interviews

City-wide integration

NHE talks to Professor Sir Ian Gilmore, former president of the Royal College of Physicians and chair of Liverpool’s Mayoral Commission on Health, about the city’s ambitious health and care integration plans. 

Closer integration of health and social care is at the heart of many local authorities’ visions for the future, but tangible action can be harder to find. Liverpool City Council has just published a radical blueprint that seeks to bring together local government with the NHS, changing the way services are delivered.

‘All Change: the platform to a healthier Liverpool’ was the result of a mayoral health commission chaired by Professor Sir Ian Gilmore, former president of the Royal College of Physicians, with input from a dazzling roster of influential figures from the health and social care sectors both nationally and in Liverpool (see box out overleaf). Their report calls for the city council, the clinical commissioning group (CCG), the health and wellbeing board (HWB), and NHS England to work together to improve health and social care across the city, and sets out 10 specific recommendations.

So what has set Liverpool out from the rest? Prof Gilmore, who holds clinical and academic posts in the city, told NHE that having an elected mayor allowed the city to move further and faster on the issue of public health.

He said: “Liverpool has done very well in some areas of public health; we’ve actually narrowed the health inequalities gap in recent years, and we’ve also exceeded our targets for smoking reduction.

“But despite those improvements, we are still, as a city, very near the bottom of the league in most health indices; cancer rates or heart disease or deprivation. Clearly there are still major challenges there.”

Huge challenges and strong support

The commission brought together commissioners covering social care, nursing, community care and mental health to investigate how Liverpool’s healthcare challenges could be overcome.

Prof Gilmore told us: “The overwhelming message we got back was that everyone accepted there were huge challenges in improving health and healthcare in the current financial situation, [but] there was huge enthusiasm and support for doing it. Everyone we spoke to really wanted to see better working between primary and secondary care, community and hospital, social services and the NHS. So right across the piece there was strong support for the concept of better integrated working.

“Everyone we’ve spoken to, all the partners we’ve asked to sign up to these principles, are keen to sit down and hammer out how this can be implemented.”

Removing duplication

In many cases, “unintentional duplication of effort and services” provides a further drain on already straitened resources – with different organisations delivering the same care, rather than a more co-ordinated approach.

Prof Gilmore added that sometimes, even, this duplication was intentional; “not because there are bad people out there, but because sometimes the system encourages it”.

He explained: “Some of the ways that health services are funded, for example, encourage hospitals to see patients rather than work with primary care and the community to manage patients better in their own home. There are many unhelpful levers in the system.”

More research into the amount of duplication currently present in health and social care will be “the next phase of work”, with a willingness needed from both the secondary and tertiary care services to “look constructively at this”.

But again there are significant barriers, and Prof Gilmore called for more central support to allow the city to make changes without any of the regulators “descending like a tonne of bricks on someone because they were a short-term financial risk”.

Right first time

The commission and the mayor, Joe Anderson, certainly didn’t want this to be “just another report that sits gathering dust on the shelf” and were “absolutely committed to the implementation; getting people around the table deciding who does what and on timelines”, Gilmore said.

There were significant obstacles to better health and social care integration, he added, but “no-one pretends that this is going to be easy”.

He told us: “Clearly there are huge financial challenges to local authorities at the moment – but often the cheapest way to do
something is to do it right the first time and to avoid duplication. I think there are opportunities.”

It’s the idea of a ‘burning platform’, radical and urgent enough to spark a change across the city: “The status quo is not an option.”

Oversight of the implementation will now be taken forward by Prof Gilmore, as well as co-chair of the commission and former chair of Liverpool PCT, Gideon Ben-Tovim.

Prof Gilmore explained: “We’re keen to not just create more committees for the sake of it – and we want to see if we can find ways to implement the recommendations within existing structures as much as possible. Because there are things like the HWB, the CCG and so on, the key is to get the right hand knowing what the left is doing.”

Further and earlier

The wider determinants of health are a core part of the new vision – things like housing, education, employment, and access to green spaces. The report makes recommendations on these areas, recognising that successful integration will require more whole-scale reform.

Prof Gilmore said: “That’s why we’ve concentrated more on areas which are within the responsibility of the mayor and the council – the ‘causes behind the causes’ of health inequalities.”

Greater focus on prevention of illness, and a stronger public health message could help residents place a higher value on their personal health, and to become “partners in their own care”.

Banning the sale of alcohol below a certain price is also something the mayor is “very committed to introducing”. Prof Gilmore, widely known for his campaigning on alcohol and the health problems associated with it, said: “It’s a really important public health message; local government can take action where central government has dodged it.”

Evidence base

The report calls for leadership to be based on good evidence, with priority given to improved data-sharing and an integrated electronic record, “to the benefit of direct patient care, innovation and research”. Research from the North West Coast Academic Health Science Network (AHSN) will help the relevant organisations to act as one and overcome the barriers to collaboration and delivery of more effective health and social care.

And the Liverpool Health Partners – a body joining local hospitals with the University of Liverpool – will provide “the engine for research and development”, which will feed into the wider AHSN to disseminate innovation.

Prof Gilmore said: “I think they’re really key. The three pillars of both of those organisations are service, education and research, and they’re all important in fulfilling this integrated plan.”

The ten recommendations for Liverpool

1. The key partners in Liverpool formally sign up to the principle of seeking to create a pioneering, high quality, sustainable Integrated Health and Social Care System for Liverpool, and lead, manage, and fund the transformation of the health outcomes of  the people of Liverpool.

2. Prevention and self-care become the primary focus in the transformation of health outcomes.

3. The system to be stimulated by a major new initiative to integrate out-of-hours services across primary, community, secondary, tertiary, mental health and social care.

4. A single unifying strategic plan developed, based on the City’s Joint Strategic Needs Assessment.

5. National bodies such as NHS England, HEE, Monitor, the CQC, the NHS Trust Development Authority, PHE, and Healthwatch to be kept fully informed of the strategic plan.

6. Liverpool Health Partners and the North West Coast AHSN play a key part, through research-based input from the academic
community and their links to industry.

7. A Neighbourhood Model to be the key way of implementing the proposed Integrated Liverpool Health and Social Care System.

8. A workforce strategy including the development of new roles assisting existing staff to work differently, giving young people access to new opportunities and supporting the recommendations of the Mayor of Liverpool’s Education Commission.

9. That the transformation of the health outcomes is research and evidence-based.

10. The City of Liverpool and all its organisations commit to the transformation of the health outcomes of the people of Liverpool by tackling the wider determinants of health and facilitating healthy choices in food, alcohol, smoking, exercise, and transport.

Members of the Commission

• Professor Sir Ian Gilmore (commission chairman)

• Dr Susan Shepherd (commission secretary)

• Dame Christine Beasley, chief nursing officer for England, 2004-2012; vice chair, NHS Trust Deve opment Authority; chair, Health Education North Central and East London

• Professor Dame Carol Black, principal, Newnham College, Cambridge; expert adviser on health and work to the Department of Health England and Public Health England

• Professor Sir Alasdair Breckenridge, chair, Emerging Science and Bioethics Advisory Committee (Department of Health); emeritus professor of clinical pharmacology, University of Liverpool

• Sir Cyril Chantler, chair, UCLPartners, Academic Health Science Partnership

• Martin Else, chief executive, Royal College of Physicians (to Sept 2013)

• Professor Chris Ham, chief executive, The King’s Fund

• Sir Robert Lechler, vice principal, King’s College London; lead, King’s Health Partners, DH-accredited Academic Health Science Centre

• Professor Sir Michael Marmot, director, UCL Institute of Health Equity

• David McDonnell, president of council, University of Liverpool; formerly global chief executive, Grant Thornton

• Molly Meacher, Baroness Meacher of Spitalfields, House of Lords

• Sir Hugh Taylor, chairman, Guys and St Thomas’ NHS Foundation Trust

Local Commission Steering Group

• Professor Mark Bellis, immediate-past director, Centre for Public Health, Liverpool John Moores University; currently director of policy, Research Development, Public Health Wales

• Gideon Ben-Tovim, chair, North West Coast Academic Health Science Network; former chair, NHS Merseyside

• Dr Simon Bowers, GP and deputy chair, Liverpool CCG

• Dr David Fearnley, medical director, Mersey Care NHS Trust

• Dr Craig Gradden, medical director, Liverpool Community Health NHS Trust

• Professor Ian Greer, executive pro-vice chancellor, Faculty of Health & Life Sciences, University of Liverpool

• Dr John Hussey, GP and medical director, NHS England (Merseyside)