Enabling this change
Developing our core infrastructure
The ambition to develop larger multidisciplinary teams in primary care and closer working with local government and the voluntary and community sector too often flounder on issues such as the availability of places to sit, information systems that can and do share information, and other basic infrastructure.
Whilst physical co-location is by no means a guarantee of better team work and integration, it helps, and generally makes things easier for local people and staff. Regardless of the physical location of staff, the ability to share information relating to individual service users within an updated framework of understanding and respect between all relevant professionals, is central to the better coordination of care.
London’s primary care estate is currently inadequate, with a regional review of estates showing that a third of London GP practices were unable to comply with the Disability Discrimination Act – a third needing to be rebuilt and 44% needing repairs.
Digital infrastructure also plays a vital role in supporting care provision across the capital. Whilst there is still work to do to bring together disparate systems across providers and ICBs, there has been extensive work in London to create joint infrastructure such as the London Care Record, which has been used almost 40 million times by health and care staff. An economic analysis shows that this has corresponded to saving health and care professionals’ time of up to a value of £44.4 million. Associated data being brought together by One London and, nationally, the NHS Federated Data Platform are critical to both individual healthcare and wider population health management. However, at a granular level, a recent RCGP survey showed that almost half (46%) of general practice staff responding reported that their PC or laptop software was not fit for purpose, with 38% saying their broadband connection was not of an acceptable standard.
The opportunity to take an approach to planning the estate and digital infrastructure that considers all the resources across a place, means that more imaginative and effective solutions can be developed than if each organisation plans this on their own.
Developing our workforce
The growing challenges in responding effectively to individual and population health needs within our current infrastructure arguably represents a “moral harm” to many of those working on the frontline of London’s health and care services. That there is fierce competition for some staff groups and the costs of living in London adds to this challenge.
This is evidenced by growing problems in recruiting and retaining staff across health and social care, including in primary, community and mental health as well as residential and domiciliary care in London. There is a risk and a reality of market failure in care services in many areas.
A successful future neighbourhood health service would provide a platform for arrangements across London to support the development of the future workforce and ways of working that bridges the divide between the need for consistency in the core offer, with the power to work with individuals, neighbourhoods and communities differently.
This will also require new roles, with appropriate cross-skilling of professionals and increased permission for those working with individuals, families and within neighbourhoods to act. It will need different ways of working enabled by different ways of contracting staff to be able to work across different settings and access different systems, as determined by the needs of patients and service users.
Facilitating the shift
Many of the issues set out in this case for change can be aided by a more coordinated and less fragmented approach to organising the very complex web of different services from across health, local government, and the voluntary and community sector.
Experience from previous attempts of health and care integration in England and internationally, is that it requires the creation of new systems and processes, the growth of new and improved inter- and intra-organisational relationships, new patterns of commissioning, continuous quality improvement, and organisational development work to make progress.
This requires leadership and resources, and does not happen spontaneously.
Without clear and consistent organisational functions to enable this, there will not be adequate ways to resolve issues, make progress happen, coordinate resource allocation and investment in shared infrastructure, and create a momentum for change. And without this, the necessary focus and accountability that is a feature of successful approaches to integrated care and population health management will be difficult to create, and the development of a clear shared narrative, understanding and vision will be increasingly impossible.
Critically, given the resource pressures across our system at all levels (including recently announced reductions in resourcing of our ICBs), and the centrality of local knowledge and relationships to make this a success, the functions required to enable better coordinated, person and community-centred care, (including but not limited to related organisational development, infrastructure and operational support), are likely to need to be hosted within existing health and care organisations working at borough level in London, if we are to make the required progress.