NHS and local government partnership working

NHS and local government partnership working

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Well good evening and welcome to this
NHS webinar. My name is Keith Willett I’m the medical director for acute care in
NHS England this is a webinar all about working with
local government, and it’s very much a clinicians guide and it’s come about
because out there in the sustainability and transformation partnerships we’ve
been asked by many of the clinicians to help them understand how local
government works they know that interface is really important and they
want to understand more about how they’re set up how the roles and
responsibilities play out what’s important to them and how they operate
so this evening we’ve got some very experienced guests with us which I’ll
introduce in a moment but we’re going to try and work our way through some of
those things and also take your questions so as a webinar you will see
that on the screen there is a chat marker and in the bottom right hand
corner there’s a box where you can type in questions so please do submit
questions as we go along we’ll collect those together and I’ll pass them over
to our guests. I think in general we can all recognise that there’s a lot
to be gained from working together but there are some inherent differences. The
approaches we take are quite different and we know from the past of some real
sensitivities in some areas and that’s particularly in many of your experiences
as clinicians. It may be preparing for facing a scrutiny committee. So we’re
going to try and cover many of those aspects but also as I’ve said any aspect
that you want to bring up with a question so please do think about
submitting them. Now we have two councillors with us this evening who are
going to help us and they’re gonna answer the questions for me and for you
I hope so I’ll let them introduce themselves so it’s Richard Kemp and
Johnny McMahon. Richard would just like to say what your role is and your
experience. Yes, I’m council Richard Kemp. I’m from
Liverpool City Council, where I’m the leader of the Liberal Democrat
opposition. Nationally, I’m Deputy Chair of the community well-being board of the
LGA which looks at our health and social policy activities and I also serve on
the health and well-being board of Liverpool City Council. Thank you very
much. And Johnny McMahon. I’m Johnny McMahon I was a GP. I retired from practice in May 2015 a couple years before I retired for a few years I was chair of the Cannock Clinical Commissioning Group and I was a
co-chair of the Staffordshire health and well-being board and after retirement I
became clinical lead for cancer end-of-life in the county. Then stood
for election, and I’ve been a councillor since May of last year and since
being elected I’ve been chair of the health scrutiny committee in the county. So I think between our two guests this evening that gives us a real opportunity to ask questions that
cover everything from health across into the national experience of Richard at
the national level with the local government so I think it’s safe and
looking at you in the eyes here to say that I think we can start with the
premise that most clinicians and in fact most people in health really don’t
have a good understanding of local government structures. What motivates
them and their accountability and I think that’s because we start from very
different places and I’ll be honest I’ve been working a lot now with local
government, social care, the community in trying to understand the urgent
emergency care services in the NHS. And I think fundamentally what’s different
well organizationally the NHS is very much a top-down structure. We’re used to
receiving directives, we’re used to playing things out in that way. Whereas
local government is very different. It’s grassroots, it’s from the bottom up it’s
a very very different thing in organizationally and accountability. But
also personally I think the clinicians and health come at this very much from a
patient focus, evidence-based interventions, doing the right thing for
individual patients. But from local government it’s different again. That’s
very much about being responsive to what their public tell them they want rather
than necessarily what they as in health would say ‘we know what’s best’. So I think
that’s quite a difference in approach and I think we all see that play out as
we address some of the questions this evening. So to put a bit more structure around that and save some evidences is he just making this up or
is that what the communities out there in health and local government think
there’s some evidence to be published shortly from Britain Thinks, which is a
insight and strategy research survey that’s been done of professionals in
both organisations. And in general there’s an agreement commonality that
the principle of integrating health and social care is the right thing to do
moving to a place-based approach for both organisations makes a lot of sense. But our past experience of that interface hasn’t
necessarily I think being being good we’ve certainly had some views and
coming back from local government views about how the NHS has approached local
government and social services in the past is: the NHS tends to engage very
late, the NHS also comes with quite a narrow focus about its agenda and it’s
problems. Rather than really appreciating the fact that local government has a
much wider remit, a lot of the social determinants of health outcomes lie
within local government be there housing be drug and alcohol services being
family children’s centres the sort of things that perhaps we don’t recognize
but also the NHS has been probably quite weak at collaborating in the past and
probably doesn’t have anywhere near the same experience for the reasons I’ve
said about how could to consult with its constituents and its public and which
local government have vast experience on so I think there’s an awful lot of value
to be had in a strong relationship between health and local government. So
that’s what we’re going to try and explore tonight but clearly there are
some specific questions there and I think if we just reflect back as those
of us who come from a health background is that if we look back at better care
fund, we look at how we set up the STPs to start off with I think that those
processes probably reflect some of the narrowness that health took and why
local government in some places was a little resistant to buy in to some of
those processes, and I think we’re still working through the in many areas also we’ve got to be sensitive NHS although yes we’ve been
financially constrained we have been protected and we’ve had a little bit of
growth over the last seven or eight years whereas local government has seen
a very different perspective. They have tried to predict adult social services
but they’ve seen cuts like we couldn’t imagine that they’ve had to handle so I
think we all need to be aware of some of that. So I’m gonna move on now to get
Richard and Johnny to talk about some specific areas but again do look at your
screen. Bottom right-hand corner if you’ve got a question you want to raise
this evening, please type it in there we’ll be picking that up, and we’ll have
an opportunity to feed that back in to our guests later on. So if I turn to
Richard first. So Richard the roles responsibilities of local government,
elected members, other officials how does the whole structure work for those of us
in health who are not day-to-day interfacing. Well you use a very key word there and
that was ‘elected’ that of course is the key difference between me and the member of our Clinical Commissioning Group or a foundation hospital whatever it is. I’ve
been elected and with 89 other people in my case we’ve been elected to Liverpool
City Council. We have put policies and proposals through to the people of
Liverpool and at the moment they’re not backing my party they’ve backed another
but enough of them back me to give me a place to raise my concerns and to do
things within the system, and that means we have a tremendous leadership of place
because no one else apart from the 90 of us has been elected to deal with the
problems of Liverpool. Now you might say you then just deal with local council
services don’t you but, if I can give you the example when I came here today I got
the 86 bus into Lime Street Station to catch the train. It’s the last bus stop
that goes on a lot all the route that goes through my ward and it’s like doing
an advice centre and I got four problems given to me today none of which related to the running of Liverpool City Council. Or the bus. Or the bus, yes. The bus was on time very good bus it was as well thank you Arriva but, that is an
indication we go out of the door and we are in our wards, we are dealing with
people. It take us two hours get a loaf of bread. So even if we’re not directly
responsible for it and we are responsible for most of the social
determinants of health we are expected to deal with whatever issue comes up and
I was saying that I’ve actually been a health service worker for more than 40
years now because I think we should redefine the roles because I think you
lot work for the national illness service and I work for the National
Health Service because, if I just imagine if everyone in this country lived in a
decent house in a nice neighbourhood a decent job with a few bob in their
pocket. How many people would be obese? How many people would be presenting with a whole range of illnesses? So my job is to keep people well. Now that means we
have very complex ways of dealing with this and in fact the system is different
between me and where Johnny works I’m an urban area. we’re a unitary council. We’re
now part of the combined authority for Merseyside. We have a regional mayor as
well as an elected mayor but, there are certain principles which carry through
all that at the heart of every council there is a cabinet it might be called
something else, it could be an executive but there that’s where the councillors
from the controlling party representing all the different or all the disciplines
make the key decisions then you have a series of structures Johnny we’ll be
talking more about scrutiny but including full council where people like
me hold the council leadership to account but again many of our debates
inside the City Council do not relate to our work as a council. They relate to
anything which, might affect the people of Liverpool and clearly health is one of the things we often debate and discuss not always
as fruitful as we might but that is our responsibility so we have for example
the health and well-being board which is where the Clinical Commissioning
Groups and ourselves meet to look at policy we are responsible for the joint
strategic needs analysis which is a health document but doesn’t just apply
to the Health Service it applies to the bus service it applies to the housing
services it applies to the leisure services our job is to promote health
using that information everywhere and the Health Service is part of it we of
course control public health although we have massively reduced
budgets to do this, and the most common interface that clinicians think about is
adult social care. Where we are trying to get people back into the community as
well as we could. Is this working well well partly in your introduction you
alluded to the circumstances in which the STPs were created and frankly they
couldn’t have been created in a worse way for local councillors because,
and the health service for that matter because frankly if the first thing I
know about a proposal from the Health Service or anywhere else is when I read
it in the paper then I go into opposition mode if people talk to me and
show me the reasons that things need to happen I go into a supportive mode. Won’t
necessary support exactly what any organisation wants includes the Health
Service but I become far more positive and the fact is we’ve done our own
survey of elected members but by and large councillors are not involved in
the STP process at all. There’s some in the health scrutiny will be involved
there be others who do relate to this but less than 10 percent of councillors
actually know what STP is. So can I just interrupt you there, and just challenge you.
That’s really important and I think there was the sensitives about the STPs and the pace at which that happened I think many
of the clinicians will recognise and they’ve sort of worked through that
already I guess in many places but I think on the on the on the corollary
there is the obviously you’ve gone through in local government significant
funding issues and many of the decisions although I’ve said in introduction
you’ve tried to protect Adult Social Care and other elements importantly many of
the decisions have been made in local government have a direct effect equally
on health. So how do you, could you just explain to clinicians in STPs how that
sort of process of financial accountability goes on in local
government, and how you would take the soundings from health and the NHS if
you like about the impact it may have in the other direction? Well we do it in a
number of ways. Principally we do it through the cabinet and then into the
health and well-being board because there we get papers from the Health
Service and various parts of the council the fire service the police in which we
challenge each other in a very positive way so this isn’t an antagonistic challenge
but to really ask some of these key questions. If you do that what does that
mean to you? and what does that mean to you? So we do try and reach a consensus
of a way forward. But there are difficulties to that Liverpool’s budget
for example has been cut by 50% in real terms. 5 0. 5 0. Yep. Since 2010, and we’ve looked with envy at the at the NHS. You’ve
lost a bit in relative terms it’s not as much as you wanted which is slightly
different but you haven’t lost that much and I find that the the the biggest
problem we have dealing with the Health Service is the way that not only
clinicians but everyone in the health service retreats not into the health
service but their own bit of the health service so for example in Liverpool the
voluntary sector funding from the Health Service was cut by 50% in one chunk last
year now we know that will have immediate effects in
our communities we know in a year’s time that’ll have a big effect on the health
service and in five years time it will have an even bigger effect but we talk
to people because we take a long-term view I’m making decisions now in terms
of roads and housing and things which will affect people in 30 years time when I’m dead. So two questions in so firstly for the clinicians those are in leadership roles
in the STPs what’s the best route of contact for them to understand the
decision makings that have gone on in the recent past that they may need to be
taking account of is that the minutes of the health and well-being board where do
they get that information so that’s the sort of the first question and on a more
positive note now relationships are forming and it’s
all about relationships I think you’d agree with that. Yeah this is. This is all about
relationships I mean you know sometimes the STPs were the first time some local
government and health people even sat in the same room so if we’re moving forward
positively then where can they find out what happened in the recent past
together they’ve got the context right and then secondly what’s the route now
that really gets the engagement going and and who should the STPs really be
engaging with in this sort of plethora of roles and the elected and
non-elected people in local government What I’ve described so far is the
formal system it’s where we have meetings it’s where we have committees
it’s where we have duties but the best place to do it is possibly the pub or a
cafe or a restaurant or an informal meeting place because I want to get into
the heart of some of these issues very difficult to do in a report like well
often challenge them I do some training sometimes within the health service and say hands up any of you here who know a councillor well every single clinician
has a local councillor every single clinician has a council leader or in
some cases an elected mayor there are all sorts of ways that they
need to break into the system and create those relationships perhaps one of the
key ones would be for ward councillors would be GPs so if I’m faced let’s say
with the hospital closure who my constituents going to talk to
first the GP what do they then tell me to the GPs interact with me as a
councillor there’s some questions I’ve got to ask about this I’m quite in favor
I’m against it whatever it is so what is the route but that’s me as a ward
councillor and every councillor including the leader of the council is a
ward councillor so I would encourage clinicians to develop relationships I
would be inviting every councillor in North Merseyside because although we
have an STP we are largely doing as in North Merseyside why isn’t the NHS calling meetings for people to get to know each other so this is very much
bi-directional isn’t it is there’s a lot that the councillors need to learn from
the health those who are thinking about transforming services or providing
services in a different way and actually doing that needs assessment from what
inevitably from an illness services is quite narrow but it’s also there’s very
much a role for them to understand the best routes in to get the right
consultation in place so they’re actually making decisions that are
likely to hold up under scrutiny and we’ll come to that later with Johnny.
That’s right. The more I know the more I can help so if a hospital is going to
close and we might have that the first question I ask, say we’ve got a problem with a women’s hospital the first question I ask is what’s that going to mean for
my wife my daughters and my granddaughters and if people can come up
to me with evidence to say clinically these are things would help your
daughter’s granddaughters etc life then I will respond much more than someone said
we’ve got to close it and I think the buggers are trying to save money. And I
think it’s a really good example because as a clinician we’d be saying what’s
a NICE guidance for that cohort of patients so that we’re doing the right
thing you’re saying no actually it’s about my constituent my family what does it mean
for them in terms of travel access but they’re the same people they are today
and that’s why we need to come together in in the middle and it’s NICE
guidance I occasionally have to read some of it I wouldn’t take it into my
ward to discuss it with people there we need to demystify some of the health
service stuff and if I could ask everyone who’s watching this whenever
you watch it to be braver and if I just give you a very brief example of that we
had a health and well-being board in Liverpool we were picketed and people
came up making all sorts of accusations against the elected mayor of Liverpool
and it would have been easy for me to say well that’s good because he’s a
different party than me but in fact he was being unfairly attacked on clinical
grounds about why we try and stop people going into hospital because we want to
keep them healthier and why we try and get them out as soon as possible
which isn’t financial grounds that’s all although that has a part so I waded
in on behalf of the Labour leadership of the council and they were clinicians
sitting around who could have made a much better job of it than me because
actually people do believe doctors but we think doctors are God and they
all sat there and I said afterwards why didn’t you come in on that debate? We
thought it was political. well I’m afraid clinicians you’re gonna have to get your
jacket off roll up your sleeve and go out into the communities because if you
set the right clinical tone to some of the debates that need to be had people
will listen to you more than me do not hide behind my skirts. So we’ve
had a question sent in and it’s about how you’ve answered all the questions
that have come through which is great so don’t take it individually but we had
come in saying what is the memorandum understanding between local authorities
and the STP and how are they how is that sort of agreed in the council or the
local authority as to as to how you approve? Well basically there isn’t
one so in all cases. Is that just for.. No generally. The STP has come to the
council as a document which was completed in 15 months was it whatever
and it comes to the health and well-being board
the council may then choose to take it as a document to Council for discussion
but the legal place it goes is the health well-being board and then it goes
straight into the scrutiny process for the scrutiny people to look at what’s
happening day-to-day there that there is a danger to that though is that by law
the people on the scrutiny committee cannot be in the cabinet and the senior
decision-makers because that’s the split exactly as we have it in Parliament so
precisely what happens varies from Council to Council in my own council for
example we oppose the STP but we’re getting on with the job of delivering
the North Mercy Health Plan so we’d already signed that off we agreed that
so is the answer if we are going through this again and obviously
we’re now into a much more positive place with these relationships is it
about finding the common ground and building up an understanding in the
relationships on that and then recognising each other’s particular
issues and trying to get co-create solutions is that what we should be
doing rather than trying to write memorandums of understanding documents.
We want to help the same people you call them patients I call them residents
we’re all there for the same purpose and my job’s some one said ‘what are you good at? You’re good for nothing something wasn’t been particularly kind
to me no rather rude language than that I said I’m not an expert on anything
except joining things up so we have 480 different professions and local
government never mind interacting with the health service that isn’t my job my job
is to say what’s the health service doing with the housing department what
aren’t you using our parks to better effect? Because that’s where I can
see real physical and mental health benefits I’m a joiner upper. So this
leads us nicely into Johnny so I hope you’re warmed up Johnny so what we’re
coming what’s coming out of this if I can just sort of paraphrase what you
said is there is something about what the NHS comes in terms of its ask and
the narrowness which you’ve very nicely explained how that
doesn’t fit with what necessary the local governments agenda might be so
there’s that element to it and I think the experience you have of working with
your constituents and with the public is so so much different so one of the
things I think that’s dawned on me over recent years is that when we get into
slightly more contentious transformations in health we tend to put
out our clinicians and many of them will be the STP leads now out into
public meetings or whatever and we give them sort of a briefing which is what I
call designing for the usual which actually most people understand that
certain services need to change because that’s where you get the best outcomes
and the best survival what we don’t tend to address which is I think what you’ve
said is what’s the plan for the unusual you know what does it mean for my wife
who happens to have multiple sclerosis who lives in a one-bedroom flat and and
is on benefits what does it mean for the individual so we don’t do it and so we
often find that we put our clinicians up in front of scrutiny committees or up in
front of public consultations and they’re not briefed in a way that
reflects what’s on the desk so so Johnny can you sort of give us an idea about a
clinicians guide to how a scrutiny committee is formed what it’s thinking
what it wants to hear and how we should be preparing ourselves well it’s the council as a whole that’s responsible for scrutiny and and the
council and usually under the leader will decide how they want scrutiny to
work what the different parameters for the different scrutiny committees are
and it came into being I think it was after 2003 Act which which brought
cabinets into local government and therefore an order for that to be done
in a way that was that with proper governance they put the scrutiny
arrangements in the net effect of that is that is effectively to
scrutinise what happens in the county in the county council for instance adult
health will clearly come under a health scrutiny committee but councils also
have the powers to call in external agencies not just health but health is
the only one that’s done with any degree of frequency and regularity they could
on occasions call in utility companies and highways and highways England but
because the only external agencies that are regularly scrutinised is the NHS the
health scrutiny committee is of a is of a different order with in terms of
magnitude and complexity within which it works and and the other scrutiny
committees well they understand each other a bit better they come from the
same culture and we come from you know we’re challenging and
and putting scrutiny into an organisation that has a very different
culture. When I first became the CCG chair and Cannock I had to appear before
the Health scrutiny committee and you’re quite nervous to begin with and I went
in there and came away and forgive me but I was immediately reminded of
Margaret Thatcher’s account I’ve been of being challenged by Geoffrey Howe it was
like being mauled by a dead sheep it seemed to oscillate between the
unreasonable and the pointless the questions and that’s simply because the
people around the table didn’t understand the system and there was no
there’s no lack of intellect around there there was no lack of will they
just didn’t understand how the NHS worked therefore they couldn’t give us
challenging questions and I’m sure that many folk were listening will resonate
with that well I would say to you that the the lack of understanding
is equivalent to your lack of understanding of the of how the county
councils work and unitary authorities and district councils it’s
as complicated and with that different structure becomes a very
different culture as has clearly been outlined so I came away wondering
whether to put it bluntly and some health
knowledge might help with scrutiny and that’s when I started thinking about
becoming a politician after retiring. So do you think in the future going to a
scrutiny committee if we’ve done that collaboration health has come the NHS
has come with a much broader understanding which has been modified by
all the potential opportunities that it does that you actually it will be a
combination of health and local government going essentially to the
scrutiny committee that things will just make much more sense on both sides.
I think that’s eminently reasonable but I think we’re a bit away from that yet.
So how do we get there well I do I think one of the things we need to do is both
parties recognise that they don’t understand the other and actually
sit down and start to have discussions about how things work I’m in a unique
position of where I come from and after we’ve had a health scrutiny committee I
spend about quarter of an hour 20 minutes with the people around
the table we get a board we say this is this is how the money works this is
how GPs are employed this is how the system is regulated and explain
the difficulties that brings about and how it’s very different from
from local government well I see no reason why STP leads can’t be invited
into councils and asked to do exactly that and it’s a two-way process is the
same thing happens from from us teaching health about how local government works
I think that understanding won’t solve the cultural differences
overnight but it’d be a good start so if if we look at the STP set up and
look what’s going forward and the opportunity to do the things that you’ve
suggested the STPs and I’ve done various events with STPs trying to do some of
that you know learning and the education side of it there’s been a gross
imbalance between the representation of health and the representation of local
government I think in all of them with local government being by far the
minority but on the health side you get a sort of mix of providers and
commissioners and you get sort of a collective who because the
local on the local government side and particularly the provider landscape in
in social care and in the community and in home care and lots of areas of local
government and in the utilities every else there’s a much much broader church
of organisations that perhaps health needs to understand can they just do
that through local government or should they be should STPs be having
conversations not just with councillors but with the providers in the support
local government services well if you’re doing it area by area the council is the
obvious place to start the process but there are lots of players but with in
most areas they are corralled by the council because we are used to working
across disciplines so in fact you could say look at all those bits of the
council don’t we need someone from the leisure services and from this department, and that department. Well
the answer is no because we’ve produced coheres policies so one or two
people can represent the council because they can represent all those parts for
the big strategic discussions you would then get into greater detail but of
course there are a range of players and the one that I particularly relate to I
think is very important it is the voluntary sector we depend on the
voluntary sector more than we’ve ever done before in councils but increasingly
I think the Health Service is going to depend on volunteers you might call we
all depend on carers some of them are paid carers most of them are unpaid
carers you know if all the carers stopped work this country would grind to
a halt but I would say the council is the first place. I think if we went to
the to the health community and said you know who are the dominant players and you know fully respecting the CCG role Johnny from where you were before but I
mean our big acute providers have got the upper hand I think people would recognise and then you’ve got you know smaller part players
which are pulling the next to the community trusts and then people like
the ambulance service here actually absolutely at the interface and central
to my view have a much lower position in it so that’s how healthy sort of setup
but you’re describing to me really that local government is very much front and
center but we know when we try to interface other than a governmental
which is where health usually interfaces you know there are twelve and a half
thousand care homes across England of which the vast majority are small family
business is running one or two institutions we’ve got more domiciliary
care providers in England eight and a half thousand then we have GP practices and
most of those are small SMEs or small companies so the health when its
functioning is trying to relate to this what appears to be a really complex
landscape and I think then to sort of retreats back and just sees it all as a
as a big sort of amorphous cloud and doesn’t know quite where to go so local
governments very much where they need to go and then you will steer STPs into how
if they need you know they need to work with care homes or they need to work
with family centers or whatever it is they’re talking almost every area there
is already a grouping where the council meets the domiciliary care providers the
residential care providers the children’s centres the specialist
charities the residence groups the amenities groups we’re there we can make
those systems work for you and with you and we replicate that as a national
level last week I met the UK HCA who is a domiciliary care providers as a
national level because we then issued guidance we do joint publications with
them giving support to our members and their so the council is the way in to
any community now I’m not saying that you can only deal with the council by
any means I’m saying they’re the way in to create the appropriate discussions
and this involves the investment and the thing
you have to invest most is the investment of time you say if I was in
the health service and I wanted to do something which might because a little
bit nasty the last thing I would do is just turn up with the report because
I’ve known for a year that this could be a problem I would have gone along to
the scrutiny committee and this doesn’t happen enough with a problem we’ve got a
real problem with dealing with the care of the elderly in X part of the borough
we think this is because can we share some thoughts with you can we share some
thoughts with the ward councillors will the ward councillors arrange not public
meetings I would advise all your clinicians never to go to a public
meeting because they can all be subverted by nasty people like me three
people can derail a public meeting, go for proper consultation say to the council we’ve
got the problem in this area will you arrange an appropriate consultation
process for us and with us so I think most people would be delighted to be
involved in that sort of discussion but you turn up with the reports I’ve only
seen when the agendas are published then you’ll have discordant conversations
because I’m going on to defend what’s there because I haven’t had the
opportunity to look at all the options and the alternatives I agree with that
entirely I think coming coming coming early to the council means the council
doesn’t get any surprises and look at a far more positive response I also think
in terms of scrutiny with STPs and it lends the opportunity for scrutiny
committees to exercise their overview function which is often forgotten then
can actually contribute to the process of the end result just explain that
overview function for those who are not familiar Well if I take an example which is not
related to the STP but it’s an example that happened to us earlier this month
and the health checks that the NHS is County Council has is asked to arrange
through through Public Health we’ve looked at the lower super output areas
only which are the technical term for the very deprived areas within our patch
and the cabinet member was conscious of the fact that
this could be subject to to challenge because it doesn’t cover everybody the
way it’s supposed to so we said to them well if you approach the the CCGs who
are now co-commissioning primary care and get try and persuade them to commission our primary care colleagues to look at those
with a high strong family history of ischemic heart disease then basically if you can get that you’ve covered the deprived you’ve
covered those with a strong family history and the chances are those
that you’ve selected out are the worried well who you didn’t need to see anyway
that’s the proposal we made and they’re looking at it now I just think that’s an
example of where we can be a bit more positive or and not on the back foot
scrutinising stuff that’s happened all the time so I mean the clinicians
listening to what you’ve both been saying I mean if I was on listening in
on this I just think well there is just a plethora of places that we could go to
learn new stuff there’s opportunities do there but you know the world the reality
is being pragmatic we’re going to have to find some things that are really
important and that are common to both so we come up with some sort of shared
thing so Johnny perhaps in your experience CCG now councillor where do
you think the fertile ground is the STP should probably be looking in general to
find the right sort of wins that would be very very popular on both sides of
this relationship it’s a tough one yeah Frankly I think if we can sort out emergency care both sides would be very happy. But I keep saying the
solution to emergency care is not in the hospital. The solutions are you know the elderly patient who has a
fall at home but lives alone in a flat you know someone can turn up the paramedics can
turn up, they’re more than capable of doing that injury assessment and saying she
hasn’t broken anything but she’s shaken up she lives alone she’s slightly
confused but that might be normal they haven’t got access there’s nothing they
can wrap around that patient so you know it’s a very so brave stroke heartless
paramedic that just plops her in her chair and drives away you know that’s a
conveyance to hospital further she gets away from her family or community her GP
her medical records she’s an admission and so you know the
ability to wrap around the patient the idea that you know you could have a
volunteer come in who could sit with a patient for that in that personal
support and we could be sure that that a rapid response community assessment
would come in over the next few hours perhaps the GP or practice would be
involved the following day and a falls team review initiated this is the
third time she’s fallen if that was the offer and I think patient resident
paramedic everybody would be happy and interestingly that’s the same thing
that we’re trying to wrap around the patient to get them home ten days later
when they’ve been stuck in hospital but now because they’ve been in bed for ten
days there ten years weaker in terms of muscle strength as we were talking about
before so you know that’s my sort of health view but I’m seeing it very from
very much from one end of the telescope is that the sort of places that people
should be starting or do you think it’s it’s got to be simpler than that to
begin with yeah I think you’ve got to find some easily understandable things
and make a success of them so let me give you an example we all know and it’s
varies from place to place but Friday night Saturday nights Thursday night and
in Wednesday at student night and Liverpool are dreadful places to be in A&E and that’s why we have the paramedics trying to get away in ten minutes
from the old lady who will always in my view need caring so let’s look at what
we could do now the obvious answer is let’s take on two more consultants three
more registrar’s five more nurses build a new.. and that is an answer but wouldn’t it be better to work with the police fire service licensing
department and the council to find a base in all the areas where there’s high
drinking where we can deal with people triage people on the spot to stop them
go into accident emergency in the first place now that takes a view that it
isn’t an institutional answer it’s a community-based answer it involves all
the relevant authorities it’s cheap and it’s quick and interesting those alcohol
intoxication management services AIMS now being studied by an NHR research
grant to give the clinicians the evidence that they need to say that’s
the right thing to do too so I mean that’s an example but because I think if
you’d thrown that out as a just a statement and before the question comes
flooding in to my desk here I’m sure somebody out there is saying yeah but
the local authority has reduced the drug and alcohol abuse services in my
locality and that’s part of the problem so and it is and so again that’s where
there’s an alternative but we’ll get to the right answer through that shared
response was that yeah yes because if the council the fire service the police
service and the accident emergency in the Hospital Trust say something then
you’re much more likely to be able to find a way of getting funding for it and
you can actually show that if we do this and there’s some experience about we
could we can prove the number of people you can keep out of the accident and
emergency unit and actually say that would free up 20% of your beds whatever
it is and this is a cost-effective way of doing it and it’s one that we can act
on because dealing with a big institution are we closing a hospital and
creating a new one we’re talking 10 years 15 years I don’t know the Royal Liverpool
Hospital will ever be built now since Carillion went but I know if we all put
our mind to it blended together what little money we’ve got used what powers
we’ve got together we could do some things very quickly so I think part of
this and one of the questions that’s come through which are I think I
understand it’s is that business about the relationships and how the NHS mustn’t mistake sort of robust challenges from local government as being sort of criticisms of what we’re
proposing it’s we should always sort of come with what’s on your desk what’s on
my desk what are the problems where’s the overlap what’s the joint solution so it’s really about building the relationship before
we start trying to lay solutions on the table yeah. Taking a more
community collaborative approach in emergency care as an example I think
what you described will be forced upon us rather than the rather us deciding to
do this simple reason that resources can be two fold it can either be money or
human resource and in many areas in medicine at the
moment we just don’t have the skilled clinicians to take the jobs and that’s
why it’s a question of not just financial sustainability of a clinical
sustainability and therefore rather than getting the two or three extra A&E
consultants which might be very hard to find we’d be we’d be forced on a more
collaborative route which I think in the long run will be better for the system.
Austerity can have it’s good points it’s making us think differently
well to be aware when we have money in the system we’ve reinforced
traditional practice yes exactly rather than do the sort of
transformations across the system that perhaps we need. Do you have
a view as to how local government how councillors sort of see that national
perspective that the NHS always has that sort of top-down what feels quite
politically led steers as to how the NHS has got to do things which then comes
with you is sort of almost sort of constrained asks that you know that’s
what we’ve been told we’ve got to do just is that something that is difficult
well it’s something we understand we do know that the NHS is a big bureaucracy I
look around this is about ten places you’ve got like this I would
guess in London so we’re familiar with that
but it does take in my view as a national local government figure if I
could put it that way some changes from the government I’m looking with great
interest at what’s happening in Manchester and here’s another form of
governance that we haven’t looked at we’re much not all but much of the
decision-making process has been given to the combined authority in Greater
Manchester led by a mayor with the transformation fund because I can’t ask
institutions to change to do something different unless we put some money in
place in the short term to make those things happen and there I believe and it’s early days yet but we’re seeing much greater
integration of things like adult social care public health housing and the
Health Service and in fact the whole document which sets this up starts off
on the social determinants of health that I was talking about before
one of the key aims of the Health Service well let’s call it the MHS the
Manchester Health Service to get people into work because so many things flow
from people being into work so perhaps we will see an evolution but that also
takes the Secretary of State not standing up in the council and saying I
take responsibility for this hospital I’m going to sort this out he’s got to
let go but he’s got to let go to someone does he let go to trusts STPs who have
no legal base. The STP can’t actually make a decision. But in some ways that’s
quite an advantage isn’t it because it means it’s based on relationships well
means it should be based on relationships I’m not convinced with
there yet in many cases but somewhere so you either let go to bureaucrats
or you’re going to let go to people who’ve been directly elected who can pull together
and that’s what I believe needs and should be done. So in this relationship and
perhaps Johnny I’ll come to you on this is this is very much sort of a given a
given take isn’t it we’ve got a we’ve got to sort of it achieve that in some ways so and would let’s take the issue which many STPs
will be concerned about and not want to focus on adult social care but clearly
and you know the patients who can’t we can’t move back into the community
because of either NHS waits for placement or for care packages or
whatever you put together what would what would local government want to see
health bringing to the table I mean we often find that hospitals aren’t very
often outward facing they aren’t sort of supporting in the community there things
that would be really useful that if health came along with those as part of
the sort of because we’re talking about a negotiation at the end of the day here
about what we can both do for each other what were the things that you would want
health to be bringing that could substantially benefit the social care
and the local authority in the structures I think I think it’s two
things one is come to the table as early as you can not come late with what can
be perceived as a fait accompli because that just that just doesn’t work the
second thing is I think that I think there is something about about
responsibility and where responsibility lies and I do think the primary
secondary care split in health which has been an anachronism for decades really
accentuates that and there’s something about about both
hospitals and and consultants taking on a role for patients actually in the
community and rather than just seeing them in outpatients Thats what I meant by outward facing sadly rather than perhaps complaining about what’s not going on in the community actually
exactly like but likewise GPs take an active interest in their patients
whether in the hospital as well and I think with modern technology through
Skype and all the rest of it that’s perfectly feasible and and that mutual
approach I think would be of help to all parties including the local authorities
because presumably health is seen as quite an anxiety issue in a lot of the
community supported services where there’s a question is is it’s got a
health element to it and you know at the moment the only ways the
NHS offers local government a response is by moving patients up a pathway to a
higher acuity higher cost setting whether that’s even into primary care or
Community Care or secondary care and that’s sort of our response which is
probably the last thing you want to be doing because actually taking the
patient taking them the resident the Constituent away and then trying to
reintegrate them is a much much bigger ask yeah I mean the question that I
always ask and I would guess almost everyone in the health service asks this
as well when I look at adult social care my mom died three years ago but I always
say would I’ve let my mom go through this and looking after your mom actually
isn’t a bad thing because at the end of the day all these people are people
they’re not numbers they’re not statistics there are people’s moms are
people’s daughters and we therefore have to relate things in a very human way but
I think by doing that you can often get a good coming together of the health and
local authority and other communities so if you want to do something you say your
children at the moment can’t get this but they would be able to if we did that
because we go in to defend what they’re going to lose because we don’t have a
good enough idea about what they’re going to get what the alternatives are
now I don’t think I’ve ever met a consultant in my community at all unless
I bumped into one in the pub or something like why aren’t clinicians
leaving the hospitals to see people actually in their communities to
understand more because they’re I bet they go back to the sort of places that
I represent I represent one of the wealthy parts in Liverpool what do they know about life and in Liverpool and the social determinants that
we’re battling to meet so that’s one of the questions that has come in is and I
guess this is very much it’s how do the big unitary authorities
provide a multiplicity of care models to suit the diverse local care models that
are needed well the fact is that even our big unitary authorities or even our
counties our counties can represent a million people actually don’t work as
one body with one set of policies because we’re small enough to be able to
define a whole series of different policy interventions so very simply I
represent Liverpool 18 Penny Lane there beneath the blue suburban skies I used
to represent Liverpool 8 the life expectancy three miles apart is 12 years
we recognise that we recognise there are differences in some of our ethnic
minority communities so our approach to dealing with health isn’t a set of
clinical options it might be to say we’re going to work with the Somali
community and particularly the Somali women about some issues in a wealthy
area there are a different set of issues for example my wife when she was the
Lord Mayor created a system so that ours is a dementia friendly neighbourhood
involving the banks and the shops and we could do that because you could clearly
identify dementia as an issue and a solvable issue because money isn’t the
problem in my area but to do exactly the same in Liverpool 8 we might have
needed to create a partnership etc in Liverpool 18 we could just do it so
we’re big enough to have some posh particular if we get together in the
combined city region areas but we’re small enough to be able to differentiate
service and we’ve had another question which is very much a step aside if you
like but it’s helping the STP clinical leads understand purdah and the impact that will have on timetables and what they’re planning to
do is something obviously we’re aware of nationally because we have that but what does it mean locally for things moving forward and
plans well it basically means you can’t produce something which is contentious
which is a new policy within if I remember 40 days of any election because
that could be say local council elections any election so last year of course we had a general election we weren’t expecting so we had purdah
and local elections that we went immediately into purdah for the general
election so in fact we had something like two and a half months because
otherwise it is seen quite rightly that a controlling party nationally or
locally could slip things in to win votes and that’s why it’s not done
that’s a sign of the strength of our democracy that such a thing can happen
okay well I think we’ve covered just about most of the areas that have been
raised and we’re anticipating evening I’ll just check from my team that we’ve
got no other questions that have come forward that we need to pick up no
you’ve obviously done a comprehensive job gentlemen so that’s that’s fantastic
I’m just going to come back to you in a moment and just say you know your last
you know two minutes what messages would you leave with clinicians who are
leading STPs that you’d like to leave them with as a parting message and I
think if I could just summarise some of the things that I think we have have
covered there and I’ll try not to get into your your two minutes but for me
there’s something here about getting over that fundamental weakness that we
have in health understand about understanding the wider health and
well-being opportunities that sit in local government and the wider health
determinants that I think we really miss out on enormously the opportunities
and we’ve had some good ideas about how to get into some of those I’m sure one
of you can say something about the timing of approaches but this is about
for me it’s about the relationships and co-creation not a word I particularly
like but it’s doing this together for mutual benefit for all the people that
we serve in in a public and for me it’s also about
something about just respecting that we come from different places and then we
aren’t gonna argue and necessarily think and approach things in the same way and
we need to just stand back and listen rather than make assumptions about how
you’re going to come up with the answers that we are asking and we do this
together so start with Richard what messages you want to leave with the
clinicians leading STPs right well I hope one of the things that’s come out
of this is that people like Johnny and I are actually human beings we don’t bite
anyone’s head off most councillors are rational I can’t say all of them are but
most of councillors are rational and we go into politics for one reason does not matter which party we’re in we certainly don’t do it as local government to make money
we do it because we have a passionate interest in our community and the people
we serve now you can either choose to harness that or you can choose to ignore
it and take us on taking us on isn’t productive because I can be really
aggressive you should see what I say to the leader of the council never mind the health service or you can inform me and involve me and make me your ally at the end of
the day I don’t have a hard and set view about what my services my constituents
need I don’t have a hard and set view about the way they should be provided or
who provides them all I want is the best for my constituents and for the people
of Liverpool because I’m a city councillor not just a local councillor so
come and use us and we’ve got a very good venue in Liverpool because we’ve named
one of our best pubs after the world’s first medical officer of health so
anyone in our area can take me to the Doctor Duncan will have a pint and
discuss all these things so go and see people doesn’t matter who you get if you know
someone go and see them and work with them about how to break into the system
because it’s going to be different in Staffordshire than it is in Liverpool.
So that’s Richard Kemp’s two minutes and wisdom Johnny McMahon I think the first thing to do is to recognise each other’s strengths the voice of a
clinician at a scrutiny committee is extremely powerful and the
role of good clinical leadership within STPs and their relationship with the
County Council I don’t think can be underestimated
likewise the council’s are unique in the sense that we have a
democratic mandate a local democratic mandate and we have an overview of the
whole system and I think that should be taken full advantage of in terms of each trying to understand the system a bit better and
getting legitimacy early before public consultation I can think of a one
particular example where approaching when I was a chair
we’re approaching the county council early meant that we didn’t get
our fingers burned and we refashioned and it was all about altering the hours
in an urgent care center we refashioned it it was it was fully
supported by the council and then we went to public consultation and the ride was far far easier than it would it be thank you
very much so really wise advice there from our two experts I’m going to thank
you on behalf of everyone listen to or will listen to this webinar for
that expertise so thank you for listening I’m sure both Richard and
Johnny would be happy to take questions if you want to send them in offline and
do that through the STP team here at NHS England thank you very much

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