Fragmented healthcare services are a challenge

Complicated, complex & difficult but Staffordshire health services must come together for better patient care

This is a massively complicated and important issue so I thought I’d first do a few lines as a sort of executive summary and then write about the detail more widely…

The NHS is made up of many independent health Trusts which don’t always put system wide healthcare benefits ahead of their own organisation’s needs

That can cause cost shunting between different parts of the system meaning delays for patients, added costs and financial instability overall

Too many people, particularly the elderly, end up in hospital by default when often it is safer and practical to treat them at home

A major investment in community based healthcare teams is needed so that over time more people can be treated in their homes rather than lives being disrupted by unnecessary hospital stays

There is clear evidence to show that people don’t want to enter hospital unless absolutely necessary and treatment, or convalescing at home, can help people back onto their feet more successfully

Financial savings and better services for patients could be achieved if the many different parts of the healthcare system alligned better and that would release additional investment for front line services

The new Staffordshire Health & Wellbeing Board is a tremendous chance to take a strategic approach across all organisations to ensure the wider healthcare services are a priority rather than organisations in isolation

And now for the detailed piece…

A little understood fact is that the NHS and wider healthcare system in the UK isn’t one body but hundreds of autonomous Trusts and organisations working independently of one another.

The basis of Staffordshire’s healthcare system which serves the 1.15million population is made up of nine major Health Trusts, County Social Care & Public Health, Stoke Social Care & Public Health and the 530 GPs formed into four Clinical Commissioning Groups (CCGs). The combined spend is around £3billion.

The CCGs are complicated bodies in themselves because each of them is a partnership of the GP practices in a geographical area. All Cannock and Stafford GPs make up one CCG and all Lichfield, Tamworth and South Staffordshire GPs make up a second. The north of Staffordshire, made up of Stoke, Staffordshire Moorlands and Newcastle under Lyme, make up the third and then the East Staffs area is the fourth.

Then you’ve got Staffordshire Social Care & Public Health which is part of the County Council and Stoke Social Care & Public Health which is part of the City Council.

Social Care looks after people in a non hospital or specialist service setting. It’s about helping people to stay independent and safe in their own home as they get older or their health changes but also about helping people to avoid hospital unless it is something of a critical nature. And if someone does need hospital care it is social care that helps to get them out as soon as possible by providing the support to get them back home (discharge).

It’s actually more than that because it includes residential care, other care and support services and dozens of other functions. But for the sake of some coherence I’ll leave all those things for another time… important as they are.

Public Health is about the wider general wellbeing of the population and particularly trying to improve that in the longer term. Things such as obesity, alcohol consumption, smoking etc. It’s about working on preventing ill-health at an individual and population level by trying to help people become generally healthier through lifestyle choices. Public Health also protects the population against, and during, pandemic or the spread of disease or food poisoning outbreaks. In fact anything that can cause a widespread specific health threat.  

Puzzled so far? Let’s keep going because the Trusts I mentioned earlier fall into four very different types currently. 

Acute Trusts. There are three in Staffordshire and they provide the hospitals and the services within them. The University Hospital Trust in the north is one, then there is the Mid Staffordshire Trust and finally the Burton Trust.

Mental Health Trusts. Two of them, one for the north and one much larger one for south. These specialise in providing services to people with mental health issues, drug and alcohol addiction, perinatal needs  and other specialist psychological services.

Community Health Services Partnership Trust. It is newly formed and covers all Staffordshire… including Stoke. I’ve written during the last couple of years about our work to create the new organisation. That happened formally five weeks ago, nearly concluding the work  we started shortly after taking office in 2009. Our aspiration then was to form a new service bringing community health and community social care services together. The final phase to move social care services into the new Trust is imminent.

This will substantially increase the amount of health and care provision available to people in their own homes, and in other community settings, and also mean a big improvement in the quality of services and patients’ experience. Bringing community health and social care services together is inegral to the thrust of our efforts to improve the wider healthcare system in Staffordshire. 

Primary Care Trust (PCT) is the last type. There are currently three of those. One for north of Staffordshire, one for Stoke and the biggest for the south of Staffordshire. These three Trusts hold the purse strings for Health money and buy in services that make up much of the NHS. Those three PCTs have now come together into what is called a Cluster. In effect they are now one but will disappear completely in due course and most of their responsibilities for commissioning health services will move to the GP Clinical Commissioning Groups. About 15% of commissioning the CCGs won’t do remains with the Cluster but as a new countywide body call the Local NHS Commissioning Board. Hold that thought… I said it was complex.

Oh, and there’s also the West Midlands Ambulance Trust but because things are complicated enough I’m going to ignore that for the purposes of this explanation of how things work… just for the moment.        

So, that sets the broad scene… current and future. The principle behind how the whole health and care system works rests with the commissioners that hold the money and the ‘providers’ who sell their services to commissioners.

The Commissioners with the money are County Council Social Care and Public Health (City Council for Stoke), GPs within Clinical Commissioning Groups, who have by far the largest slice, and the Local NHS Commissioning Board for specialist services commissioned on a regional or national basis.

The Providers who want to sell their services are the Acute Hospital Trusts, Mental Health Trusts, the Community Health Partnership Trust, commercial health and care providers of services and the voluntary and charitable sector. Some of the above providers, such as the Hospitals and other Trusts have a virtual monopoly because of public sensitivities around commercial providers delivering some types of services. And the ‘market’ has been broadly closed, public funding wise, meaning it is mainly self funders and people with health insurance that pay for their own healthcare that has stimulated some private hospitals and other services. 

It’s worth noting that for reasons I won’t bother explaining the arrangements set out above are broadly more sensible than what was there before. They are even a little simpler with greater democratic accountability at their heart in the form of a new County Council board I chair called the Health & Wellbeing Board… more about that later.   

Let’s move on to the core issues for the future.

Each of those autonomous bodies that make up the healthcare sector have financial and operational responsibilities to their own organisation as well as to the wider ‘joined up’ healthcare system. And that’s a big challenge because, as you’d suspect, organisational self interest often takes priority over the wider healthcare sector.

That can result in what is called cost shunting from one organisation to another and causes delays for patients as they leave one part of the system into another. The ‘who’s going to pick up the bill syndrome’ is a problem. And far too many people, particularly those who are older, end up in hospital unnecessarily because there are not enough community health and care services. Clinical technology and treatment has advanced so far in the last two decades that many older people can be treated more safely at home than in hospital… well away from hospital acquired infections, some of which are impossible to eradicate for biological reasons. 

As well as being safer in many circumstances, it is also considerably cheaper to treat someone in their home rather than incurring the massive ‘hotel’ costs that are the hospital building. That statement causes political meltdown far too often and entirely without reason. It’s about moving health resources, staff and provision around… out of hospitals and into community teams. That’s safer but also cheaper meaning more money available for critical services such as A & E and more specialist consultants. 

Hospital should be the place of last resort, not first. It is important that patients return to normality of life as soon as it is cpmpletely safe to do so. And so potentially reducing the capacity of hospitals and using the money saved to increase community provision of care services makes perfect sense from a patient safety, financial and practical point of view. But even suggesting that gets uninformed and scaremongering hares running.

It’s also a complicated thing to do because it has to be done in a sequenced way in order to ensure community services are built up well in advance of hospital capacity reducing. That needs extra investment because of double running costs. That upfront investment in community health and social care services would lead to financial savings in a completely different part of the healthcare system. So one part invests and another part benefits financially from savings. 

Because there’s fragmentation in the wider system that investment doesn’t happen and nothing changes. And why would hospitals help to do that when it reduces there organisational income? Similar fragmentation exists right across healthcare services and it is blocking improvements to patient care and stopping the liberation of more money to reinvest in different services and groundbreaking drugs. 

But in Staffordshire, progress is being made, albeit slower than I would like. And the new Partnership Trust which has just been launched dramatically increases the level of community health and care services available. That’s a major step forward so more people can be safely treated at home where appropriate to do so rather than ending up in hospital or institutionalised care.

There is however a long, long way to go to get the different parts of the healthcare system working in synergy, more efficiently and more effectively. To progress that will need strong strategic leadership which encourages and, where necessary, effects positive change in an environment which is often comfortable with the status quo.

That’s where the new Health & Wellbeing Board will assist. It has statutory powers around bringing health and care services together but more importantly has the top people from the key commissioning bodies, including GPs, sitting around the table.

I chaired the first meeting of the Board recently and the signs for cooperation were promising. The opportunities for  improvements in the quality of patient care and the effectiveness and efficiency of the wider £3billion system are entirely real. But above all, the changes in emphasis away from default hospital care instead towards more care in a community setting where appropriate, needs sensible and balanced public discussion.

The collaborative shift in approach is needed across the whole healthcare sector, not just parts, if we are to realise the unique opportunity we have to permanently and positively affect the lives and wellbeing of thousands of Staffordshire people every year.

We live in challenging times but with those challenges come some great opportunities and I genuinely believe we can build on the work to date across Staffordshire’s health and care services and develop a more coherent, efficient and patient focused system for the future.

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