Doncaster Council and CCG have a history of collaborative working, and the BCF has enabled local partners to work towards more comprehensive integration. Building on approaches such as One Team Working with its co-located health and social care teams, work has started on more fundamental reform. The aim is to deepen integrative approaches based around locality working and primary care.
How public health became involved
When based in the PCT, public health was central to both NHS strategic planning and joint planning with the council. This role was maintained when it transferred to the council, with public health taking the lead for several aspects of the BCF and wider integration.
What others say – Councillor Pat Knight, Cabinet Portfolio Holder for Public Health and Wellbeing:
Public health has made a big contribution to integration in Doncaster. It provides a bridge between the NHS and the council which helps both partners work more effectively together. Public health’s experience of working both in the NHS and the council helps both to understand how the other operates, which is very useful in the work towards greater integration.
The BCF was a good piece of joint work which brought partners round the table to look in more depth at activity and costs, and the DPH was fully involved in this work. Public health provides skills in research, evaluation and data analysis, and has helped the council develop a better understanding of population health both across the city and at ward level. This helps the council to better engage in the integration agenda.
Public health contribution to integration
Strategic leadership
The DPH is an executive director of the council, and the council’s director lead for the HWB, which oversees the BCF. The DPH is also the lead within the council for linking with NHS initiatives such as the primary care strategy.
The cabinet member for health and wellbeing is chair of the HWB and responsible for leading on integration, working closely with the portfolio holders for adult social care and children. The chief officer for the CCG is the vice chair.
The BCF has three strands: ‘vibrant and strong communities,’ ‘choice of support’ and ‘healthy and safe.’ The DPH is the council’s lead on the ‘healthy and safe’ strand, and is responsible for providing research and evaluation across the BCF programme.
Public health also leads on specific integration areas such as falls and information and advice, and supports performance management, reporting to the HWB.
Brokering relationships
Because of its links with the CCG and the council, public health can be seen as an ‘honest broker’ with an understanding of the issues and pressures facing both organisations. Public health has been involved in problem solving and finding solutions both at a senior, strategic level and in operational delivery. For example, it was involved in working with the CCG, local medical committee and adult social care to increase GP support for council intermediate care beds.
Evidence, outcomes and evaluation
The public health team provides data analysis and an evidence base which supports the direction of change. Examples from the BCF and other integration work include:
- An information pack analysing Doncasterspecific factors in non-elective admissions covering age, diagnosis, geography, length of stay etc.
- Based on the above, a resource pack providing the evidence base for key interventions that have led to a reduction in emergency hospital admissions in the areas of falls, chronic obstructive pulmonary disease and asthma.
Public health has identified the need to get better at understanding ‘big data,’ moving beyond basic analysis to being able to make accurate forecasts. It is working to better join up health and social care data and to turn the JSNA into a future-facing resource. It has been involved in commissioning a system which for the first time will allow a view of integrated health and social care information through a series of online dashboards.
Public health was involved in a major study into the housing needs of older people to provide the analysis and evidence base for a strategic plan for housing and accommodation options.
The study covered the range of housing issues, including general stock, extra care, residential care, adaptations, and community support. It involved quantifiable data, a literature review and the views of local older people. Overall, the study found the need to develop specialist housing and intermediate accommodation options to avoid hospital admission or facilitate discharge, and concluded that housing, health and care could work more effectively together. These findings have been fed into the strategy.
Public health is involved in the evidence and evaluation aspects of a review of intermediate care, which aims to shape a new step up, step down model that better reflects the integration of health and social care.
As well as carrying out in-house research, the council has an academic partnership with Sheffield Hallam University and Sheffield University which have been involved in a number of projects to inform the integration agenda.
The council uses an outcomes-based accountability model which has been adopted by the HWB for the BCF. Public health has been involved in developing outcomes for a number of programmes and has also contributed to the Doncaster Outcome Tool, a framework for measuring quality of life and outcomes for people who use services. The tool has been tested with a group of people, three months after they received adult social care support, with interesting findings.
The evaluation found little change in overall quality of life scores, but there were variations on some components such as positive changes in self care, carrying out usual activities and anxiety/depression. On wellbeing there were positive changes on all outcomes, suggesting that service users’ perceptions of their health and wellbeing improve after initial engagement with social care. More work will be done to develop the tool, including introducing benchmarking and comparative data to better understand impact. Results from using the tool will also be fed into the blended value assessment model which is also being developed.
In the blended value model, programmes and activity are evaluated based on their potential for a blend of financial and social value. The academic partners have helped to pilot this approach in the area of assistive technology. The analysis considered the reduction in inpatient admissions, avoided A&E episodes, and delayed admission to residential care, and suggests that use of assistive technology leads to a £2.10 public sector cost benefit on every £1 invested. Public health will be involved in work to test the blended value approach more widely.
The academic partners are conducting a year-long study to understand people’s experiences of going through the hospital discharge process and what can be done to make this more positive. Interim findings suggest that many people have very little understanding of what is available to help them post discharge, and what they are entitled to.
An integration programme prior to the BCF established a community funding prospectus for the voluntary and community sectors, focused on developing innovative solutions to support and maintain independence in adults. The programme has been evaluated in relation to factors such as co-production, innovation and cost effectiveness prior to a decision about its future beyond 2016.
What others say – Jackie Pederson, Deputy Chief Officer of Doncaster CCG:
Public health has been integral to developing the BCF from day one. Responsibility for planning and shaping the BCF is shared across public health, adult social care and the CCG, with each taking the lead for areas which fall within their areas of expertise, interconnecting within an overall programme for integration. For public health this includes the areas of prevention, such as developing community assets and self help. As a team based in the council, but closely connected with the NHS, public health has a role in working across the system, making connections, but also providing challenge and a different perspective.
As integration develops, all partners, including public health, will need to work in different ways, such as increased joint commissioning and more detailed data analysis. New models are emerging, with the CCG taking on responsibility for co-commissioning primary care, looking to develop a complex case management approach, and reviewing intermediate care. These developments will need to be joined up, and complemented with social care and preventative approaches.
Developing preventative approaches
The public health team views integration as an opportunity to engage with partners to promote health and wellbeing through developing preventative approaches. The ‘vibrant and safe communities’ strand of the BCF has an emphasis on upstream developments.
Further work needs to be done with the next stage of BCF planning, including establishing a target operating model, in which preventative approaches are embedded. Public health will also look at the potential of pooling elements of the public health grant within the BCF.
As part of the Public Health England Well North programme to reduce health inequalities, the public health team is working with a local community using a ‘4D’ developmental model – discover, dream, design, deliver.
The programme has two main themes:
- finding people who are not known to services, but who are at high risk of needing support as a focus for local integration
- working with communities to develop assets, using the method of ‘appreciative inquiry’ – a method of changing social systems, such as communities, with a view to developing economic and environmental regeneration using questions.
The CCG is developing a primary care strategy to reflect its full range of commissioning powers, delegated from NHS England. Prevention and self care will be an element of this strategy, and public health will contribute to an integrated approach to this area.
Contact
Dr Rupert Suckling Director of Public Health [email protected]