Asset-based approaches in local authorities: the Wigan experience

Wigan is a metropolitan borough in the North West of England, it is the second largest borough in the Greater Manchester conurbation and is therefore one of the 10 Greater Manchester boroughs involved in Greater Manchester devolution. As part of the devolution settlement, Greater Manchester (12 NHS clinical commissioning groups, 15 NHS providers and 10 local authorities) and NHS England agreed a historic Memorandum of Understanding to develop a framework for joint decision-making on integrated care bringing together health and social care budgets of £6 billion. This represented a significant shift back to local determination of how resources, previously commissioned nationally or regionally, are most effectively deployed to work with local citizens to improve health and reduce long-standing health inequalities. This is set out in the Greater Manchester Health and Social Care Partnership “Taking Charge” Plan within which there is a welcome focus on well-being and prevention at the heart of the agreement and the current development of an MOU with Public Health England makes the potential realisation of both Derek Wanless’ vision of the “fully engaged scenario and Michael Marmot’s Fairer Society, Healthy Lives recommendations integral to Greater Manchester’s future economic success.

The agreement with NHS England affords the ability to pursue a whole system approach through local government’s wider remit for civic leadership and greater freedom to pursue local objectives with a predominantly local, rather than national, performance regime. It also harnesses the potential of the wider Greater Manchester devolution framework and Greater Manchester’s well-established political and strategic governance to implement a place-based approach to public health leadership making Marmot’s vision of addressing interlinked health determinants: employment, planning, housing, transport, skills, education and leisure as well as integration of health, social care and well-being services; a reality. This is firmly embedding “health in every policy” and improving health outcomes at pace and scale through evidence-based transformation of core business, not small stand-alone projects.

Wigan has been at the heart of the devolution programme but our journey of The Deal starts well before Greater Manchester devolution was on the agenda going back to 2010 when the council had to face some difficulty decisions in relation to the introduction of austerity and year on year significant reduction to its revenue grants.

Wigan has a population of 320,000 and is the ninth-largest metropolitan authority in England and second largest council in Greater Manchester. The council is responsible for an annual revenue budget of £231 million a year. Adult social care accounts for around a third of the council’s net resource and over 7,000 people are supported within adult social care each year.

The total annual health and social care spend across the borough is £669 million.

• Nearly 98 per cent of Wigan's population are White British
• 65 per cent of the borough’s population are of working age
• 23 per cent of residents have long term illness
• There are nearly 34,000 carers of which 3,000 are likely to be children
• Nearly 100,000 people in the borough are living in the most deprived quintile
• Rates of homelessness are high: 3.63 per 1,000 households compared to 2.48 per 1,000 for England
• Higher than average rates of obesity
• 16 excess cancer deaths each for women and men under 75 years against the England rates 2012-14 (majority are lung cancer deaths)
• Our population aged 65 and older will increase by 30,000 over the 20 years.

Since 2010, Wigan Council has achieved £134 million in savings and, according to the Institute for Fiscal Studies' English local government funding: trends and challenges in 2019 and beyond, this is the third largest proportionate reduction in funding across the country through Government austerity.

To address this significant financial challenge, the council acted quickly and decisively and took the opportunity to do things differently building on the borough’s involvement as one of six local authorities to be awarded ‘Creative Councils’ funding supported by NESTA and the Local Government Association to test new ideas about how public services are delivered. This led to politicians and senior management fundamentally thinking about a new relationship with residents and communities taking on the lessons from the Creative Councils’ work in Scholes which had a powerful impact and challenged the way we work with service users and the wider community. This was crucially coupled with a commitment to invest in local people and civic society at scale and even more, crucially, taking:

1. An invest-to-save approach: prioritising community, prevention, early intervention.
2. Frontloading and over programming the internal savings plan with the focus on cash flow not just savings.

The development of The Deal was therefore based on this different approach to financial planning and management and a key set of public service reform principles:

A new relationship between public services and citizens, communities and businesses equals "Do with, not to".

An asset-based approach that recognises and builds on the strengths of individuals, families and our communities rather than focusing on the deficits. Having a “Blank Mind” when having conversations. Treat citizens as full of strengths to be revealed.

Behaviour change in our communities that builds independence and supports residents to be in control

A place-based approach that redefines services and places individuals, families and communities at the heart. Stay close to neighbourhoods and mobilise people around them. • A stronger prioritisation of well-being, prevention and early intervention. • An evidence led understanding of risk and impact to ensure the right intervention at the right time.

The essential components of The Wigan Deal are:

• Strong narrative: a simple concept that everyone can understand but is profound in its implications
• A belief that this is a movement not a project: rooting the approach in public service values: “sense of vocation”
• Leadership at every level: commitment and senior sponsorship
• Workforce culture change: training and core behaviours that define how we work, whatever the role.
• A different relationship with residents and communities: building self-reliance and independence
• Permissions to work differently: leadership backing: ‘we will support you’
• Redesigning the system: testing our systems, processes, ways of working against our principles: ‘do they make the culture and behaviours we want more or less likely?’  
• Enabling staff with the right tools and knowledge: using new technology to support new ways of working and new roles
• A new model of commissioning and community investment: market development and new arrangements for commissioning
• Supportive enabling functions: breaking down barriers to progress and facilitating the change.

In adult social care where the Deal transformation started, the case for change was irrefutable. In 2011/12, there was a projected overspend of £6.9 million, with rising demand for services. At the time, adult social care was a traditional service model with a care management focus. There was a lack of leadership and direction, accountability issues throughout the service, dis-engaged and risk-averse staff and bureaucratic processes with multiple assessments. The newly appointed Director of Adult Social Care and Health had, in his previous role, been instrumental in developing the People at the Heart of Scholes work which underpinned the development of the “different conversation” approach of the Deal.

• Know your community
• Community Book
• Market shaping
• New commissioning models
• New roles:
  • Community Knowledge Workers – knowing their patch
  • Volunteer community connectors
  • Community Link Workers within primary care.

Two years after the original Wigan Deal was developed and with the impending transfer of public health back to its original home in local government from the NHS, The Deal for Health and Wellness was developed which builds on the overall principles of The Deal and applies them within the context of transforming the health and well-being of the population and the health, care and wellness system across the Borough. It is asset-based, application of “different conversations” between citizens and health and social care staff and targeted investment in building community resilience for health and wellness – the approach has been integral to the development of the integrated care organisation.

The Deal for Health and Wellness

Our part

• Support families to give children the best start
• Create training opportunities and jobs
• Provide seven day access to GP services
• Help communities to support each other
• Help you to remain independent for as long as possible
• Provide leisure facilities to help keep you healthy and active.

Your part

• Lead a healthy lifestyle and be a good role model
• Take advantage of training and job opportunities
• Register with a GP and go for regular check ups
• Get involved in your community
• Support older people to be independent
• Make the most of leisure facilities and be active.

Heart of Wigan which is the Transforming Population Health programme for the borough continues to promote physical activity, through the utilisation of green spaces and active travel, to improve the health of Wigan residents. The success of Heart of Wigan has been built on strategic leadership and collaboration from across our partners. Heart of Wigan encompasses the commissioning of all health improvement services, building on the six strands listed below:

1. North Karelia whole system CVD prevention
2. Hear Start from Seattle
3. Phase 3 transformation workstreams afford the greatest opportunity to achieve accelerated impact across clinical and non-clinical areas
4. FSPH Health Improvement Level 2 (Heart Champions)
5. Community defibrillator rollout
6. NHS Health Checks plus vascular dementia risk

The Healthier Wigan Partnership is a partnership of health and care providers and commissioners bound together by an Alliance Agreement Key service components are:

• Reformed primary care in clusters in 30-50,000 population
• Integrated community services
• Implementation of the Start Well offer
• Public health interventions wrapped around GP surgeries
• Community based mental health alignment to SDFs
• Shift of hospital activity (diagnostic and treatment) to community
• Place based working across health and care and a full range of public and voluntary sector services
• Philosophy and behaviours reflective of Wigan Deal principles, for example, shortly all staff from all organisations will be attending a common and immersive “Be Healthier Wigan” experience: How the Healthier Wigan Partnership fits with wider Public Service Reform and the Wigan Education Partnership.

Our “Health Movement for Change” now totals 23,000 citizens and currently includes: 1,350 Health Champions, 495 Heart champions, 856 Cancer Champions, 10,000 +Dementia Friends, and  200+ Young Health Champions

The Community Health champions are:

1. embedded within existing programmes
2. made up of members of the community, front line staff and volunteers from across the public voluntary and private sectors
3. our current developments include the roll–out of Autism Friends, In Mind Champions and the recently launched Communities in Charge of Alcohol programme led by the residents of Hag Fold.

Wigan was the Alzheimer Society Dementia Friendly Town of the Year 2016 and we aim to be the first Autism Friendly Borough. Some comments from participants in the Health Movement for Change are given below:

Most of the group of young Mums had disengaged from school. They had poor literacy, no qualifications and an absence of praise."

The qualification is the first one she has got. That’s a real achievement. She left the course much more confident and with a qualification she can put on her CV."

I try and act as a role model. I go for a walk each lunch time. I’ve also talked with family and friends and even placed bowel cancer awareness leaflets in the toilets at church."

We’ve really embraced it at Electrium. It’s amazing how many people are interested in a healthier lifestyle."

Our impacts

• 10 programmes across the borough creating over 100 Young Health Champions
• Successful video campaign raising awareness of sepsis, toxic shock syndrome and meningitis reached nearly 2000 people.
• Joseph Roberts has won the RSPH Young Person Health Champions Hygiea Award
• Third fastest improvement in care home quality nationally
• 100 per cent of directly delivered services rated ‘good’ or ‘outstanding’ by Care Quality Commission
• Wigan is the happiest place to live in Greater Manchester
• 72 per cent of residents strongly believe that they belong to their local area
• A balanced budget with growth earmarked in 2018/19 of £26 million of cashable efficiencies simultaneous to improving services and outcomes
• Getting people home from hospital: Wigan best in North West and fifth in country
• Admissions to nursing residential care have reduced 15 per cent and at a faster rate than the England average
• 75 per cent of residents supported by our outstanding reablement service require no further on-going social care support.

Improvements

• In the past three years healthy life expectancy has increased in Wigan by one month for males and 23 months for females and female healthy life expectancy is now at England average of 62.6 years
• In the past six years early deaths attributed to CVD have reduced by 29 per cent for males and 25 per cent for females 
• In the past six years early deaths attributed to cancer have reduced by 16 per cent for males and 9 per cent for females. Wigan is now similar to the national rate (previously Wigan has had a significantly higher rate).
• The proportion of adults who are physically active has increased from 48 per cent in 2012 to 63.4 per cent in 2017
• Over 14,000 children doing the Daily Mile every day plus extended to two-year-olds via The Daily Toddle in 20 Nurseries
• Smoking rates for routine and manual workers is for the first time, lower than the England average range at 22.8 per cent (England 25.6 per cent) (overall prevalence is 15.5 per cent, fifth year running in England average range)
• Smoking rates at time of delivery have reduced from 16.7 per cent in 2016 to 14.8 per cent in 2017 – this is the greatest improvement for four years (England 10.6 per cent)
• Hospital stays for alcohol related harm have reduced from 2358 in 2014/15 to 2192 in 2015/16. This is the second year that numbers have decreased and the gap between Wigan and the England average has reduced significantly since 2013/14
• Teenage Pregnancy rates at 23.1 per 1000 now in the England average range (20.8)
• All childhood vaccination programmes achieve 95 per cent herd immunity including MMR and for children in care (better than England for both these statistics)

Challenges

• 31 per cent of children in Wigan are not school ready for reception (this is at England average) but the figure is 50 per cent in some localities and amongst those accessing free schools meals
• Breastfeeding at six to eight weeks is only 29.7 per cent 
• One in four of the children in one of our primary schools lives in a house with a reportable incidence of domestic violence in the last two years
• 40 per cent of residents at highest risk of unplanned hospital admission are adults of working age – often with complex dependency on public services
• Significant proportion of activity in our GP practices is socio-economic – debt, domestic abuse, loneliness, access to work, cold homes
• Loneliness is a major determinant of hospital admission for older people
• Access to quality work for adults of working age is a health protective factor

Lessons from Wigan

• Identifying and linking with change agents, people who have an enthusiasm for promoting health and wellbeing, is the best way of building society and system-wide commitment.
• Local transformation is based on the quality and nurturing of relationships and human connection – “connecting people back to the humanity of their communities”
• Asset-based community development as per Cormac Russell’s approach and based on their early work as a NESTA creative council.
• Having “different” conversations between the citizen and frontline staff, for example, strengths based, co-creation with, as opposed to “doing to” using ethnography and anthropology to underpin staff training and transform organisational behaviours and culture equals Infecting the NHS with Wellness
• A whole society, whole system approach to health and well-being informed by the experiences of North Karelia in CVD prevention, Marmot’s Fairer Society: Healthy Lives and “fully engaged scenario” set out in the Wanless reports in the early 2000s on the long term sustainability of a publicly funded health and care system.
• Combining these three principles and underpinning them with “servant leadership”, for example “expert on tap rather than expert on top” approach and our Deal for Communities investment fund, for example, investing in the ideas, talents and passions of local people equals “Citizen-led” Public Health.

In conclusion: “The transfer of public health was a once in a generation opportunity to transform the health and wellbeing of the people of Wigan. The Marmot vision is very clear about what needs to be done: employment, planning, transport, housing, education, leisure, social care – all are interlinked and have an impact on physical and mental health. Wigan has taken every opportunity to appoint the right staff to support transformation, and two of the most important attributes are energy and motivation for change. Innovation is key to future progress, and staff must be given the time and space to try new things, and to make mistakes at times and learn from them. Wigan has developed a culture of giving good people the time and space to do great things. Evidence-based working is important, but evidence can only be achieved in the first place by trying something new.”