccoouunnttaabbllee CCaarree OOrrggaanniissaattiioonnss (ACOs) –integration of primary and acute care systems(PACS) is envisaged on the lines of anAccountable Care Organisation (ACO) such asthose in the USA, Europe and elsewhere. TheNHS Five Year Forward View is suggesting thiskind of vertical integration although thecomplexities of achieving this are recognised:

“PACS models are complex. They take timeand technical expertise to implement. Aswith any model there are also potentialunintended side effects that need to bemanaged. We will work with a smallnumber of areas to test these approacheswith the aim of developing prototypes thatwork, before promoting the mostpromising models for adoption by thewider NHS.” (NHS Five Year Forward View. NHS England.2014)

5. Davies et al, ‘Public health workforce of the future: A 20-year perspective’, Centre for Workforce Intelligence,March 2016

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• IInntteeggrraattiioonn ooff uurrggeenntt aanndd eemmeerrggeennccyy ccaarree –this will include redesigning the way in whichA&E departments, GP out-of-hours services,urgent care centres, NHS 111, and ambulanceservices are delivered.

• aa sshhiifftt iinn iinnvveessttmmeenntt ffrroomm aaccuuttee ttoo pprriimmaarryyaanndd ccoommmmuunniittyy sseerrvviicceess – includingstabilising core funding for general practicenationally over the next two years andenabling Clinical Commissioning Groups tohave the option of more control over thewider NHS budget.

The Forward View also recognises that thereneeds to be national support and leadership toenable these new care models to be developedeffectively. This will include the nationalleadership of the NHS acting coherently togetherto provide meaningful local flexibility in the waypayment rules, regulatory requirements andother mechanisms are applied. This does notmean further national structural reorganisationbut rather supporting diverse solutions and localleadership to develop services as they need to.This is key to innovation, which has often beenhampered by restrictive regulatory controls andthe lack of freedoms to integrate budgets andwork more collaboratively with partners fromwithin and outside the NHS family.

Contrary to appearances the NHS actually has astrong record of performance improvements andefficiency savings ranging from 0.8% over thelong term to 1.5% - 2% in recent years. TheForward View believes that an efficiency target of3% could be possible by the end of the nextdecade but this will depend on:

• investment in new care models;

• sustaining social care services, and

• over time, seeing a bigger share of theefficiency coming from wider systemimprovements.

One of the key challenges will be ensuring thatthese efficiency savings can help close theprojected £30 billion funding gap:

“Delivering on the transformationalchanges set out in this Forward View andthe resulting annual efficiencies could - ifmatched by staged funding increases asthe economy allows - close the £30 billiongap by 2020/21.” (Five Year Forward View. 2015 NHSEngland)

NHS England set out new steps to be takenduring 2015/16 to deliver the NHS Five YearForward View. This was the first time that theannual planning guidance has been jointlyproduced by NHS England, Public HeathEngland, Monitor, the NHS Trust DevelopmentAuthority, the Care Quality Commission andHealth Education England. As part of theallocation of an additional £1.98 billion for everylocality across England the joint annual plan:

• sets out seven approaches to a radicalupgrade in prevention of illness, withEngland becoming the first country toimplement a national evidence-baseddiabetes prevention programme;

• explains how £480 million of the extrafunding will be used to supporttransformation in primary care, mentalhealth and local health economies;

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• makes clear the local NHS must work togetherto ensure patients receive the standardsguaranteed by the NHS Constitution;

• underlines the NHS’s commitment to givingdoctors, nurses, other staff and carersaccess to all the data, information andknowledge they need to deliver the bestpossible care;

• details how the NHS will accelerateinnovation to become a world-leader ingenomic medicine and testing andevaluating new ideas and techniques

Simon Stevens, the Chief Executive of NHSEngland, said:

“...the health service can’t just keeprunning to catch up. Instead we need tobegin to radically reshape the way we carefor patients, which is why there is suchwidespread support and enthusiasm forthe NHS Five Year Forward View.” 6

It is clear that collaboration, integration andinnovation are at the heart of the NHS Five YearForward View and these principles are key torealising the long term sustainability of the NHSand social care.

Cities and localgovernment devolutionIntegration and sustainability should also beviewed in the context of devolution, whichprovides an opportunity to deliver servicesdifferently through local empowerment. TheCities and Local Government Devolution Act2016 received Royal Assent in January 2016. The

main provisions of the Act allow for thedevolution of powers from the UK government tosome of England’s towns, cities and counties.This includes: the introduction of directly electedmayors to combined authorities and allowingdirectly elected mayors to replace Police andCrime Commissioners (PCCs) in these areas.

The Act also removes the current statutory limitationon the functions of these local authorities, e.g.these are no longer limited to economicdevelopment, regeneration, and transport.Finally, the Act enables local authority governanceto be streamlined as agreed by councils.

The negotiations between the UK governmentand local authorities (or groups of localauthorities), to bring any transfer of budgetsand/or powers into effect known as devolutiondeals took place during 2014-15, and by March2016 twelve devolution deals had been agreed:Cornwall, East Anglia, Greater Lincolnshire,Greater Manchester, Liverpool City Region;London, North East Combined Authority,Sheffield City Region, Tees Valley, West England,West Midlands Combined Authority and WestYorkshire Combined Authority.

Following the initial deal in 2014, GreaterManchester and NHS England signed up toarrangements to bring together £6 billion of NHSand social care budgets so that joint planning ofthese services deliver better care for patients.

Other devolution deals that include plans forhealth and social care include: a London Healthand Social Care Devolution Programme Boardestablished in January 2016, accounting to theLondon Health Board and The North EastCombined Authority establishment of a

6. NHS England, ‘Health leaders set out new year plan for a sustainable NHS’, 2014,https://www.england.nhs.uk/2014/12/forward-view/# (accessed June 2016)

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Commission for Health and Social CareIntegration (in partnership with the NHS).

Although Greater Manchester is at the mostadvanced stage of planning for devolution ofhealth and social care the potential advantagesof this approach are being keenly watched bymany other towns and cities.

Leaders of health and social care across GreaterManchester are making progress on work in anumber of areas, including: extending seven dayaccess to primary care, radically upgradingprevention and public health, helping those withmental ill health into work, transforming treatment,care and support for people living with dementiaand making Greater Manchester’s AcademicHealth Science System a national leader:

“By the end of this year they will have aStrategic Sustainability Plan in place toshow how they will deliver a clinically andfinancially sustainable set of health andsocial care services for the people ofGreater Manchester. The production of theStrategic Sustainability Plan will bealigned with the Spending Review processthat applies to NHS, Public Health andLocal Authority social care funding.” 7

One Public EstateOne Public Estate (OPE) is a pioneering initiativedelivered in partnership by the Cabinet OfficeGovernment Property Unit (GPU) and the LocalGovernment Association (LGA). It providespractical and technical support and funding tocouncils to deliver ambitious property-focusedprogrammes in collaboration with centralgovernment and other public sector partners.

The Government published its first estatesstrategy in 2013 and updated this in 2014 toencompass an expansion of the scope of workincluding a leap in the scale of the ambition thatwill use the estate strategy to deliver improvedand integrated public services and as an enablerfor growth:

“In line with what many private sectororganisations have achieved, we expectthis to increase productivity, reduce costs,improve wellbeing, and contribute to widerobjectives such as localism, sustainability,and reducing pressure on the transportsystem.” (Government’s Estate Strategy, 2014.Cabinet Office)

Between now and 2020 the government expectsto reform how the state uses property, so that it:

• removes artificial boundaries betweendepartments, local authorities and otherpublic bodies;

• works in ways that minimise the need foroffice space;

• uses estates efficiently, and

• gets rid of surplus in a way that maximisesreceipts, boosts growth and creates newhomes.

The potential gains from the One Public Estateprogramme are significant, for example, theOffice for Budget Responsibility estimates localauthority capital receipts to be £11.2 billionbetween 2015 – 2020. Councils have alreadysold £10.6 billion land and property between

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7. HM Treasury, ‘Further devolution to the Greater Manchester Combined Authority and directly-electedMayor’https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/443087/Greater_Manchester_Further_Devolution.pdf (accessed June 2016)

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2010-2015 and local authorities in England hold£225 billion of assets, including over £60 billionin property not used for schools or housing. Byusing assets more effectively councils can createlocal economic growth, and deliver moreintegrated public services including health andsocial care:

“At its heart, the programme is aboutgetting more from our collective assets –whether that’s catalysing major servicetransformation such as health and socialcare integration and benefits reform,unlocking land for new homes andcommercial space, or creating newopportunities to save on running costs orgenerate income.” (One Public Estate. April 2016. Invitation toapply)

The OPE specifically recognises the strategic valuein uussiinngg eessttaatteess aass aa lleevveerr ffoorr ggrreeaatteerrttrraannssffoorrmmaattiioonn. This is one of the key essentialinsights that the model for integration andinnovation is based on, alongside recognition that:

• seeing property as a strategic asset can reapsignificant rewards. It can be an effectivecatalyst or enabler for reforms such as healthand social care integration, benefits reform anddigitisation; and for local economic growth;

• local priorities should be the driver withproperty the facilitator to achieving goals;

• Councils are at the heart of successfuldelivery – they have the democraticlegitimacy, dedicated interest and breadth ofresponsibilities to lead local partnerships.

The NHS EstateIt is estimated that the NHS has a total land areaof just over 6,500 hectares, a mass that equatesto the size of Wolverhampton and its localauthority boundaries. With total occupied floorspace equalling nearly 25million m2 it is thebiggest organisational occupier in the UK.8 Thescale and size of the NHS estate comes atconsiderable cost i.e. estates running costs arethe tthhiirrdd llaarrggeesstt eexxppeennddiittuurree ffoorr tthhee NNHHSS afterstaffing and drugs.9 When facilities managementand maintenance services are included the costsof financing the NHS amounts to ££99bbnn. On top ofthis there are an estimated ££44..33bbnn costs toeradicate the current NHS backlog inmaintenance.

This in part can be attributed to the building’sage profiles. For example, over 1155%% of the NHSestate was built before 1948, prior to when theNHS was established and before around 8800%% ofthe UK population were even born.10 In additionacross NHS trusts, on average 4.18% of theiroccupied space is currently under-utilised.Nevertheless, despite this context of a complex,costly and inefficient estate, the NHS is assetrich and there is significant potential for thefinancial benefits of these assets to beunlocked. The Department of Health, writing in2014, explains that:

“… [The NHS] estate has importantcontributions to make in deliveringsavings and reducing running costs. Thesemust be undertaken to meet thechallenges of funding the NHS in thefuture and will form part of thegovernment’s drive to increase theefficiency of the public sector estate.

8. Health & Social Care Information Centre, ‘Estates Returns Information Collection – ERIC 2014-15’, June 20169. Department of Health, ‘Hospital Estates and Facilities Statistics 2013-14’, (2014, accessed June 2016)10. The EC Harris NHS Estate Efficiency Annual Review, ‘NHS Estate Efficiency Annual Review: Delivering BetterHealthcare Outcomes More Efficiently’ 2013

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Accordingly, a significant step change inthe way this estate is managed has to beachieved.” 11

With just under 770000 hheeccttaarreess of NHS landidentified as surplus or potentially surplus in2015, releasing capital from disposal is oneavenue of revenue generation.12 For example,NHS Trusts reported in 2014-15 an income of justunder ££115566mm from building and land sales.13

This potential can be used to support:

• Revenue generation

• Efficiency savings

• Better health outcomes

However disposals have been contentious asthey have been associated with the notion of“selling off the family silver” and using assetsales to plug revenue gaps. There arealternative approaches that could bring moresubstantial, longer term benefits, for example,as argued in a joint Health Foundation andKings Fund paper:

“… the greatest opportunity for realisingvalue from the NHS estate is, in fact, likelyto be the generation of new revenuestreams (from both used and unusedestate), rather than capital receipts fromsale of surplus land and buildings.” 14

These new opportunities include developingleaseback arrangements with propertydevelopers or using land for community goodand social impact investment e.g. leasing toother local public service providers ordeveloping social housing stock.

Social investment andimpactSocial Investment including Social Impact Bonds(SIBs) are designed to transform the outcomesof publicly funded services by using paymentsby results to focus on social impact e.g.improved health and social well-being ratherthan inputs (numbers of doctors or social careworkers) or outputs (numbers of hospitaloperations or residential care placements).

The Centre for Social Impact Bonds in theCabinet Office sets out the benefits of theapproach:

“SIBs can increase the diversity oforganisations able to deliver publicservices, including social enterprises andcharities. Funds like the YouthEngagement Fund have contributedtowards the development of 32 SocialImpact Bonds across the UK, supportingtens of thousands of beneficiaries in areaslike youth unemployment, mental healthand homelessness.” (Centre for Social Impact Bonds, CabinetOffice)

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11. Department of Health, ‘Part A: Strategic framework for the efficient management of healthcare estates andfacilities’, October 201412. Department of Health, ‘2015 Surplus Land Data Collection’, (2015) accessed athttps://www.gov.uk/government/publications/release-of-nhs-owned-land-for-development13. Health & Social Care Information Centre, ‘Estates Returns Information Collection – ERIC 2014-15’ (accessed June 2016)14. The King’s Fund & The Health Foundation, ‘Making change possible: a Transformation Fund for the NHS’,July 2015

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The transformative features of SIBs include:

• Aligning financial rewards with socialoutcomes. SIBs focus payments on thesocial outcomes that services achieve, suchas improved employment rates or lowerhospitalisation levels.

• Bringing together distinct expertise fromdifferent sectors. Service providers oftenhave deep understanding of a particularcohort of people and the type ofinterventions that are effective. Sociallyminded investors may have both finance andcontract measurement experience, as well asa desire to have a social impact. SIBs allowcommissioners to bring together thesecomplementary requirements.

• Driving innovation in the social sector. SIBsshift the financial risk of new interventionsaway from the public sector, towardsinvestors, resulting in innovation anddiversification of service provision.

• Improving value for money of publicspending. SIBs enable government to onlypay for interventions that are effective.

(Centre for Social Impact Bonds, Cabinet Office)

A broader approach to social investment wouldenable commissioners to leverage public fundsalongside attracting private investors to fundearly and preventative action on complex andexpensive social problems. This is alsoimportant in breaking down public perceptionsabout the role and contribution of privateinvestment in health and social care as theapproach to social investment sets out clear

benefits that are driven by social outcomesrather than financial gains.

Combining public transformation funds withprivate investment provides a way by which newservices can be tried that allows greaterflexibility for those providing the services toadapt and change the service according to theirexperience and means that they don’t have toshoulder the whole burden of costs if they don’twork.

In this way new models of health and social caredelivery can benefit from social Investment byleveraging private and public investment forbetter outcomes on a shared risk basis. It alsohelps services have a greater emphasis onprevention and brings in a wider range ofagencies from across the social sector includingsocial enterprises who can bid for and manageprojects under government covenant protection.One of the most significant advantages of socialinvestment approaches are that they enablegrowth in the social sector and support socialsector agencies to play a part in servicetransformation as equal partners:

“The voluntary sector are only brought inat last minute as an after thought but weprovide essential services and need to beat the heart of change andtransformation.” (Social sector stakeholder)

“The social sector is growing and has astrong record of innovation and providingservices that are closer to people andmore in line with their needs.” (Social sector stakeholder)

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New technologyDigital technologies and services are maturing ata pace that provides opportunities to create andconsume services in a more personalised andtargeted way. By placing the individual at theheart of the transformation, helping them tounderstand their own needs, and link intosmarter digitally enabled technology, the healthand social care sector can continue transformingto meet the demands of both the individualcitizen and the populace. However, the focusshould be on IT enabled businesstransformation, so that new technologies areapplied in the right context:

“In areas such as health, understandingthe environment in which the technologymust work is as critical as the technologyitself. Third party organisations need to beable to understand the healthenvironment, such as things like ‘InfectionControl’ so that solutions are fit forpurpose. Organisations need to workcollaboratively with third parties whoclearly understand the full businessenvironment and can advise and adapttheir solutions as needed.” (Private sector stakeholder)

“It is important that projects are driven bybusiness need and requirements and arenot purely focussed on the physicaltechnology, otherwise, this can and doescompromise how people want to work andthe benefits which could be achieved.Organisations should put the businessfirst and IT should support what is neededto change the business functions.” (Private sector stakeholder)

“In certain organisations there is a culturalproblem with people not willing to adaptand change their ways of working for anumber of factors, the main one being fearof the unknown. When looking into adigital programme of change,organisations need to bring the employeesalong on the journey and should get theminvolved as soon as possible to gainbacking and adoption. Adopt the ‘do itwith them’, rather than ‘do it to them’approach.” (Private sector stakeholder)

The following model (developed by Sopra Steria,one of the sponsors for the Breaking Barriersprogramme) is broken into six interlinked topicareas to describe how new ways of working andemerging technologies can deliver a betteroutcome for the health and social care sector, aswell as the citizen experience.

These topics cover a number of core outcomesand benefits relevant to the utilisation oftechnology within Health and Social Care toimprove health and wellbeing such as:

• Contributing to better economic outcomes,though demand management andautomation of non-critical processes

• Adding value with improved performancethrough the introduction of digital servicesand self-help solutions

• Joining-up data to enable secure andinformed management of complex demands

• Equipping the right resources at the rightplace to save lives

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• Achieving interoperability for seamlesscommunication

• Enterprise-wide visibility for improvedfinancial control

newways of

working to support better

outcomes

The Digital PatientBy increasing the adoption and rangeof available technology it is possibleto create a mesh of connected devicesthat integrate and collaborate so thatcitizens can actively manage their ownhealth and wellbeing moving towardsmore personalised services

The organic health service Digital capabilities are able to connecta variety of people, processes,disciplines, organisations andprofessionals to provide services,which meet the needs of today’sindividuals, but also can organicallygrow and respond to change as

The connected health serviceTo be a truly connected service, whichis driving beneficial outcomes,organisations must go beyond theformal service offerings from the NHS,Local Authorities and Social Careteams to enable as well as to deliver

Intelligent insight & automationThe more insight which can beobtained from available data, themore organisations can understandthe conditions and demand, whichcan drive new ways of engagementand new service and assist theunderstanding of demand patterns.

Invisible technologiesFor individuals who need assistedliving, invisible technologies cansupport the removal of complex andinvasive technologies and offer morefreedom and confidence to live athome longer whilst still knowing helpis available should it be needed.

Disruptive solutionsThis maturing of capability to deliveran on-demand platform and serviceofferings is changing the way solutionsare viewed, as there is no longer anoperational need for complex digitalarchitectures for simple engagements.

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Achieving greater integration of health andsocial care is a long standing policy andlegislative ambition but substantial progress inachieving this has proved elusive. A new modelfor integration is needed that can address thebarriers to change across system, financial,outcomes, workforce and infrastructure levels.The model needs to build from the ground upstarting with collaboration on estates andinfrastructure that enables integration ofworkforce, budgets and the system of servicedelivery and accountability. In this way greaterinnovations can be realised that will result inimprovements in people’s lives and betteroutcomes in services and interventions that aresustainable for the future.

CollaborationCOLLABORATION noun:1. the action of working with someone to

produce something: synonyms: cooperation,alliance, partnership, participation

2. traitorous cooperation with an enemy; synonyms: fraternization, colluding,collusion, conspiring

Unfortunately the history of collaboration inhealth and social care is more one of ‘traitorouscooperation with an enemy’ than workingtogether to produce something. This is in partdue to the way that health and social care isstructured with separate organisational forms:governance, funding and accountability. Whileany successful change needs leadership, it isalso possible for leaders themselves to becomebarriers to change. This is best illustrated by theso called ‘prisoner’s dilemma of game theory(see below). The prisoner’s dilemma is ametaphor used in game theory to explain why

two completely ‘rational’ individuals mightchoose not to cooperate, even when everythingsays it is in their best interests so to do.

The Prisoners’ DilemmaTwo members of a criminal gang are arrestedand imprisoned. Each prisoner is in solitaryconfinement with no means ofcommunicating with the other. Theprosecutors lack sufficient evidence toconvict the pair on the principal charge.They hope to get both sentenced to a year inprison on a lesser charge. Simultaneously,the prosecutors offer each prisoner a bargain.Each prisoner is given the opportunity eitherto: betray the other by testifying that the othercommitted the crime, or to cooperate with theother by remaining silent. The offer is:

• If A and B each betray the other, each ofthem serves 2 years in prison

• If A betrays B but B remains silent, A willbe set free and B will serve 3 years inprison (and vice versa)

• If A and B both remain silent, both ofthem will only serve 1 year in prison (onthe lesser charge)

(Poundstone, 1992)

For leaders of health and social care thedilemma is one of accountability and sharedresponsibility with national regulators such asthe Care Quality Commission (CQC) and NHSImprovement playing the part of the police. So,in the case of patients such as the frail elderly,or those with long term conditions andrehabilitation needs, who are in hospital beds

Building a sustainable future – amodel for integration and innovation


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but who would be better placed in thecommunity or at home, where does theresponsibility lie for the failure to make thishappen? Is this a health issue or is it one ofsocial care?

The prisoner’s dilemma only arises becausethere are two prisoners locked into the dilemma.If there were one clear line of accountability andresponsibility for both health and social care inthe local system, entirely new approaches toresolving the issues will arise:

“We need to be focused on outcomesacross the whole system and not our ownorganisations.” (Public sector stakeholder)

“There are too many players and they areall competing with each other, why can’tthere be one single body responsible forthe entire local system? ” (Social sector stakeholder)

IntegrationINTEGRATION noun:

the action or process of integrating – “economicand political integration”: Synonyms:combination, amalgamation, incorporation,unification, consolidation, merger, fusing,blending, meshing, homogenization,homogenizing, coalescing, assimilation

There are many examples of health and socialcare organisations combining, amalgamating orincorporating different services. Others havesought to create unified systems through greaterconsolidation, organisational mergers, fusing ormeshing of service elements.

There are few examples that have fully succeededin homogenising or assimilating health and socialcare in a way that is truly integrated. The mostrecent examples of integration consist of servicesthat have taken over the functions and delivery ofanother through legislative permission, such asthe competitive procurement rules under section75 of the Health and Social Care Act.

But these are mostly transfers of existing healthservices to another contractor rather thanintegration of core service elements acrossdifferent parts of the health and social caresystem. They are focused largely on verticalintegration when what is required is a strongerfocus on horizontal integration.

Vertical and horizontal models forintegrationBoth vertical and horizontal models of integrationare proposed in the NHS Five Year Forward View.However, these are largely conceived within thecontext of health care organisations and systemswith only limited scope for vertical integrationbetween the NHS and local authorities.

Vertical integration is characterised by:

• Top down, command structure

• Linear collaboration

• Focus on efficiency savings rather thanstrategic change

• Limited flexibility for innovation

• Rule bound

• Narrow integration

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Vertical integrationGovernment or a national agent usually initiatesvertical integration. It is a closed system with atight rule structure that restricts scope forcollaboration, innovation and further integration especially for partners not within the closedstructure.

Vertical integration is based on systems andorganisations rather than place and people. Thekey driver is efficiency savings rather thanstrategic transformation.

Horizontal integrationHorizontal integration involves government ornational agents acting as a facilitator and enabler.Horizontal integration is place and people basedrather than systems and organisations.

It is an open, negotiated system with maximumscope for collaboration, innovation and furtherintegration including stakeholders who mightotherwise be unable to take part, e.g. public,private and social sector providers, employers,communities. The driver is strategic changerather than a sole focus on efficiency.

Horizontal integration is characterised by:

• Shared control

• Focus on strategic change rather thanefficiency

• Networked collaboration

• Maximum flexibility for innovation

• Negotiated rules

Innovation

INNOVATION noun:The action or process of innovating:Synonyms: change, alteration, revolution,upheaval, transformation, metamorphosis,variationInnovations have also been described asbetter ways of meeting new requirements orneeds; and as an original, more effectivemethod for breaking into new markets.

If there is one term that is at risk of being over usedand is probably least understood in health andsocial care - it is innovation. A term that is “crucialto the continuing success of any organisation” it isalso variously defined as being about change,revolution, upheaval, restructuring and variationincluding new ways of using technology.


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Almost anything new can be seen as innovationand that is part of the problem in seeking todefine innovation as an essential principle in amodel of change and transformation. The risk isthat in the drive for innovation we seek changefor change’s sake. Rather, innovation should beseen, as a means to achieving an aim thatotherwise could not be realised without a newway of conceiving the problem and/or solving it.

Innovation is clearly about new ways of doingthings and whether revolutionary or altering,innovation needs to be considered in terms ofoutcomes, i.e. innovation should serve purposerather than the purpose being innovation. So,rather than approach innovation as somethinggood in itself we need to ask first what anyparticular innovation is meant to achieve?

Innovation should be judged by whether or not itdelivers the promised outcome. And herein liesanother problem. To be clear about the purposeof innovation we need to understand the desiredoutcome:

“If you want something new, you have tostop doing something old” (Peter F. Drucker)

“Organisations can jump on specifictechnology without understanding ordefining why they need somethingdifferent. There needs to be a cleardefinition and understanding of theoutcome which is being aimed at.” (Private sector stakeholder)

“Everyone is talking about Digital thisand Digital that, vendors are pushingtheir versions of products and tools and

organisations are finding it increasinglydifficult to understand what is mostappropriate. Organisations need to bevery clear of what the outcome is they aretrying to achieve and then find aservice/company/product, which candeliver the outcome. Trying to investigateall possible options will simply confusethe situation further.” (Private sector stakeholder)

Collaboration, integration and innovation areinterdependent steps for addressing the criticalchallenges facing health and social careservices. The model provides a new way ofthinking about health and social care that goesbeyond the current narrow conceptions ofdiscreet services and population groups. Themodel recognises that health and social careneeds have changed and it is focused onpositive outcomes in terms of improving livesrather than solely treating illness or managinginfirmity in line with the Fifth Wave of publichealth.

The model uses collaboration, integration andinnovation as levers for change in designing andimplementing new ways of delivering servicesthat are more cost effective and are betteraligned with local area Sustainability andTransformation Plans. This will be possiblethrough the new powers being granted toelected mayors that will enable local area systemtransformation and leadership across the public,private and social sectors. The modeldemonstrates how actions taken in four areas:shared estates and infrastructure; workforcedevelopment; financial and budgetary alignmentand whole system leadership can provide asustainable future for health and social care.

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1. Shared Estates andInfrastructureThe physical environment in which many healthand social care services are provided aredisjointed and in many cases no longer fit forpurpose. Ownership is split between localauthorities, individual trusts, GPs and NHSproperty bodies such as NHS Property Servicesand Community Health Partnerships. Manyhospitals retain their Victorian infrastructure withall the problems that accompany this, forexample inefficient and wasteful heating andwaste systems, deteriorating buildings that areinaccessible and have poor or little use ofnatural light. The buildings and infrastructure forsocial care services are often little better andindividual service teams are located away fromtheir counterparts in health and related services:

“In the event of a fire or naturaldestruction no one would re-build theseestates in the same way.” (Public sector stakeholder)

However, despite these deficiencies health andsocial care estates represent one of the mostsignificant areas for releasing capital assets andachieving significant cost savings. But theincreased efficiency and cost savings that anintegrated approach to health and social careestates could bring, is not just about therationalisation of the estate but using estates asa lever for collaboration that can address widersystem and service transformation:

“The health estate is a hugely valuableand relatively untouched portfolio whichhas significant potential to reduce costand release value back into the system, as

well as be a catalyst for operationalchange by delivering a reconfigured realestate infrastructure platform to supportthe delivery of new models of care.” (Public sector stakeholder)

Collaboration is critical to unlocking thepotential benefits from the combined health andsocial care estate. Asset ownership is currentlyfragmented so there is a need to review thecombined estate in terms of creating a singleportfolio or a sub set of scale portfolios. A moredynamic portfolio, moving from fixed to variableuse should be incorporated into the localSustainability and Transformation Plans. Thiswould also ensure that the plans are morealigned on an integrated basis with sharedresponsibility across the NHS and local authoritypartners. In this way the STP property strategieswill have a clearer service strategy for anintegrated health and social care estate.

Collaboration of this kind, between public,private and social sector agencies, on a morestrategic and focused approach to area basedchange for health and social care would enablethe following:

• realisation of greater cost savings throughshared facilities and buildings developmentand management;

• alignment of strategy for local arearegeneration and development andSustainability and Transformation Plans;

• release of assets for pump priming of ring fencedinvestment to support service re-configurationand integration in line with the NHS Five YearForward View and the One Public Estate;



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• integration of service delivery acrossorganisational boundaries;

• improved access and use of services that aredelivered closer to where people reside andwork;

• innovations in design and infrastructuredevelopment that would support improvedoutcomes from health and social care;

• more flexible use of buildings and facilitiesto enable change and adaptation as serviceneeds and demands change.

This is already in evidence through thegovernment’s approach to One Public Estate andmoves towards colocation across local authorityservices, benefit services, jobcentres andhousing associations. However, much lessattention has been paid to the needs of primarycare provision and there has been much lesscollaboration between the NHS and localauthority partners about area based planningand needs. Sustainability and TransformationPlans go some way towards this but these plansneed to be better aligned with local authoritydevelopment and transformation strategies. Thecomplexity of design, delivery and managing amodern, integrated health and social care estaterequires a model that provides flexibility,financial robustness and ensures property is notan outcome, but a catalyst for future change.

1.1 Designing and delivering afuture estate footprintOne of the greatest barriers to designing anddelivering a future estate footprint for health andsocial care is the poor history of collaborationbetween NHS and local authority partners:

“Collaboration at a strategic level islacking. As a local authority we are muchmore advanced in this than our NHScolleagues – there has been a reluctanceto engage on a strategic level.” (Public sector stakeholder)

“We need a partnership approach - thinkingdifferently, more strategically so we canscan the horizon and start thinking wheredo things need to be in 10 15 years time?”(Private sector stakeholder)

The key factors that result from this lack ofcollaboration, as discussions with a number ofkey stakeholders in the review process havehighlighted, are:

• poor integration of strategy between NHSand local authority partners;

• lack of service co-design between NHSorganisations, local authorities and thesocial sector;

• few ideal sites for integration at local levelswith the consequence that new fundingmodels to support new build developmentsare required.

Despite a positive direction of travel with localhealth and wellbeing boards, NHS propertycompanies and the planning for localSustainability and Transformation Partnerships,these are fundamentally operating in anenvironment of silos with the key focus onindividual organisational sovereignty betweenproviders. This is despite the fact that there areshared strategic objectives across providers,commissioners and local authorities:

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“NHS bodies ought to work with localauthorities and property developers whenundertaking estate rationalisation.” (Public sector stakeholder)

“Short-term decision-making was one ofthe main problems preventing a morestrategic approach to estatemanagement.” (Public sector stakeholder)

Health services have tended to design and plantheir estates in isolation from other localpartners with acute hospitals taking the mainshare of development funding and infrastructurecosts. Developments have also been focused onhistorical service delivery patterns rather thanfrom the perspective of service use. This hasinhibited the development of an estates andinfrastructure strategy that is forward lookingand able to better meet the changing patterns ofdemand and needs for services:

“We need to link top strategy anddemographic mapping with the local areain a practical demonstration of change –It’s not about facilities management beingdone better, but better health outcomesand prevention.” (Public sector stakeholder)

There is a growing consensus that the design ofhealth and social care estates and infrastructureat local levels must change to continue tosupport the health and social care needs of thecurrent and future population. This approach isbeing promoted by the Five Year Forward Viewwith the development of NHS England’s ‘HealthyNew Towns’, which look to design modern healthcare services and estates at the inception of

town planning. These kinds of initiatives showhow policy permission to rethink estates andinfrastructure strategies is increasingly coming tothe fore:

“The difference is how we can start to usethe One Public estate strategy to createwider change in health and social care,including more multi-disciplinary workingpractices, partner roles, breaking downthe silos – there hasn’t been enoughthought about this from our NHSpartners.” (Public sector stakeholder)

Similar new thinking (as proposed by Lord Darziof Denham in his reviews of both national andLondon healthcare systems15 and supported inthe NHS Five Year Forward View) on better waysto utilise NHS primary care estates can be seenin alternative GP led health centre models, suchas ‘polyclinics’ which are moving routine acuteservices to primary and community care-basedsettings, producing an accessible one-stop-shopmodel:

“We need to really re-think the acutehospital model.” (Public sector stakeholder)

One-stop-shop models, or more widely, PublicService Hubs, which combine services, staff andbudgets from a range of related providers, is thedirection of travel being pursued by theGovernment Property Unit with their GovernmentHubs programme with local authorities:

“A Public Service Hub is more than justabout delivering a cost-effective propertysolution for the public sector. It is about


15. Darzi, A., ‘Healthcare for London: A Framework for Action’ July 2007,


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creating modern, appropriate space fororganisations to proactively respond tonew demands on their finances andservices.” (Private sector stakeholder)

The Public Service Hub model, as illustrated inthe OneHub Bradford case study, is a potentiallypowerful vehicle for integration of health andsocial care services. The process involves threeelements:

1. Development of a delivery and financingpartnership between a head lease holder(usually the local authority) and a privatedevelopment agency with access toinstitutional fundsInitial collaboration on the delivery partnership iskey. This works best when a lead public agency,usually a local authority, takes a head lease roleproviding land for new build development. As theholder of the head lease the local authority canprovide a government covenant assurance thatenables a property development agency, withaccess to institutional funds for the capital costs,to be engaged as a partner:

“New property leases ought to be morecommercial in order to offer good value forthe taxpayer.” (Public sector stakeholder)

On the basis of the government covenant thedevelopment partner can provide the new build ona long term lease at the end of which it is returnedto public ownership. Because the occupancy isbeing designed for multi-agency use the revenuecosts i.e. rental can be sustainable and dependingon the number of agencies involved could providefunding for further social investment:

“Close down isolated, out dated hospitalbuildings and reinvest for better facilitiesthat are closer to the patient.” (Public sector stakeholder)

It is important at the planning and developmentstage that partners recognise the need to moveto execution and delivery of outcomes and notremain too fixed on planning:

“A collaborative approach between healthand social care leaders with a robustunderstanding of the financial imperativesfor each will focus minds and support jointdecision making.” (Public sector stakeholder)

2. Engagement with key services acrossthe public and social sectors that will takeup occupancy as lease holdersThe second element promotes collaboration atthe level of service providers across health andsocial care. This involves thinking about thechanging demands and needs for social careand new ways of working i.e. combing primaryand community care services with hospitaloutpatients and social sector partners to deliveran integrated early identification and preventionservice model. However, this needs to befacilitated and supported to overcome thechallenges and barriers to culture change:

“The big challenge is to make the ‘doing’happen, it needs culture change andleadership.” (Public sector stakeholder)

“There needs to be the appetite to do it atCEO level - then a tough skinned person tomake it happen at the ground.” (Public sector stakeholder)

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3. Analysis of current and future service useand workforce practices to ensure agileworking and maximisation of environmentaland technological innovation in design The third element uses the application of agileworking principles for shared space and services.The ‘actual’ space usage of staff and organisationscan be understood and designed for the new waysof working. Intelligent design principles enablecolocation to reduce individual running costs andensure that the facility is flexible for changing andfuture development of service delivery, needs andquality outcomes. Colocation also promotescollaborative working between agencies with widersavings achieved by reducing duplication andincreasing understanding across previouslydisparate elements in care pathways.

This approach to shared estates andinfrastructure supports the direction of travelbeing promoted by the Department of Health andthe Cabinet around estate management andallows for service transformation, majorregeneration and property development to takeplace, with no risk placed on the public sector orspending of taxpayer money:

“The provision of suitable estate for NHSservices should fully exploit the benefitsof integration and colocation with otherrelevant organisations. Engagement withlocal authorities and other public sectororganisations could lead to joint rationalisationsof assets and associated services.” 16

The design function can apply not only to agileworking practices but also to energy saving andthe standardisation of business processes. Theseprinciples have been put to good effect in the ‘designfor function’ approach of modern hospitals in Holland.

Case Study- OneHub Bradford

The challengeDespite being one of theUK’s biggest and fastestgrowing economies,Bradford has historicallybeen an underdevelopedcity with high levels ofdeprivation, unemployment anddisparate public services.

The local authority, City of BradfordMetropolitan District Council, realised theyneeded to undertake a large-scale program oftransformation to regenerate public spaces,improve services and deliver economicgrowth. Alongside this, the councilunderstood that their own estates wereunwieldy and inefficient and requiredrationalisation and modernising.

SolutionThe local authority recognised the need for anew approach that would develop more effectiveworking practices and sustain private and publicsector jobs. The initial solution envisagedbetter use of existing local authority buildingssuch as the library, which was underutilisedand occupied prime city centre space.

Using the Public Service Hub model as itsstarting point, a unique developmentpartnership, OneHub Bradford, wasestablished involving the Council and aPrivate Development Consortium made up ofthree Companies: McClaren Group,Chiltington Land Ltd. and DragonGate asdedicated programme managers. It focusesupon the re-use of the Jacobs Well site which


16. Department of Health, ‘Part A: Strategic framework for the efficient management of healthcare estates andfacilities’, October 2014


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until May 2016 was home to the Authority’scorporate service HQ. The location providesthe opportunity for a central, accessible andambitious base for public service integration.

OneHub Bradford is in the process ofdeveloping this significant opportunity for keypublic service providers. It maximises thevalue of government as an occupier of choice,a process that is designed to ensuredeliverability but minimises capital costs foroccupiers and risk for the council.

Crucial to the process is the programmemanagement. The programme involves acomprehensive engagement process withmultiple service providers on their currentchallenges and future needs. In addition toensuring the future is built around the citizenand service, and not short term expediency, theprogramme identifies opportunities forinvestment in modern working, shared spaceand longer term integration patterns, and placesthese into the Hub’s blueprint. This in turnenable an affordable BREEAM Excellent facilitythat avoids the punitive financial constraints ofPFI. By maximising the benefits of modern agileworking, the purpose built Hub saves money forthe occupiers through intelligent use of flexiblespace. The lease arrangements include anoptional turnkey facilities management packageand standardised fit out, to ensure collaborationis encouraged at every level. An HM TreasuryGreenbook business case for each potentialoccupier is undertaken at ‘no cost, nocommitment’, to provide transparent value formoney comparisons at each key stage.

BenefitsAlthough still at a relatively early stage

OneHub Bradford, based on the PublicService Hub business model, is successfullyengaging a range of public, private and thirdsector partners through service redesign andgreater integration. Pre-occupational analysisfor organisations going into the hub, projectaverage savings of 42% from existing usage.

It has also enabled the council to reuse a legacysite to develop a modern and dedicated facility forkey public service providers to work in. Ultimatelyit will achieve a collaborative environment throughshared space and co-location.

The Report Authors would like toacknowledge the contribution of DragonGate,Chiltington Land Ltd. McLaren Property andCity of Bradford Metropolitan District Councilfor this case study

The Dutch experience ‘Design forFunction’

The ChallengeWhilst the emphasisinevitably differs in individualcases, the challenges facedin healthcare today arebroadly the same in eachcountry: an aging population, asurge in chronic disease, technology advancesin the diagnosis and treatment of disease andmore informed patients – all factors which areleading to a rise in the cost of healthcare.This is often seen together with a rise inpatient numbers, budgetary pressures and anailing infrastructure, which all leads to a hugechallenges for hospital administration.

The Dutch healthcare system relies on a

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framework between patient, care providers,health insurers and the government as overseer.Prior to 2006 there was widespread publicdissatisfaction with the healthcare system relatedto the combination of lengthening waiting listsand spiralling costs that were characterised bya supply-based and densely regulated system.Healthcare reforms put into place in 2006liberalised the Dutch hospital market.

The SolutionThe solution in this context lies in theimplementation of smart solutions,understanding different behaviour in hospitalprocesses and an intelligent and flexible designof healthcare facilities. It usually starts with clearplanning of a facility and a master plan. Part ofthe solution is also found in standardisingprocesses and design which can help improvethe quality of care, patient safety and costs.

We have found that in some hospitals in theNetherlands, a target for standardisation of 80%of hospital processes leaves the organisationfree to focus on the remaining 20% that are notstandardised, to improve and optimise theirprocesses. The standardised processes also

offer monetary savingsin the training of staff.Processes where staffare not essential caneither be automated(Automated GoodsVehicles), or

outsourced.

New ways ofcombining

infrastructure and ITalso leads toimprovements. Thetracking of people candetermine the amount of climate controlneeded in a building. We have seen exampleswhere this “pull effect” of a climate need hasled to a 30% reduction in energy costs inspecific buildings. Royal HaskoningDHVimplemented such a system at AmsterdamAirport Schiphol, and the same technologycould be utilised across hospitals.

Design also plays a role in the optimisation ofthe hospital, specifically if it is a Greenfieldproject, but also in refurbishment projects.The planning process is one of the mostcrucial aspects of the hospital. Decisionsmade at an early stage will inevitably influencethe rest of the project. Decisions on thefunctionality need to be made at thebeginning of the design process and shouldoffer flexibility to be able to adapt to anyfuture changes in healthcare.

BenefitsAlone or in combination, the design and processimprovements should lead to an optimisedinitial cost as well as operational cost.


Patient

HealthProviders

Health InsuranceCompanies (21)

Government

Photo with permissionZuiderland hospital


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Process improvements on the other handleads to higher quality of care and even areduction of the average length of stay (ALS)in a hospital. The California HealthcareFoundation uses tracking tools to increasepatient flow, and has shown that for a 275bed hospital, reducing the ALS by 4 hours isequivalent to increasing physical capacity by10 beds. These improvements should in thefuture lead to less bricks, more bytes and adifferent behaviour in our way of working inthe hospital of the future!

The Report Authors would like toacknowledge the contribution of Dirk Joubertfrom Royal HaskoningDHV for this case study

1.2 Managing services for the future Ensuring sustainability for a future shared estatemodel for health and social care requires beingmore creative with how facilities are managed andmaintained. This includes planning for futurechange of service demands and needs so thatestates are managed flexibly and able to adapt tothese changing requirements. In order for this to beeffective it needs to be done on the basis of areaplanning and integration of health and social care.

Some new building and facilities managementservices have been enabled in the past throughprogrammes such as the Public Finance Initiative(PFI). However, these are often perceived to haveleft public services with unsustainable levels ofdebt and high interest payments, while beingcaught up in overly restrictive procurementcontracts that have prevented changes andadaptations to meet new circumstances andservice demands. New ways of thinking aboutpartnership between public, social and privatesectors on facilities management are needed:

“One of the key problems is the failure ofthe NHS to understand what private sectorcompanies could offer, it is because theylacked expertise and didn’t understandthe implications of large compoundinterest rates in PFI contracts.” (Public sector stakeholder)

“There is a lack of shared thinking in theNHS, multiple single service contracts thatare inflexible and don’t supportinnovation; little collaborativeprocurement. This is despite the widermarket moving forward with total facilitiesmanagement estates contracts andcombined partnerships for energy thatwork on the lifecycle of needs.” (Private sector stakeholder)

Facilities management services are normallyprovided on an organisational basis rather thanthinking about the potential cost savings andimprovements that could be made from having aunified, system wide approach to facilities:

“To be more sustainable in the futureestates teams need to take a morecommercial and strategic approach throughmore flexible, longer term contracts.” (Public sector stakeholder)

The Carter Review estimates that minimumsavings of £1bn could be realised through betterand more efficient estates and facilitiesmanagement, including better use of space andinvesting in energy saving schemes.17 This in partcan be attributed to a lack of relevant expertise:

“Many estates directors in CCGs andTrusts have engineering or facilities

17. Lord Carter of Coles, ‘Operational productivity and performance in English NHS acute hospitals:Unwarranted variations’, February 2016, p.13

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management backgrounds, they lack theexperience to manage property effectivelyand make savings in the long run.Chartered surveyors and other propertyprofessionals would be better placed tomanage NHS estates” (Public sector stakeholder)

Placing estates and facilities management in thehands of those who are expert to lead this canbring significant benefits:

“Good facilities management is about thepatient - everything we do is from thepatient perspective and this can overcomethe private public sector barriers.” (Private sector stakeholder)

“We need to apply professional capabilityand expert management to this challengeto achieve better outcomes.” (Public sector stakeholder)

The private sector does have this dedicatedexpertise and there are increasing examples ofhow this is being used and developed withinpublic sector services. But the history ofantipathy to perceived private sectorencroachment in the NHS can also be a barrierto the NHS and local government fulfilling itspurpose of delivering high quality care andensuring “that valuable public resources areused effectively to get the best outcomes forindividuals, communities and society for nowand for future generations”.18

Managing facilities from within each separateorganisation also means that leaders aredistracted from their core tasks of providinghealth and social care:

“There is no use of property managementservices currently in the NHS, instead theyhave in-house estate teams and the onlyarea of outsourcing is facilitiesmanagement.” (Private sector stakeholder)

“Because the estates teams are all in-house, hospital senior management arenot able to just focus on patient care andhealth outcomes, which is detrimental.” (Private sector stakeholder)

“Relieve the executive from worrying aboutleaky pipes.” (Private sector stakeholder)

Re-procurement of facilities management on abroader basis (area or sub-regional) wouldenable leveraging of economies of scale, whilstensuring local, high quality delivery on anintegrated basis. Estimates of potential savingsare significant i.e. approximately 20%.

Case Study: Leeds GeneratingStation Complex

ChallengeEnergy supply for LeedsGeneral Hospital came froma large generating stationthat had been constructed bythe then Yorkshire RegionalHealth Authority. It was originallybuilt to supply only the Leeds General Hospital(LGI), but later, in the 90s, it was adapted totake on the adjacent University of Leedscampus. The contract for the station came toan end in 2015 and was reaching the end of itsexpected life. One of the main challenges was


18. NHS England, https://www.england.nhs.uk/about/our-vision-and-purpose/ (accessed June 2016)


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to reconfigure the station from what was towhat it needed to be to meet the futurerequirements. This part of the process neededto be very carefully project managed toensure any interruptions to supply duringservice changeovers would not affect patientcare. The Trust and University agreed fivecommon objectives:

• To provide a resilient and secure utilitysupply

• Maximise the cost/benefit opportunitiesoffered by the procurement

• To make a major contribution towards theTrust’s and University’s carbon saving targets

• To provide a contract which offersflexibility to respond to commercialchange

• Maximise the associated commercialopportunities which may exist for bothorganisations

SolutionA joint Trust and University Project Board wasestablished, with each organisation having anominated senior responsible officer and ajoint working group within each organisation.The model works on standard OJEUprocurement documentation, but uses atripartite agreement between ENGIE, LeedsTeaching Hospitals and the University ofLeeds to provide a clear contractual structure.The technical challenge was to design, buildand operate critical energy infrastructureupgrades including the replacement of allgenerating and boiler plant infrastructure.

Benefits• Two equal partners Leeds Teaching

Hospital NHS Trust and Leeds University

• £30m of public sector investment

• 25 year contract to provide services

• £3.5m pa of guaranteed savings

“We must never forget that the secure,resilient supply of utilities is key topatient care. Without this service thequality of that care must never bereduced. Whilst I’m a professionalengineer, I’m never far away from thepeople who are reliant on the service.” (Mick Taylor, Deputy Director of Estatesand Facilities/ Head of Estates –operational services)

The Report Authors would like to acknowledgethe contribution of ENGIE for this case study

Case study: Collaboration to saveenergy costs - Liverpool EnergyCollaboration

ChallengeUsing £12.4 million ofprivate investment, ENGIEwill construct, operate andmaintain gas-fired CHPenergy centres for the three NHSTrusts, as well as carrying site-wide upgrades to energy-consuming services.

SolutionThe Liverpool Energy Collaboration wasestablished as a procurement partnership

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involving three NHS Foundation Trusts:Aintree University Hospital, The Walton Centreand Liverpool Women’s Hospital.

“In upgrading the energy infrastructure foreach of the Trusts, we will ensure theyhave a more reliable, resilient andresponsive energy services. In parallel, bymaking optimum use of low carbonenergy sources as well as upgradingservices in the building to maximiseefficiency, we will deliver guaranteedsavings with a fast return on investment,while also reducing environmentalimpact.” Paul Rawson, ENGIE’s Divisional CEO forEnergy Solutions

AAiinnttrreeee UUnniivveerrssiittyy HHoossppiittaall - The project workswill take place over 2 years and will incorporate:

• Steam conversion of the entire site with anew Low Temperature Hot Water heat network

• Installation of a 1.2MWe combined heatand power unit to provide significantfinancial savings

• Installation of 14 MW of boiler capacity toprovide thermal resilience to the site

• Provision of laundry equipment to enablethe Trust to continue to generate revenuefrom providing external services

• Replacement of heating, ventilation andair condition theatre equipment

TThhee WWaallttoonn CCeennttrree - The project works willtake place over 1 year and will incorporate

• Enhancing resilience and making savingsthrough the integration of both the Trust’sbuildings in the new Aintree UniversityHospital heating network

LLiivveerrppooooll WWoommeenn’’ss HHoossppiittaall - The projectworks will take place over 1 year and willincorporate:

• Enhancing resilience and improvingefficiency through the installation of a twonew burners for the Trust’s boilers.

• Installation of a 380kWe CHP to providesignificant financial savings.

• Installation of a new chilled water assetsto provide financial savings and enhanceresilience.

BenefitsThe collaboration managed to achieveeconomies of scale for the three truststhrough a single procurement and a two trustsingle site CHP, along with the control andassurance for each trust of separatecontractual arrangements.

• Guaranteed financial savings of over £1.2million per annum across the entireAintree/Walton Centre site.

• Reduced the demand on energy byupgrading lighting and improving variouspumps

• Combined yearly reduction in carbonemissions is projected to be nearly 5,000tonnes, representing an average carbonsaving of 29%.



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• Value through the collective project andservice delivery across their three sites.

• £1.2m annual guaranteed savings


Case Study: CroxleyGreen BusinessPark, Watford

The challengeRejuvenating a dated, out oftown Business Park to providea modern and effective workingenvironment with a community feel, working offan environmentally friendly and sustainableplatform. Croxley Green Business Park is a 75acre estate that comprises of 9 office blocks andan industrial area with 25 units. The site is hometo over 50 companies and 2,500 employeeswith a total area of 710,000 square feet. Theannual service charge budget of £2.4 million,giving an overall figure of £3.40 a square foot.

There was a feeling that occupiers werefinding the Business Park inaccessible withouta car, which limited their movement duringthe working day. There were also issues withon-site amenities such as waste managementwith no recycling facilities available and justone small café within the facility.

SolutionThe first step was to obtain feedback from thestakeholders in the park, which includedoccupiers and service providers. There was aclear need for major infrastructure andaccessibility improvements. The overall

achievement of the works carried out inresponse to the feedback was to create asignificantly improved working environment inwhich occupiers had the ability to work andplay, whilst improving access to the site for alland driving up the park’s sustainabilitycredentials at the same time. Newly developedamenities developed on site included cateringand café facilities, an indoor gym and outdoorsporting areas, along with a recycling centre.

BenefitsExisting on-site facilities were greatly improvedwhich led to the benefits of inward investmentfrom new businesses to increase the capacityof the Business Park. The community feel ofthe park became significantly stronger throughshared activities and the use of communalareas by all. The engagement and education ofthe tenants was pivotal in the success of theparks’ waste management solution and thehard work by all involved was acknowledged in2012 by receiving the Waste Industry award for‘Waste Management Initiative in theCommercial & Public Sector’.

Significant cost savings have been obtainedgiven the reduction in landfill tax paymentsand recycling credits achieved fromcardboard, plastic and wood. These savingshave been recycled into the service charge -cardboard is currently fetching up to £100 pertonne. Collaboration with the local authoritysaw bus services improve greatly from a singlebus service at either end of the working day,to a frequent bus route that was free of chargefor staff of the companies occupying the park.

The Report Authors would like to acknowledgethe contribution of M J MAPP for this case study

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2. Workforce developmentMeeting the changing demands and needs forhealth and social care will require new ways ofworking and a workforce that is equipped withthe right competencies to deliver these:

“There are too many barriers to get people

into a registered nursing profession - givethem different routes into care - new rolesand functions - new skills.” (Private sector stakeholder)

Current professional divisions will need to bebroken down so that workforce development canbe planned and delivered on a crossprofessional and competency basis.


• Disparate estate footprint• Complex and inefficient management and design • Lack of capital• Legacy sites• Antipathy to previous PFI models


Impa

cts

Acti

ons

Ou

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• Integration of estates rationalisation via OPE• Integrated property strategy at national level• Integrated service delivery pathways supporting strategic outcomes• cost savings

Barriers

• Collaboration across heath & social care commissioners and providers• Accountability and responsibility for strategy aligned • Innovation in design, funding and technology across multiple partners• Shared FM management

• Align estates strategy across the NHS and local government • Establish a national Property Centre of Excellence • Application of Public Service Hub model• Create area based FM frameworks

Shared Estates and Infrastructure


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2.1 New ways of workingThere are significant differences in the healthand social care workforce that will need to beaddressed if more collaborative and integratedways of working are to be achieved. For example:

• the social care workforce is larger than theNHS e.g. 1.363 million employed by the NHScompared to 1.63 million in social care;

• the social care workforce is more disparateand located across a number of differentagencies and employers including those inthe private and social sectors;

• Health Education England (HEE) providesblock training contracts for NHS Trusts, butthe mechanisms for ensuring that social carestaff responsible for NHS patients receivetraining are poorly developed with manyTrusts acknowledging that they cannot copewith the disparate nature of the local areasocial care workforce;

• career pathways for social care staff are less welldeveloped and this has an impact on retention;

• there is an enormous growth potential totrain and educate social care staff that todate have not had the same opportunities astheir NHS counterparts;

• there is a need for the skills gap to be filledbetween nurses or allied professionals andthe care assistant level;

• there is an urgent need to address diversity andequality in the health and social care workforce, e.g.poor progression amongst blackand minority ethnicstaff (BME) and experiences of discrimination.

The social care sector has one of the worst recordsof any sector for training and development of theirstaff. This has clearly been impacted by budgetrestrictions, but the spotlight is on the sector asthere is a move towards integration of health andsocial care and an emphasis away from the acutesector to community provision.

There is a significant demand for more highlytrained care assistants to take on more ofassistant practitioner roles. This is due to anumber of factors:

• The social care sector is dealing with higherlevels of demand for people with increasinglymore complex and multiple conditions,especially amongst older people who wouldpreviously have been in long stay hospitals.However, the majority of staff in residentialcare are trained to Level 3 at best.

• Previous regulatory requirements stipulated that50% of care assistants in any one establishmentshould be trained to level 2 or above but thiswas abandoned as unworkable due to the highlevels of turnover. As a consequence nearly allof the Skills for Care money has been spent onapprenticeships at Levels 2 and 3.

• Health Education England have a £5 billionbudget which has traditionally exclusivelygone to the NHS even though there arecontinuing care patients (NHS funded) innearly every care establishment.

• There is a shortage of nurses in all caresettings (there is likely to be a 30,000 shortfallnationally in the next two years. The Centre forWorkforce Intelligence (CfWI) estimate it couldbe as much as 64,000 nationally.

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Not having skilled staff has serious consequencesfor the health and social care system.

“Without the necessary skills in residentialcare, there is lack of preventative care,which leads to emergency admissions andalso leads to bed blocking as the homescannot look after the elderly when theyreturn from hospital. Up-skilling of careassistants is therefore extremelyimportant, as recourse to the acute sectoris extremely expensive and inefficient.” (Public sector stakeholder)

In order to compensate for the lack of nurses,care assistants will need to be skilled up asAssistant Practitioners and eventually nurses sothat the social care sector can generate its ownskills and not be overly dependent on trainedstaff from the NHS.

Some national developments are being plannedon this basis e.g. the Nursing Associate role thatis due to be introduced from 2017. The proposalfor a new support role that could bridge the gapbetween nursing and social care arose from theShape of Caring Review19 and therecommendations of the Cavendish Review20.This included proposals for a new CareCertificate and training to develop additionalskills and knowledge for working alongside CareAssistants and Registered Nurses.

The role is aimed at developing the scope ofpractice so that it enables associates to workalongside care assistants and registered nurses toprovide high-quality person-centred care acrosshealth and care settings. A national

curriculum and the establishment of test sites willsupport the role across England. It is anticipatedthat 1,000 individuals will be recruited to the testsites in 2017. Health Education England havestated that a new care role with a higher skillsetcould achieve the following:

• supplement, augment and complement thecare given by Registered Nurses;

• build the capacity and capability of thehealth and social care workforce to care forservice users across different settings;

• widen access and entry to the nursingprofession for Care Assistants and makingcaring a career;

• support career progression enabling agreater skill mix in the caring and nursingworkforce to work flexibly and responsively.

2.2 The Apprenticeship LevyNew ways of working and new roles for thehealth and social care workforce can besupported through apprenticeships. The way inwhich the government funds apprenticeships inEngland is changing from April 2017:

• Employers with a pay bill over £3 million ayear will be required to make an investmentin apprenticeships through a levy.

• The levy will be charged at a rate of 0.5% ofthe annual pay bill including a levyallowance of £15,000 per year.

• The levy will be paid direct to HM Revenue


19. Lord Willis, ‘Raising the Bar - Shape of Caring: A Review of the Future Education and training of RegisteredNurses and Care Assistants’ March 201520. The Cavendish Review, July 2013.https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/236212/Cavendish_Review.pdf, (accessed June 2016)


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and Customs (HMRC) through the Pay as YouEarn (PAYE) process.

From January 2017, employers eligible for theApprenticeship Levy will be able to register withthe new digital apprenticeship service andcreate a digital account. Funds will enter thedigital account on a monthly basis, and a 10%top up will be applied at the same time. Thismeans for every £1 that enters an organisation’sdigital account, they can access £1.10 to spendon apprenticeship training.

The NHS will be the largest provider for theApprenticeship Levy but some concerns have beenraised about the Levy with regard to the NHS:

• traditionally NHS workforce roles have notbeen suitable for an apprenticeship model;

• applying a levy based on employee earningsmay not take adequate account of the rangeof training and skills required in particularsectors;

• given the size of the workforce and thediversity of roles, the NHS would be unableto get back what it has paid in.

However, the fact that in the short term at leastthe NHS will be a net contributor to the fund withspare capacity, provides an opportunity forcloser working with partners in the public,private and social sectors to developapprenticeships that can better meet thedemands and needs for health and social care.This will require formal collaboration betweenhealth and social care partners and local FurtherEducation (FE) and Higher Education (HE)establishments to develop a framework by which

the potential benefits of the Apprenticeship Levycan be realised. This could include:

• the establishment of specific health andsocial care pathways to support futureemployment needs;

• education pathways for adults to retrainunder the new apprenticeships. Existinghealth and social care staff could participatein these programmes and work experienceopportunities could be enhanced to ensurethe right people are employed;

• the apprenticeship route could provide newways of developing skills escalators for entryinto professional qualifications e.g. this maybe advantageous with respect to nurseeducation which will in future be funded viaa system of loans, rather than bursaries;

• FE and HE institutions could offer part of theadult learning budget as a shared vehicle tosupport health and social care workforcedevelopment;

• opportunities to develop on the job trainingprogrammes using a combination of NHSand local authority apprenticeship funds;

• pooling of NHS and local authority trainingteams so as to maximise efficiency of delivery.

One of the ways by which local areas couldsupport the above is through the establishmentof Apprenticeship Training Agencies (ATAs)based on the shared employment opportunitiesthat would come from collaboration acrosshealth and social care, hospitals, councils,housing associations and colleges. In this way,

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Apprenticeships could be delivered on a crosssector basis e.g. placements in the NHS, thelocal authority and other partners and with alocal College.

This approach requires taking a different mind-setto the potential for partnership working andcollaboration across FE and HE. To do thiscorrectly, a team of people who are willing and ableto understand FE, Apprenticeships, professionalaccreditations and other ways of thinking abouttraining and skills will be needed at local levels.These individuals will also need to be able to adaptcurrent systems to a new student market in HE sothat students are able to move up from lower skillbased programmes into a HE environment.

For example, Colleges could provide Level 2 & 3qualifications as well as assessments of priorlearning for students to come on to aprogramme, which includes Levels 4 - 6. Inother cases, they may offer a foundation degreewhere students then transfer to HE to completetheir degree. This could be achieved by usingthe Apprenticeship Levy and other employerfunded places for these programmes by whichpublic, private and social sector employers pooltheir resources to meet the training needs fortheir communities. This approach is beingdeveloped at the University of East London.

2.3 Competency based learningCompetency based learning (CBL) is an approachto life-long learning that focuses on specificcompetencies rather than time spent in classrooms or on pre-defined courses. It uses a rangeof learning techniques and assessments thatenable students to build up credits as theyprogress through a skills escalator thatrecognises when students have achieved aparticular competency:

“Competency based learning approacheshave a lot to offer, not a job for life but lifefor job - give people escalators anddevelop a workforce that can be grownand controlled for the future needs -connect up all the partners with local FE todo things differently.” (Public sector stakeholder)

There is increasing recognition of the value thatCompetency Based Learning (CBL) can bring toprofessional development and the model isideally suited to apprenticeships. Otheradvantages of CBL include:

• recognition of prior accredited learning, e.g.students with existing competencies will onlyneed to demonstrate these rather thancomplete a new course;

• students can work at their own learning paceand potentially complete placements andcompetencies in a shorter time frame thanwith traditional classroom based education;

• the CBL approach is attractive to adult learnerswho struggle to maintain commitment totraditional based learning opportunities;

• curriculum development can be more closelyaligned with employer requirements so thatcompetencies better meet the demands andneeds of service users;

• flexible learning approaches have been shownto improve retention and progression amongststudents from different ethnic groups;

• employers can have greater confidence thatthey will be able to fill skills gaps and have aworkforce that is fit for practice.



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Competency Based Learning atthe University of East London

The challengeThere is a growing populationwith complex long termhealth needs requiring experthealth and social care skills.Sixty-five per cent of people inhospital are over 65 and Eightyper cent of people in care homeshave dementia or cognitive impairment. InEngland and Wales from 2010-2013, demand forhealth and social care for those aged 65 and overis expected to increase by over 80% to 1.96million. (House of Lords, 2013)

These figures show the importance of improvingthe care available for older people, yet there isoften a disparity between the skilled staff andpractitioners needed, and those available on theground. Staff with specialist knowledge and skillsremain seriously under resourced which too oftenleads to unnecessary hospital admissions, under-diagnosis and lack of preventative approaches tohealth and wellbeing. These issues are particularlyprevalent within the care of older people.

The solutionA Competency Based Learning (CBL) Healthand Social Care programme has been designedat the University of East London (UEL), creatinga career pathway that leads to qualificationsfor those wishing to work with elderly people.The programme is work-based with elementsof e-learning, and has been designed for careworkers from a variety of settings who wish tospecialise in health and social care.

The Health and Social Care Programme, devisedin response to the growing and ever more

complex needs of older people aims to give thework with older people the status it deserves,whilst creating a career pathway from Apprenticeto Registered Professional. The curriculum isbased on a patient-centred care framework ofstandards (the 360 Standards Framework) andhas been developed with extensive input fromemployers, the older person and their families.The programme embraces integration as thepathway can be used across all allied healthdisciplines, social, domiciliary, community careand within acute hospital settings.

BenefitsThe CBL programme emphasises practicalapplication of knowledge in the workplace, andtimely completion will make a huge difference tothe up-skilling of care workers. This programmewill contribute towards either a Foundationdegree for the Specialist Older Persons Careworker or a BSc Hons degree in Health andSocial Care. Foundation and Honours degreestudents are taught together for a number of themodules but assessment methods will differ foreach type of degree. This will enable a betterunderstanding of each other’s role and promotebetter working between each group, as studieshave shown there are often difficult workingrelationships between the two sets of staff.

“Our aim is to help promote integration inhealth and social care as the model canbe used in all care settings and studentsfrom different settings are taught togetherpromoting a shared understanding of personcentred care in their different settings.”

The Report Authors would like to acknowledge thecontribution of the Professor Nora Colton fromUniversity of East London for this case study. Forfurther information please email [email protected]

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2.4 Inclusive leadershipHealth and social care leaders at executive,elected and Board levels will need to develop aninclusive leadership style and competencies.This means being able to operate across sectors,organisational and professional boundaries anddiverse communities and interests:

“The importance of leadership and sharedpurpose underpinned by ongoing dialoguewith all stakeholders in the communitycannot be overstated.” 21

In addition to ensuring that leaders can beeffective in collaboration, integration andpromoting innovation for health and social care,inclusive leadership will bring benefits in ensuringthat the full range of talents of a diverse workforceare supported and developed. This is essential forensuring that health and social care organisationsmeet their duties under the Equality Act 2010 andfor demonstrating continuous improvement underthe NHS Equality Delivery System (EDS). It is alsoessential for ensuring that high quality careoutcomes are achieved for all the population andin meeting key targets for reducing health andsocial care inequalities.

The need for inclusive leadership ishighlighted in the first NHS Workforce RaceEquality Standard (WRES): 2015 Data AnalysisReport,22 which was published in May 2016.The WRES was included in the 2015/16 NHSStandard Contract for NHS providers, andfrom 1 July 2015, provider organisationssubmitted their baseline data against thenine WRES Indicators. The aim of the WRES isto ensure that black and minority ethnicemployees have equal access to career

opportunities and receive fair treatment inthe NHS workplace:

“In its simplest form, the WRES offerslocal NHS organisations the tools tounderstand their workforce race equalityperformance, including the degree ofBME representation at seniormanagement and board level. The WREShighlights differences between theexperience and treatment of White staffand BME staff in the NHS. It helpsorganisations to focus on where they areright now on this agenda, where theyneed to be, and how they can get there.” (Sir Keith Pearson. Chair, Health EducationEngland and Chair, WRES StrategicAdvisory Group)

By using and understanding the WRES data NHSorganisations are expected to developevidence-based action plans that will lead tocontinuous improvements on the workforce raceequality agenda:

“Research and evidence strongly suggestthat less favourable treatment of Blackand Ethnic Minority (BME) staff in the NHS,through poorer experience oropportunities, has significant impact onthe efficient and effective running of theNHS and adversely impacts the quality ofcare received by all patients.” (Yvonne Coghill and Roger Kline. Co-directors WRES Implementation Team, NHSEngland)

The first report on this data shows that whilesome organisations are making good progress


21. NHS Confederation, ‘Stepping up the Place: The Key to Successful Health and Care Integration’, June 201622. NHS England, ‘NHS Workforce Race Equality Standard’, May 2016,https://www.england.nhs.uk/about/gov/equality-hub/equality-standard/, (accessed June 2016)


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and have embraced the agenda for change, thereare many others that have yet to make significantprogress. Some of the key findings include:

• Higher percentages of BME staff report theexperience of harassment, bullying or abusefrom staff, than white staff, regardless oftrust type or geographical region. Communityprovider and ambulance trusts are morelikely to report this pattern.

• BME staff are generally less likely than whitestaff to report the belief that the Trustprovides equal opportunities for careerprogression or promotion. This pattern isstrikingly widespread regardless of type ofTrust or geographical location.

• BME staff are more likely to report they areexperiencing discrimination at work from amanager, team leader or other colleaguecompared to white staff, regardless of trusttype or geographical location.

• Sharing replicable good practice andprocesses will be an essential element tohelp facilitate system-wide improvements inworkforce race equality.

Having the right commitment to promotingequality and improving diversity amongst thehealth and social care workforce is essential tothe future sustainability of these services. Forexample, it is associated with more patient-centred care, greater use of innovation, higherstaff morale and access to a wider talent poolthat can support the required changes in skillsand competencies. One of the key factors thatwill influence change in this area is inclusiveleadership:

“Work on the WRES will only make animpact when it is located withinmainstream business and governancestructures, and when NHS Boards andsenior leaders lead the way through notonly what they say but also what they dowithin and outside of their organisations.Boards are encouraged to availthemselves to developmental initiativesand leadership programmes where theemphasis is on inclusive workforces andhealthcare services.” (NHS Equality and Diversity Council. May2016. p73)

Inclusive leadership will only be fully achievedthrough effective collaboration and partnershipworking. This means establishing new ways ofthinking and fresh strategies for partnershipsand collaboration to break patterns of ingraineddiscrimination and disadvantage. This is anessential step in making integration work:

“Inclusion is not a soft option; it requiresstrong leadership and needs to bematched with resources and commitment.However, the rewards are immense. Healthand social care organisations that makeinclusion part of their day to day businesswill be able to demonstrate that they areadding public value and that the voicesand opinions of those who use and rely onhealth and social care services matter andare being taken account of in decisionmaking throughout the organisation.” (Professor Lord Patel of Bradford OBE. TheLeicestershire Inclusion LeadershipDevelopment Programme – IncLeaD theToolkit - a guide for NHS leaders. June2012)

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3. Financial and budgetary alignmentOne of the biggest barriers to collaboration,integration and innovation across health andsocial care is the lack of alignment in financialand budgetary accountability:

“We have to be bridging the gap betweenhealth and social care if we want to

address the budget shortfalls. It meansfront loading public health and makingprevention the priority but we have tocreate the right financial incentives topromote this.” (Public sector stakeholder)

“We need to join health and social carebudgets to make services more integrated.” (Private sector stakeholder)


• Skills gap• Professional divisions• Underdeveloped career pathways• Disparate workforce


Impa

cts

Acti

ons

Ou

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• Development of new roles in workforce• Improvements in student progression and outcomes• More diverse workforce and improvements in BME staff progression and retention

Barriers

• Maximising resource benefits at local level• Development of skills escalator for workforce• Development of executive and Board leadership for inclusion

• Cross sector arrangements for shared use of the Apprenticeship Levy • Introduction of Competency Based Learning • Improved use of WRES data to support inclusion leadership

Workforce Development


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This is a problem at a national level in terms of thelegislative framework for health and social care,whereby budgetary control is split between theDepartment of Health and the Department forCommunities and Local Government. The BarkerCommission addressed the issue in 2014 andrecommended that England moved towards asingle, ring fenced budget for health and socialcare. This finding has been further supported bythe House of Commons Health Committee’s inquiryon the future of social care, which concluded thattrying to address the problem though piece mealsolutions that seek to build bridges across thedivide had not worked and were insufficient tomeet the demands and needs of the system(House of Commons Health Committee 2012).

Some legislative freedoms have been created totry and alleviate this division such as those thatenable joint funding through the Better CareFund. BBuutt aass yyeett tthheerree aarree ssttiillll iinnaaddeeqquuaatteeiinncceennttiivveess ttoo eennccoouurraaggee NNHHSS aanndd llooccaall aauutthhoorriittyylleeaaddeerrss ttoo ccoollllaabboorraattee aanndd wwoorrkk ttooggeetthheerr iinn aanneeffffeeccttiivvee aanndd iinntteeggrraatteedd wwaayy.. Given the starkeconomic pressures being faced by all sides ofthe system it is clear that new ways of workingtogether are required and these will need to gobeyond the sharing of piecemeal budgets.

The Better Care Fund was initially allocated£3.8bn and this could be further supplementedby additional voluntary contributions, bringing thefund up to £5.3bn. In November 2015 theChancellor announced in the spending review thata further £1.5bn would be allocated to the Fund byMarch 2020. However, despite the promisedincrease in funding, a recent survey of Directors ofSocial Care found that almost half (43%) believedthat the Better Care Fund has had virtually noimpact on care budgets or service quality.

Arguments about which department should cedecontrol of its finances continue for example, the KingsFund23 argued that control of social care financesshould be placed in the Department of Health. Thesuggestion is that local Health and Wellbeing Boardsshould have control of an integrated health andsocial care budget for their area, although the KingsFund survey findings questioned whether theseBoards are currently fit for this purpose:

“…although many health and wellbeing boardswere making good progress in developingrelationships and were beginning to addresspublic health issues, there were wide variationsin how well they were performing and in theircapacity for future development. Most healthand wellbeing boards signalled an aspiration toplay a bigger role in commissioning both healthand social care services for their localpopulation but there was little sign thatthey had begun to grapple with theimmediate and urgent challenges facingtheir local health and care economy.” (Humphries, R & Wenzel L. 2015. p. 23)

In particular the Kings Fund concluded that:

“…far more work would be needed to buildthe confidence that NHS organisations havein the potential of health and wellbeingboards to become a single commissioner.” (Ibid. p. 37)

Health and Wellbeing Boards are relatively new andso it might be expected that they are still developingand that in time they can become better able tomanage the responsibilities of an integrated budgetand system as part of Sustainability andTransformation Plans. The LGA is actively working tosupport this and to strengthen local politicalleadership across the health and social care system.

23. Humphries, R. Wenzel L. ‘Options for Integrated Commissioning: Beyond Barker’, The King’s Fund, London, 2015

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3.1 Devolved budgets for health andsocial careThere are precedents for integration of health andsocial care in the devolved nations of Scotlandand Northern Ireland. Health and social care hasbeen aligned in Northern Ireland since 1973through five regional Health and Social Care Trusts.In Scotland the Public Bodies (Joint Working)(Scotland) Act 2014 provides a new legislativeframework by which health and social carecommissioning and delivery will be integrated. TheAct requires Health Boards and local authorities towork together in partnerships with integratedbudgets that as a minimum will cover adult socialcare, community care and some aspects of adulthospital care. Locality planning will take place at asub-partnership level with joint commissioningincluding national and local outcomes.

In Wales the Wellbeing of Future Generations(Wales) Act 2015 (WFG Act) is being introduced.The WFG Act will encourage public bodies to workin more integrated ways for the wellbeing of thepopulation. The Act also establishes a singlestatutory Future Generations Commissioner forWales and new Public Service Boards in eachlocal authority area. The Commissioner and thenew Boards will work towards improvement goalsacross economic, cultural, and environmentalwellbeing including health and social care.

In England new models, strategies and structuresare evolving for Combined Authorities to take onresponsibilities for integrated health and socialcare budgets. Although we may see differentmodels develop in different areas one of themost advanced currently is Greater Manchester.

3.2 Devolution of health and socialcare - Greater ManchesterIn Greater Manchester devolution of the £6 billion

health and social care budget is being placedunder the control of the Combined Authorityalthough regulatory control will not be devolved.The plan for integration of health and social carein Greater Manchester provides a potential modelby which other combined authorities under theleadership of elected mayors could align thebudgets for health and social care with a primaryfocus on prevention and increasing wellbeing andprosperity for residents.

The local authorities and CCGs across GreaterManchester have agreed to work collaboratively,building on the Better Care Fund. Once fulldevolution is achieved in 2016/17 it is envisagedthat health and wellbeing boards will agree thestrategic priorities for the delivery of integratedhealth and social care. The arrangementincludes the establishment of a GreaterManchester Strategic Health and Social CarePartnership Board that will work to ensureconsistency across local areas with pooledbudgets being used where relevant.

DevoManc was one of the first DevolutionCombined Authorities with the Greater ManchesterCombined Authority (GMCA) established across allten local authorities in April 2011. In 2014 theGrowth and Reform Plan was agreed building onthe long history of collaboration and underpinnedby the shared political agreement of each of theauthorities to provide stable, efficient and effectivegovernance that will increase prosperity for all ofpeople living in Greater Manchester.

The Greater Manchester Association of CCGsinvolving all 12 Clinical Commissioning groupsacross Greater Manchester was established in2013. In February 2015, the Government, the GMhealth bodies and local authorities and NHSEngland agreed a Memorandum of Understanding



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giving local control over an estimated budget of £6billion each year from April 2016. Local businesseswere aligned with the strategic plan for growth andreform through the Greater Manchester LocalEnterprise Partnership (LEP). The alignment ofhealth as a key political and economic concernwas critical to gaining wide consensus on theinclusion of health in the strategic plan.

Recognising that health is a key lever in realisinggrowth and prosperity is one of the principles forsuccessful integration. This is also key to thecentral vision for DevoManc, which seeks fromthe outset to have an approach that is focusedon people and places rather than organisations.

Silo mentalities and structures are one of the biggestbarriers to integration and overcoming these requiresleaders to lift their sight from organisationalboundaries and to start to view health and social carefrom a much wider perspective. This brings freshinsights to thinking and strategic planning but italso enables a framework in which collaborationand innovation become the drivers for greaterintegration. This can be seen most clearly in thebreadth of ambition contained in the DevoManc plan:

• whole system transformation including newhospital models for acute and specialised services;

• the alignment of primary care, communityand mental health services, social care andpublic health to shift the focus up stream forgreater prevention and early identification;

• a single estates function

• single workforce transformation plan

• single information governance and datasharing agreement

“Addressing together the issues ofcomplex dependency will help thosefurther away from the job market to movetowards jobs and assist the low paid intobetter jobs. Reform of Early Yearsprovision is key to increasing productivityof parents and, in the future, theirchildren.” (Greater Manchester Strategic PlanDecember 2015)

There are nine early implementation priorities:

• public health place-based agreement andprogrammes;

• seven-day access to primary care;

• a dementia programme to transform treatmentcare and support for people with dementia andtheir carers and families based in Salford withGM wide collaboration and implementation.

• realignment of hospital services as set out inthe Healthier Together programme;

• transforming children and young people’smental health services;

• alignment of workforce policies;

• improving independence for people withlearning disabilities and/or autism;

• supporting people with mental health-related barriers into work;

• establishing an academic health science systemknown as Health Innovation Manchester (HIM).

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Case Study: Redesigning carepathways for dementia care

The ChallengeDementia has beenidentified as a key priorityas part of the GreaterManchester (GM)Devolution agreement. Theambition over the next fiveyears is to improve the livedexperience of people with dementia and theircarers whilst reducing dependence on thehealth and social care system. People withdementia and their carers will be at the heartof this transformation programme.

SolutionDementia United is central to the GMprogramme of reform for mental healthservices and will engage with health andsocial care commissioners, providers andpractitioners across the public services. Thedementia challenge in GM is one ofstandardisation, care pathway re-design andnew care models and implementation. Thefollowing objectives will be crucial to achievethe Dementia United goals by 2021:

• IIddeennttiiffyy ppaattiieennttss eeaarrllyy - supporting themto live well and to manage their health

• PPrreevveenntt ddeetteerriioorraattiioonn aanndd ssoocciiaall iissoollaattiioonn- through regular monitoring and supportto avoid unplanned admission to hospitaland long-term residential care

• PPrroovviiddee hhiigghh qquuaalliittyy hheeaalltthhccaarree iinn tthheeccoommmmuunniittyy - to prevent unnecessaryhospital admission

• PPrroovviiddee hhiigghh qquuaalliittyy hhoossppiittaall ccaarree - to

enable short and efficient hospital stays

• The operational delivery of this work relieson coordinated programme support andthe active participation of GM’s 10 localauthorities and 12 Clinical CommissioningGroups. Nominated locality leads areworking in cross-GM partnership to co-design this work and ensure it isintegrated into locality plans.

BenefitsThe programme aims to cover 5 broad areas,reflected by a series of ‘pledges’:

1. Improve the lived experience for bothpatients and carers

2. Reduce the variation of care delivery andoutcomes

3. Co-production and redesign of services

4. Each newly diagnosed individual toreceive ‘key worker’ support

5. Adoption of digital technology

The programme not only reduces dependence onhealth and care services but also aids financialsustainability within the region. If successfullyimplemented, the initial cost-benefit of theDementia United programme is an estimated grossfiscal benefit £49m to local authorities and theNHS of over five years. Dementia United’s workwith local commissioners will test new paymentmodels for dementia care. For example, a shift incontracting from activity based to outcomes basedcommissioning will be tested as part of

the programme. This shift will enableconversations with social financiers who will be



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approached to invest in dementia services inGM, bringing in social investment alongsidepublic money to ‘ignite’ the transformationwork and deliver improved outcomes.

The aim of the Dementia United programme isnot only to transform the experience of thoseliving with dementia today, but to be at thevanguard of how health and care services arefunded, commissioned, designed, delivered,experienced and evaluated in the future.

The Report Authors would like toacknowledge the contribution of ProfessorMaxine Power of Haelo for this case study

3.3 Public health financingPublic health was moved under the control of localauthorities in 2013, however cuts in the budgetallocation for public health have already taken placefor example, £3.38bn was made available in 2016/17(£77m less than 2015/16) and this will be further cutin the subsequent year by £84m to £3.3bn. Thiscomes on top of £200m in-year cuts for 2015/16.

The Comprehensive Spending Review (CSR) alsoset out plans for public health expenditure to fall byan average of 3.9% up to 2020 and for the currentring fencing arrangements of the public healthbudget to end after 2017/18. In the longer term it isanticipated that public health funding will comefrom the retention of local authority business rates.

There are potential threats and opportunities to thesedevelopments. On the one hand shrinking publichealth expenditure could undermine attempts to shiftthe focus of health and social care up stream toprevention. But on the other hand greater local areacontrol of public health expenditure could be used toincentivise the movement towards integrated healthand social care recognising that public health andwellbeing is central to local area prosperity and wealth.

Case Study: Argenti - Efficiencyand Innovation in Social CareHampshire County Council & PAConsulting:

The ChallengeLocal government willexperience a real reduction inspending power until 2019-20, despite the recentlyannounced £416 million packageof transition measures. For thosewith social care responsibilities, the ability toincrease Council Tax by 2% has offered somedegree of respite. However, for a number ofauthorities it has neither proven politicallyacceptable to increase the bill nor been sufficientto meet service funding needs. Similarly, servicepressures and community expectations aredemanding more from local authorities. As aresult, alternative approaches to providing careservices need to be considered. Like all providersof adult care, Hampshire County Council facesthis combination of significant cost pressures andrising demand. Of the county’s total population,around 15,000 vulnerable adults have beenassessed as having eligible social care needs.The majority of this group, approximately10,000 people, are receiving services at home.

SolutionCare providers must radically rethink the rolecare technology plays in both mainstreamsocial care provision and within the wider caresystem. Following the Official Journal of theEuropean Union’s new approach to telecare,Hampshire appointed “Argenti” (a consortiumled by PA consulting which included Medvivo,Tunstall Healthcare and CareCalls) to takecomplete responsibility of the service from itsredesign through to assessments,installations, equipment provision and

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monitoring – up until 2018. The service nowmanages the increasing demand of those inneed of ‘lower-level’ care, who are not yeteligible for Council support, but have theirown resources. Referred to as the “privatepay” offering, the Council has been able tosignpost such individuals to a separate butjointly branded service since October 2014.

BenefitsThe council supports a substantial growth in thisservice as it helps alleviate the pressure on publiclyfunded services. Indeed within two years ofoperations, 4200 users received telecare as part oftheir mainstream care package - well above theinitial target of 2000 users and resulted in a NETsaving of £2.7m. It is also likely that an additionalNET saving of £1.4m will be delivered by the end ofthe third year in the summer of 2016. Importantly,these savings have not been at the expense ofservice quality - 95% of users surveyed felt the newapproach increased their feelings of safety andsecurity in their home and 98% said they wouldrecommend the service to others. A furtheradvantage is that these individuals not only receivethe same recognised high quality service thatCouncil service users enjoy but also, should theirfinancial circumstances change and they becomeeligible for publicly funded services, the individualcan seamlessly transition into those services.

As the service has developed into its third year,the positive impact of the partnership has nowbeen seen beyond the Council. Telecare greatlyreduces the occurrence of people with dementiabecoming lost or confused within the communityand costs a fraction of the £6,000 police searchcost. In addition, there are large financialbenefits to the local health system as the serviceleads to a reduced the rate of ambulance callouts, hospital transport, admissions and stays.What Hampshire’s experience clearly shows is

that thinking differently about service provisioncan secure significant financial savings andimprove the quality of care for vulnerable people.

The Report Authors would like to acknowledge thecontribution of PA Consulting for this case study

3.4 Creating a unified health andsocial care budgetary frameworkFurther devolution of health and social carefinancial and budgetary responsibilities isinevitable. As these developments continue,national and local health and social care leaderswill need to prepare for a unified framework bywhich pooled budgets and financial controls canbe shared across local areas. This will requirethe following:

• collaboration between the Department ofHealth and the Department for Communitiesand Local Government – agreement will beneeded that a single department takes controlfor an integrated health and social care budget.This could, for example, be a new Departmentfor Communities and Wellbeing. Collaborationalso needs to be supported at Cabinet level inline with the proposed Cross Government LifeChances strategy and fund, based on outcomesand social finance principles with investmentand savings being shared across the system. Asimilar approach for health and social carecould facilitate Cabinet colleagues tocollaborate, e.g. top slicing budgets andallowing Departments to participate in a sharedcommunities and wellbeing fund on conditionthat they collaborate and integrate;

• collaboration between NHS England and theLocal Government Association on thedevolution of budgetary control for primaryand some aspects of specialist care to localand sub-regional areas – this will need to be



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considered on the basis of localities wherecombined authorities have been establishedrather than single CCGs;

• collaboration between local authorities andCCGs – the local area budget for health andsocial care will need to be configured on thebasis of devolved administrations withcombined authorities and elected mayorstaking overall control for the integrated

health and social care budget.

Creating a unified health and social carebudgetary framework is one of the mostchallenging aspects of the model. It requirescollaboration and leadership at national,regional and local levels but the politicalcommitment and public support for the GreaterManchester devolution plan for integrated healthand social care shows how it can be achieved.

• Existing financial deficits in the NHS and local government• Focus on short-term efficiency savings• Silo mentalities and structures • Inadequate incentives at local and national level


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• Resources matched to local area priorities • no of devolved authorities able to integrate local health & social care• Better planning to support shift from acute care to prevention

Barriers

• Lead accountability for integration • Removal of barriers to collaboration and integration at government level • Alignment of primary and community health care with social care and public health

• Unified health and social care budgets via mayoral combined authority powers • Combining of resources and accountability in one department and cross-Cabinet levers for collaboration • NHS England and LGA to agree framework to devolve control of primary and community services

Financial & Budgetary Alignment

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4. Whole system integration and innovationWhole system leadership at executive andelected levels is needed to move fromcollaboration to integration and innovation. Aslocal area health and social care leaders act tocollaborate on shared infrastructure and facilitiesmanagement, workforce development and aunified framework for financial and budgetarycontrol it will be possible to establish integratedservice delivery models. This will in turn enableinnovation in the business model and deliverymechanisms for services that improves lives,increases quality and outcomes and builds asustainable future for health and social care.

4.1 New ways of doing businessIf the NHS were being created today it is unlikelythat it would be established on the samebusiness model, i.e. as a single encompassingsystem that seeks to be all things for all people.Across the service sector new business modelsand disruptive innovations have shifted servicedelivery from ‘one shop fits all’ to tailored,bespoke services that are increasingly delivereddirectly in the home:

• we email, text, message and share photosfrom wherever we are with mobile devices.

• we purchase books, food and houses fromthe comfort of our living rooms using laptopsand tablets.

• we book and pay for travel and holidays on lineand know exactly where we will be and when.

And yet, we cannot book an appointment with aGP on the day we need it, or in some cases inthe next few weeks and we spend hours of ourtime in uncomfortable and unfriendly waitingareas in hospitals with no knowledge of howlong a wait it will be before we see a doctor.

At any one time our health and social caresystem is operating at least three distinctbusiness models simultaneously:

1. TThhee rreettaaiill cclliinniicc – this may be a GP Practiceor a consultant’s waiting room. It is the shopfront where the highly intuitive, diagnosticwork is done.

2. TThhee bbuussiinneessss pprroocceessss cclliinniicc - this is where theapplication of standardised, evidence basedtreatment and care practices take place.

3. TThhee ffaacciilliittaatteedd nneettwwoorrkk – much less commonin practice though increasingly desired bypatients and public - this is where preventionand early intervention is paramount.Decision making is shared and service usersand carers are enabled to manage their ownhealth and care.

(Clayton M Christensen, The Innovator’sPrescription)

Each of the above business models is valuableand each can be improved. But to provide allthree from within a single organisational structureis no longer sensible or sustainable. Likewise,making improvements in one without adequateawareness of the alternative advantages of theothers, risks spending time and resources in oneway that may be better spent in another.



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“There are more than 9,000 billing codesfor individual procedures and units ofcare. But there is not a single billing codefor patient adherence or improvement, orfor helping patients stay well.” Clayton M. Christensen, The Innovator’sPrescription: A Disruptive Solution forHealth Care

The Carter review is focused on business processimprovements and has identified significant savingsthat could be realised through greaterstandardisation and common adoption of routinetransactions and treatments. There is no questionthat this approach is needed and the promise offinancial savings and better care outcomes isessential. However, there may be a need for moreradical thinking alongside this about where best toplace business process improvements and whetheralternative business models are in fact a better way todeliver these. For example, moving the simplestprocedures now performed in expensive hospitals tooutpatient clinics, GP Practices, and patients’ homes.

This also means re-thinking health and careservices so that they act now on prevention needsas part of an integrated, area based system, makeintelligent use of new technologies and arefocused on innovation in service user outcomes.

‘Game Changer’ – Halton ClinicalCommissioning Group

The ChallengeObesity reduces lifeexpectancy by an averageof three years and cost theUK economy an estimated£15.8 billion per year in 2007.Indeed around 8% of deaths inEurope are now attributed to

people being either overweight or obese.Research has shown that developing goodhabits in childhood can reduce the occurrenceof obesity later in life. With this in mind, HaltonClinical Commissioning Group (CCG) in theNorth West of England have set themselves thechallenge of reducing the obesity rates inHalton’s year 6 children - currently at 36. 2%.

SolutionThe ‘Game Changer’ scheme has beendeveloped to harness the power and brandingof professional sport clubs with the aim oftransforming how primary-school childrenapproach physical activity. Commercialcompanies provide sponsorship and support toensure the project has long-term sustainabilityand ongoing value. For example, Sopra Steriaare supporting the programme managementand governance as well as assistance in areassuch as website management, data collectionmechanisms and data analytics.

Key components of the programme include:

• Children will be challenged to be activefor 80 minutes per day

• Each School will sign a ‘Game Changer’pledge to commit to embedding morephysical activity and exercise in theschool day

• The Widnes Vikings rugby league team willwork with schools to assess impact acrossan agreed 24 week focus period basedaround physical activity and healthy eating

• School staff will be upskilled tounderstand how they can embed morephysical activity within the classroom

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• All schools, pupils and parents will haveaccess to the ‘Game Changer’ App, whichwill be developed with Halton CCG, SopraSteria and LJMU

• Commitment to exploring how fitnessdevices can be incorporated to supportparticipant engagement, the App andassist broader participant measurement,monitoring and evaluation procedures

‘The Game Changer project helps toimprove the long term health and lifeexpectancy of children in the Haltonarea by encouraging better health. Theproject can be more widely introducedto address a growing national problem’

Benefits• Increase in physical education and

exercise

• Behavioural change and improved eatinghabits

• Development of long term health benefitsfor the children of Halton as they growinto Adulthood

• Reduction in obesity in children andadults

• Improved life expectancy

• Long term decrease in healthcare costsassociated with obesity

The Report Authors would like toacknowledge the contribution of Sopra Steriafor this case study

4.2 Understanding innovations aspart of strategic changeAn area based approach to integration for healthand social care would also enable innovations inservice delivery models that make greater use oftechnological advances. However, these need tobe understood within the right context andstrategy in order to ensure that technologicalinnovations are embedded and used to theirbest effect:

“Fear and lack of understanding abouttechnology is a barrier. Embeddedtechnologies can be used to transform caresuch as use of fit bits and motion trackersfor monitoring elderly care needs.” (Private sector stakeholder)

“Organisations don’t understand whatdigital technology and capabilities can beutilised for, they are sometimes seen asjust an expensive gadget. It is vital toensure that organisations understandwhat the technology is capable beforeembarking on a change.” (Private sector stakeholder)

Disruptive InnovationOne of the primary purposes of collaborationshould be to create an environment in whichinnovation can thrive. This means workingtogether with the explicit recognition thatinnovation can be disruptive:

“The challenge both for the NHS and for itsindustry partners is to pursue innovationsthat genuinely add value but not cost –the NHS for its productivity and qualitygoals and industry for its internationalcompetitiveness. Indeed, adding value



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and reducing cost is the basis of the NHSQIPP challenge. This puts a premium ongame-changing innovations that changepatient pathways and traditional deliverysystems, and that are implemented in away that strips out the processes that nolonger add value.” (Innovation Health and Wealth,Accelerating Adoption and Diffusion in theNHS. DH. 2011)

New approaches to integration and technologicalinnovation can be further strengthened throughdisruptive innovations, i.e. responses to newbusiness models that demonstrate change inpractical, realistic and replicable ways. Notchange for change’s sake but change that:

• shifts the focus of care up stream intoprevention and early identification – this isnot about new interventions, though it mayinclude these, but rather, the need to reduceand manage demand on the high end, highcost elements of service delivery;

• uses the levers for change, e.g. the release ofassets through estates rationalisation,improvements in facilities and ITmanagement, energy consumption andwaste disposal to realise environmental andsocial impacts alongside improvements inquality and outcomes from care;

• creates new funding opportunities throughthe leverage of institutional funds combinedwith government covenant assurances, e.g.enabling private development of newpurpose built, smart health villages andpublic procurement hubs.

The term disruptive innovation (first coined byClayton Christensen over twenty years ago)referred to the way that new, less expensive andbetter products replace older ones and in sodoing creates a new market that is more flexible,more cost effective and closer to the consumer.The classic example is the personal computerbut more recent examples have been seen indigital music downloads and streaming, e-booksand the iPad.

However, disruptive innovations are oftenmisunderstood as only applying to commercialmarkets or being solely about technologicalinnovations, though the latter are often key. Infact, disruptive innovation needs to beunderstood within the context of businessstrategy and this is increasingly being recognisedas a valuable concept for health and social care.

Within a changing system different forms ofinnovation require different strategicapproaches. For example, in health and socialcare there are many examples of innovationsthat have reduced costs and improved outcomessuch as new surgical procedures, use oftelemedicine, advances in drug therapies andtechnical aids to support independent living.Some of these have been disruptive, i.e. theyhave radically changed the way services aredelivered and structured. However, othersoperate as additions to existing services withoutactually altering the way the service operates.

What is needed is a new strategy for disruptiveinnovation in health and social care that fits withthe changing business models and will supportnew ways of working and delivering services aspart of broader structural change. In order to

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achieve this there are certain factors that willneed to be considered:

1. DDiissrruuppttiivvee iinnnnoovvaattiioonnss ssttaarrtt wwiitthhiinn nneewwsseerrvviiccee ppaatthhwwaayyss – rather than seeking tooverhaul an existing service pathway, adisruptive innovation would seek to identifya new way of meeting the needs of existingand potential users more effectively throughan alternative pathway. An example of thiswould be using new technologies andinterventions for prevention and earlyidentification of diabetes.

2. DDiissrruuppttiivvee iinnnnoovvaattiioonn iiss aa pprroocceessss – adisruptive innovation usually starts smalland builds up scale as it becomesrecognised as something that is more costeffective and of higher value to the end user.In this case the disruption is less about theproduct or the system and more about thegradual acceptance that the new way ofworking is better. This takes place over timebut it is also influenced by the degree ofresistance from existing service providerswho fear loss of influence and/or are slow torecognise the benefits of the innovation.

3. DDiissrruuppttiivvee iinnnnoovvaattiioonnss mmaayy lleeaadd ttoo sshhiiffttss iinniinnvveessttmmeenntt – this is why disruptiveinnovations need to be considered within thecontext of business strategy, because as theinnovation demonstrates higher quality andgreater cost effectiveness it will require ashift in investment to become sustainable.

This may be part of a longer term strategy but itneeds to be built into planning for innovation atthe outset. In terms of health and social carethis is about moving the focus of interventions

upstream and reducing demand and need forthe high end, more costly interventions andtreatment.

This is particularly important when thinkingabout the transformation needs for hospitaldesign and delivery. Hospitals are currentlymonolithic structures occupying large areas ofestates with an all-encompassing servicedelivery model.

As disruptive innovations are put in place thechallenge to existing hospital provision will be inre thinking the use of these estates so that theysupport integration and innovation rather thanbe seen to act against it:

“Why is Outpatients in the hospital? Bringit forward into the community wherepeople are, we don’t need this in thehospital.” (Public sector stakeholder)

“Hospitals have to change, we should bethinking about creating a health campus -have all things on one site. It’s also abouthow we change expectations - what publicthink/expect a hospital can do.” (Private sector stakeholder)



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Case Study: My Nearestapplication

The ChallengeMany public sectorservices have low rates ofaccessibility andavailability, meaning thatregularly performed tasks areoften hard to carry out. Hinckleyand Bosworth Borough Councilwere looking to extend the availability andaccessibility to services and provide mobileaccess to a number of regularly performedtasks. This included the need to accesscontent specific to a user’s location, makepayments, report issues and request services.

SolutionThe development and implementation of amobile web solution, which can be accessedfrom smart mobile devices. Users set theirlocation, and the app then personalisescontent and gives them access to the mostregularly used services such as:

• Information on services or planning applications

• Paying council tax and other bills

• Report missed bin collections

• Request the collection of large items orwaste

• Contact the council

• News

The application has subsequently beentailored for use by other council’s to providesimilar information for their own citizens. Theability to tailor the application allows it to beused within the healthcare sector to providepatients and citizens with specificinformation to support their health needs. Forexample, to find your nearest healthcareprovider, order prescriptions or find otherhealth-related information.

BenefitsThis solution builds on the council’s existinginvestment in CRM and the website by:

• Supporting channel shift

• Delivering efficiency savings

• Delivering more accessible and inclusiveservices

• Meeting increased customer demand formobile access to services

“HBBC’s website is four star and islisted in the top 20 best websites in thecountry. Their mobile solution is alsocommended and reviewed as‘completely hassle-free’.“ (SOCITM 2014 Better Connected.)

The Report Authors would like toacknowledge the contribution of Sopra Steriafor this case study

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Case Study: 7 Day Access-Answering the Prime Minister’sChallenge through practical strategy

The ChallengeBury GP Federation Limited,a Federation of 30 GPpractices across Bury inGreater Manchester,successfully securedsupport for its ‘Easy GPProgramme’ under the PrimeMinister’s Challenge Fund toimprove access to GP services and stimulateinnovations in the way primary care serviceswere delivered. The main element of Bury’sproposal was providing extended access to GPservices – offering 8am to 8pm on weekdaysand 8am to 6pm on weekends and bankholidays. Bury GP Federation approached PAto be its design and delivery partner for thenew service and to lead on the launch

SolutionThe approach was to design and launch anew Primary Care service for the populationwithin 6 months, then scaling up to fullcapacity within a further four months. Theapproach focussed on:

• CCoo--ddeessiiggnniinngg tthhee sseerrvviiccee wwiitthh tthheeFFeeddeerraattiioonn aanndd iittss kkeeyy ssttaakkeehhoollddeerrss: Acollaborative approach to the designprocess was undertaken to create earlybuy-in and joint ownership, ensuring localinsights were used to consider theoptions for the range of services andapproaches to delivery.

• CCoommbbiinniinngg aannaallyyttiiccaall aanndd iinnttuuiittiivveetthhiinnkkiinngg: Access to clear, objective data

on patient behaviour and service demandacross Bury to guide decision making wassecured to ensure local insights.

• PPaattiieennttss aanndd SSeerrvviiccee FFiirrsstt: The focus wason creating a service that was clinicallyand commercially sustainable and deliversthe right customer experience. The pilotwas launched with only the most essentialorganisational infrastructure required todeliver this experience, providing patientswith the opportunity to experience theservice at the earliest opportunity.

• RRaappiidd && rriiggoorroouuss tteessttiinngg aanndd rreeffiinneemmeenntt:A flexible business model was built thatenabled different elements of the serviceto be tested, refined and improved rapidlywith limited sunk costs. The sequentiallaunch enabled actionable data to guidedecisions about how best to furtherimprove the service.

BenefitsThe main focus of Bury’s proposal was on‘patient convenience’, making GP servicesmore available and responsive to thepatients’ needs. There were four key strandsto the programme, namely:

• Extended working hours for GP services

• Routinely offering patients the choice of atelephone consultation as an alternative toa face to face appointment at the surgery

• Increasing the number of patientsregistered to use online services to accessGPs

• A comparison website for GP practices



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Through this locally and nationally importantprogramme, Bury GP Federation introduced anew service within 6 months that offers up to1,400 additional GP appointments per weekand provides patients with flexibility of accessto GP services. Through the process theFederation also became more operationallyresilient through delivering this borough wideservice and established itself in a leading rolefor transforming how services can be deliveredat scale within the local health system. Theservice is popular with patients andrecognised as one of the most Successful 7day access pilots in the country, with visitsfrom key stakeholders including the PrimeMinister and the Health Secretary.

The Report Authors would like toacknowledge the contribution of PAConsulting for this case study

4.3 Social investment as a tool forintegration and innovationSocial investment models have also been usedto provide large scale facilities managementservices on sites for example, at the the OlympicPark in London public, private and social sectorpartners have developed a Community InterestCompany (CIC), which is responsible for theonsite management of the Olympic Park. The CICensures social investment through therecruitment and use of local volunteers, many ofwhom have been long term unemployed.

This model holds particular value for thinkingabout transformation and development ofestates in health and social care, in particularthe approach to procurement:

“It is about the development of people andrelationships not just land and estates, the

procurement process was clear that youcouldn’t win the contract unless you wentbeyond corporate social responsibility, itneeded to be about making a genuine relationship with local people.” (Public services stakeholder)

The process for establishing the CIC at theOlympic Park included getting the local supplychain partners on board so that sustainable andrealistic employment and work placeopportunities could be provided for volunteers.At the same time the procurement process wasnot overly restrictive but involved flexibilities forinnovation:

“Be clear about outcomes and objectivesbut don’t get too hung up on the targetsand specification, you can’t ignore thesebut they can be used to understand whatthe key issues are and how to makeimprovements in priority areas.” (Public services stakeholder)

What is also apparent from the Olympic Parkmodel is that local commissioners often havegreater freedoms to innovate than they mayrealise or want to acknowledge:

“It’s the public sector commissioners thatare the block to real change not thebusiness sector. They are either too timidor they don’t really want to make changeon the right scale.” (Public services stakeholder)

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Case Study: Our Parklife - SocialImpact, Legacy and Communities

ChallengeTo help deliver the legacy ofthe 2012 London Olympicand Paralympic Games whilstcreating measurable socialimpact for local people,connecting them to park servicesand providing employment,volunteering and training. Promotion of the park’ssustainable legacy through whole-life managementof the landscape, essential infrastructure andsocial assets for the clients and communities.

SolutionThe establishment of “Our Parklife”, aCommunity Interest Company (CIC) that wasproposed to bring together skills and experiencefrom the private, charitable and social enterprisesectors in one organisation. This approach isbuilt on the belief that a successful park isconnected to its local community. To achievethis, the vision for delivering the Energy FacilitiesManagement contract has to be linked to thedelivery of the London Legacy DevelopmentCorporation’s “Priority Themes” for social,economic and environmental regeneration in thelocal area that represent the regeneration legacy.Our Parklife’s founding partners bring togetherthe range of technical skills and experiencerequired to deliver the range of activities andrelated outputs needed by the contract. Fromthese outputs the overall outcomes and socialimpact can be assessed and measured.

Social impact is the effect of an activity on thesocial fabric of the community and wellbeing ofindividuals and families. In trying to measure

social impact the CIC are looking beyond theusual financial measures to try and assess theadditional social, environmental value createdas a result of activities.

BenefitsThe park created approximately £1.255 millionof economic value for the local economy byemploying 70% of their staff from the localarea, 50 of whom were previously unemployed.This enabled reduction of benefit paymentsand increased incomes. Over 200 Volunteersregularly help on the Park giving over 6,000hours annually creating £1.8 million of value.

Why a Community Interest Company?The structure of a Community InterestCompany (CIC) was chosen because it:

• Brings together the skills and experienceof the private, social and charity sectors

• Provides a focus on Priority Themes

• Utilises existing networks of funding via partners

• Asset and profit locked

• Can benefit from other sources of funding

• Encourages community ownership

• Is for a specific community purpose

• Can deliver revenue generating services tosupport its aims




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4.4 Alliance ContractingNew legal frameworks are required to supportcontracting and procurement for integrated services.One such framework is Alliance Contracting.

Alliance contracts are a way of procuring acontract where all parties are committed tofinding the solutions to problems rather thanfixated on setting and following specifications.They originally developed from the oil andconstruction industry in Australia. Clients neededa better and faster system than the traditional wayof having several contractors on a major projecteach waiting for one to finish before they couldstart their part. The Alliance gives them a jointownership of the project and, sometimes, arisk/reward system that incentivises them to workto a shared goal and resolution of problems:

“There is a perception of public versusprivate sector, it can be a struggle to buildrelationships because it’s demoralising soeverything is very task focused.” (Private sector stakeholder)

“Business partners need to align with andunderstand the NHS - walk in their shoes,clinical engagement is needed at the start.” (Private sector stakeholder)

“We have to realign the interest of bothparties to share benefits, for example carpark charges. But it means bringingflexibility in to the system - a sensiblediscussion about what works and how todo it best.” (Private sector stakeholder)

The contracts have a governance structure thatinvolves all parties in the decision making needed

to create beneficial outcomes. In the governancethe client/commissioner can also be part of thecontractor/provider and has as much involvementin delivery as other parties. This can be especiallyimportant for social care partners who often feelless able to participate as equal partners:

“Voluntary and independent sectorpartners need to be at table as equalpartners, we should be recognised forwhat we can do for service users and notjust as an add on, we are fundamental tocare.” (Social sector stakeholder)

“The NHS and local authorities need usmore than we need them.” (Social sector stakeholder)

Within an Alliance there is a sharing of the riskand the rewards within the contract and therecan be added benefits to all parties and thewider community of service users and others. Inaddition, as providers develop their own systemsand service delivery mechanisms they can allowthe contract to evolve and vary without the needfor technical contract variations and the inherentrisk of claims that comes with variations.

All parties are represented within the strategic andpractical decision making teams that can be setwithin the governance structure. It is essential thatall parties have ownership of any problems thatarise and in the solutions used to solve them.

The NHS Standard ContractCurrently the NHS Standard Contract is notcompatible with some forms of Alliance Contractsalthough since 2014/15 it has been acknowledgedas a potentially valuable framework for the NHS:

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“Some forms of Alliance Contracting arenot currently compatible with the NHSStandard Contract, specifically wheremultiple providers are signatories to asingle commissioning contract – but thekey characteristics of alliance contractingcan be accommodated in a structureinvolving one or more NHS StandardContracts. Any commissioners who arekeen to discuss an Alliance Contractingapproach are encouraged to contact theNHS Standard Contract Team.” (NHS Standard Contract 2014/15 -Technical Guidance final version. March2014. NHS England).

The latest technical guidance is the same,however, it does state that NHS England haveproduced a model Alliance Agreement, whichcommissioners may use as a starting point fordevelopment of their own alliancingarrangements with providers. This is a welcomeinitiative and one that will support integrationacross NHS and social care services, although itcould be strengthened by ensuring that that theNHS Standard Contract is made fully compatiblewith the use of Alliance Contracts.

4.5 Regulation and inspectionThere is widespread recognition of the criticalissues and challenges facing the NHS and localauthorities, in particular with respect to the needfor greater collaboration, integration andinnovation in health and social care. However,significant barriers remain in providing the rightregulatory support for those responsible forleading and delivering health and social careservices to make the required structural andorganisational changes to address thefundamental issues:

“Regulatory changes are required,especially with respect to the healthtechnical memorandums which are overlyrestrictive and prevent better ways ofworking.” (Private sector stakeholder)

“The regulatory and legal framework cankill innovation and collaboration - itcreates disincentives.” (Private sector stakeholder)

Regulatory and inspection regimes need to beintegrated at local levels in order to support theprocess of change and enable innovations andnew ways of working to become the norm. Thisdoes not mean weakening or relaxing thethresholds for high quality services.

Central regulatory and inspection agencies needto be prepared to work with local leadcommissioning agencies and CombinedAuthorities to negotiate an appropriate approachto inspection and regulation that fits with thelocal area strategy and priorities for integrationof health and social care.



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• Outdated business models• Restrictive legal framework• Top down regulation and restrictions• Lack of single, unified frameworks• Technology not imbedded into service delivery models


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• Individual leaders and practitioners able to task others for integrated outcomes • New service delivery models and interventions result in improved outcomes• Benefits of social investment realised as part of integrated systems• Cross sector, multi-agency partnerships• Quality and standards measured and maintained on basis of an integrated system

Barriers

• Alignment of executive and elected officers accountability • Appropriate innovations as vehicles for improved outcomes• Strengthening of private and social sector partnerships• Legal framework for contracting supports integration and innovation• Quality thresholds and regulations aligned with local area strategy

• Establish whole systems leadership for delivery• Develop strategies for innovation that support new ways of working, including technology • Leveraging of social investment programmes• Develop use of Alliance Contracting for commissioning integrated delivery• Establish local area frameworks for regulation and inspection

Whole System Integration and Innovation

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The challenges facing health and social care areunprecedented and represent a significant threatto the long term sustainability of services. What isclear is that change is urgently needed and thesystem cannot continue in the same way. Healthand social care needs have changed with fargreater demand and need for up streaminterventions that are focused on prevention andearly identification. At the same time the financingfor health and social care is in need of reform andthe need for smarter, more effective ways ofworking and delivering services are imperative.

There is wide spread support for greaterintegration between health and social careservices including shared use of estates andresources, joint workforce development, singlefinancial and commissioning structures andalignment across the whole system with crosssector leadership and accountability. However,various barriers stand in the way of this including:

• the perceived failures at past attempts toreform health and social care;

• political and public fears about the perceivedencroachment of private sector interests inhealth and social care delivery and antipathyor distrust of public and private partnerships;

• workforce development and skills gaps, inparticular the need to equip staff with thecompetencies to deliver new ways of working;

• failure to adequately engage and involvepatients, service users and the public in theprocess of change and development so thatthey feel able to participate in decision making;

• inappropriate or outdated business models

and regulatory frameworks that do not meetthe changing patterns of demands andneeds for services;

• cultural barriers that reduce the willingnessand responsiveness to change and the needfor more inclusive leadership.

Many new initiatives in support of integrationare underway but in order to build a trulyintegrated system it is necessary for outcomes,budgets, workforce skills, commissioning andinspection to be fully aligned. The modeldemonstrates how estates rationalisation andcolocation can be used to encourage and drivecollaboration, integration and innovation andabove all be a catalyst for developing politicaland executive leaders who can operate acrossthe public, private and social sectors.

The model is not intended to be a ‘one size fitsall’ approach but rather to act as a vehicle bywhich local areas can adopt elements of themodel to fit with their local area needs anddemands for health and social care. Thefollowing recommendations are intended togenerate debate and to provide potentialsolutions to overcoming some of the mostsignificant barriers to achieving effective changethat can improve lives and build a sustainablefuture for health and social care.

Conclusion


Recommendations

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Recommendation oneCollaboration needs to be strengthened betweennational and local leaders including between theNHS and local authorities and between theDepartment of Health and the Department forCommunities and Local Government.

Recommendation twoFinancial accountability and budgets for healthand social care need to be aligned as part of aunified system under the direction and control ofa single government department. This couldpotentially be, for example, through a newDepartment for Communities and Wellbeing.Cabinet level collaboration needs to befacilitated through the use of shared fundingarrangements as part of a common pooledresource for health and social care. This needsto be replicated at local levels through singlecommissioning authorities covering both localauthority and health services.

Recommendation threeCollaboration between providers andcommissioners needs to be supported throughnew legal frameworks such as AllianceContracting. A legal contracting framework isrequired that drives and incentivises collaborationrather than competition, based on a no disputeculture that provides parity for public, private andsocial sector organisations – an Alliance Contractcan provide this essential foundation.

Recommendation fourWhole system leadership is needed at executiveand elected levels with political and executivedecision making power over the whole system.An elected Mayor with powers beyond healthand social care including policing, justice, skills,transport, economic regeneration and housing

can bring unified budgets, coherence anddemocratic legitimacy to the system.

This should sit within combined authoritystructures under the newly mandated powers forelected mayors and be replicated in cross sectorAccountable Care Organisation frameworks. Inorder to realise this there needs to be supportfor both elected officials and officers so thatthey are able to work across systems andprofessional disciplines, able to task others anddevelop a multi-skilled, competent and inclusiveworkforce.

Recommendation fiveWorkforce development needs to be alignedacross health and social care taking account ofthe new apprenticeship levy system and usingCompetency Based Learning modules as part ofa skills escalator.

Recommendation sixA distributed service delivery model is requiredbased on the gradual development of multi-service hubs. These could be focused on specificcare pathways or service user cohorts, e.g.diabetes, dementia care etc. As these multi-service hubs are developed the local hospitalprovision can be adapted with the release ofhospital estates as part of a joined up OPEstrategy between NHS and local authoritypartners. NHS England should ensure that localproviders and commissioners have incorporatedthese approaches in Transformation andSustainability Plans.

Recommendation sevenInspection and regulatory regimes need to bealigned on an outcome basis at local rather thannational levels.

Recommendation eightThere needs to be a national and localcommitment to long term outcomecommissioning – beyond existing politicalhorizons. This should include recognition thatsignificant system change is being undertakenwith longer timeframes for improvementaccording to the scale and pace of change, e.g.over 5 and 10 year timeframes.

Recommendation nineDevelopment of integrated health and socialcare services should include parity amongstpartners from across the public, private andsocial sector with an explicit aim of usingtransformation in service models to help buildthe social sector.

Recommendation tenThere needs to be acceptance and understandingacross the system that willingness to innovateand make effective change means, learning fromnew ways of working and that in the process ofchange some things will work and some will not.To better support the process of change thereneeds to be resources for research, developmentand evaluation, including local area feasibilitystudies.

Recommendation elevenLocal change programmes need to harness theimpact of digital innovation on services andoutcomes as part of a strategic drive towardsprevention and public health improvement.

Recommendation twelveLocal area change and transformation plansneed to maximise the possibilities and potentialprovided by social investment to help drivetransformation.

02 Executive Summary15 Introduction17 The Vision22 Methods26 Context36 Building a sustainable future – a model for integration and innovation5555 CCoonncclluussiioonn


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