This blog explores the Living Longer, Living Better programme in Manchester and the role of Macc and the voluntary sector.
Living Longer Living Better, known as LLLB, is the major joint programme in Manchester between Health Services and Manchester City Council and is overseen by the Health and Wellbeing Board. In a context where Manchester has some of the highest rates of people with long-term conditions and some of the worst outcomes in the country, its aim is to reduce unnecessary hospital admissions through integrating hospital-based and community-based services. The key document is “An Integrated Care Blueprint for Manchester” which was put together by senior Health and Local Authority officers but without any involvement of Macc or any other voluntary sector organisation.
The blueprint uses as its starting point the National Voices definition of integration
“my care is planned with people who work together to understand me and my carers put me in control, coordinate and deliver services to achieve my best outcomes.”
It lays out an ambitious vision of services that I assume most people will agree with:
“We will develop a health and social care system which commissions and provides more co-ordinated care in the community to enable people to live longer and live better”.
One understandable response to the blueprint would be: “so why aren’t you already doing this?”
Integration of services is not a new issue. Over the last 30 years, there have been hundreds of reports, policies, and even legislation all pushing the need for integrated services. One of the pressures driving it now is of course the need to cut costs which is particularly severe at the moment but has ever been there. Resources have never matched levels of need and possibly never will.
It hasn’t already been done because it is mind-bogglingly complex to achieve. There are any number of factors that push toward dis-integration and fragmentation. There is: a large mix of providers; continual re-organisation; conflicting guidance; multiple sources of external interference; professional interest and boundaries; cultural differences between providers; difficulties in sharing information; safeguarding concerns; public pressure to keep hospitals open; organisational inertia; and lack of transitional funding.
Integration of services needs a root and branch transformation of public services. This is the real ambition of Living Longer, Living Better. The problem is managing a process of public service transformation on a grand scale. Perhaps the question we should be asking is:
“Since your previous attempts to bring about integration of services failed how are you going to approach it in a different way this time?”
Many senior staff in Manchester City Council and Health Services have been involved in many previous attempts to transform service and want to try and do things differently and embrace different ways of working. Perhaps the prime role of Macc and the VCS is to support and encourage this cultural shift toward a different way of thinking and planning. If the process of transformation works then the voluntary sector will be in the heart of the new model, our services and support will be a key part of an integrated web of care with people at the centre. The alternative is disastrous - limited resources being wasted and more and more rationing of care.
One of the levers that the government has put in place to encourage the change is the Better Care Fund (BCF), however this is not new money, it is a ring-fenced NHS budget that has to be transferred from hospital based services to community-based ones. It is intended to assist in the process of transformation but the timescales to show results are very short and, as many have already pointed out, may actually hinder the process of transformation rather than aid it, as attention is diverted to short-term projects. Little of this money is likely to come to the VCS unless they are already involved in joint projects with the NHS that can demonstrate direct impact on hospital admissions.
In Central Manchester the BCF is being used to fund projects such as: Pro-Active Elderly care Team; GP led in-reach to facilitate discharge; Alternatives to Transfer – GP referral Scheme; Intermediate Care Assessment and Treatment Team; and Intravenous Adult Community Therapy. However, despite these new initiatives rates of hospital admission continue to rise and there is urgent investigation going on to understand why. However, there are so many different factors involved both in how services operate and in the impacts of external factors such as increasing poverty.
So, to return to the central question of this article. How can Macc and the VCS support the LLLB transformation of public services? We need it to succeed both for the sector and more importantly for the people of Manchester who use public services. We have a different perspective, a different world view, based on our values and our experiences, which is a vital counter balance to a public sector approach.
How to Bring About Change
LLLB has the usual apparatus of bureaucratic change, plans and targets, governance arrangements, mounds of paper, strategies and working groups. Macc is represented on some of these and Dave Williams from Manchester Carers Forum has been heavily involved but there has been little other direct input and there needs to be more but of a different kind. Few voluntary sector organisations apart from those with dedicated policy workers, like Macc, have the time or determination to wade through the papers and sit in meetings where, at best, they will only understand a proportion of the agenda and can only make a limited contribution.
Change through strategies, plans and meetings will be insufficient to meet the scale and complexity of the challenge of LLLB but there is a different model, one which the VCS is far more familiar with than the public sector as we don’t have the same level of formal power. This different model is about building networks of change, encouraging and enabling people to be involved, using networks based on values and trust, exposing people to different ways of thinking and bringing people from many backgrounds into creative collisions that create new visions. Innovation doesn’t just come from the top, it comes from within every part of the system and conflict of interest and ideas are used rather than avoided. This model accepts the need for mess and plurality as long as there are networks that bind services together and the final form that change will take is often unpredictable. It’s a world where plans and targets are less important than vision, leadership and values.
Macc’s role and that of other VCS orgs is to demonstrate our different culture of change and to pull the public sector more into our ways of working. In order to do this we need to understand their culture sufficiently to aid the transition, something that the VCS is uniquely placed to do, we mediate between cultures as a matter of course. There are major pitfalls, however, one is that we may try to become the same as the public sector, use the same language and conform to the same values, in which case what is the point of the VCS. Alternatively we may be driven to cynicism and despair by the public sector’s frequent inability to cross cultural boundaries.
The key way to foster change is to bring the public sector into our world rather than go to theirs. We need to show them a different way of working in a positive and constructive way as “bad” experiences can drive them back into defensive and exclusionary ways of working. We need to control and moderate our passion and frustration.
One part of the wider LLLB programme is the £450k Reducing Isolation Grants Programme managed by Macc on behalf of the Health Service, which provides a number of grants to VCS orgs working with older people. As well as providing direct services, the purpose of this grant programme is to build relationships between VCS groups and health commissioners through a buddying scheme which links commissioners to individual project,s and holds conferences where commissioners and VCS orgs can openly discuss how the projects work.
Organisational Form
Another key part of what we have to offer to the public sector is our knowledge of organisational form and how this impacts on how services operate.
We’re used to forming partnerships, collaborations and alliances and aware of the dangers and advantages. Our understanding of governance arrangements tends to be vastly greater than most public sector officers as we have to deal with policies, trustees, boards all the time. We understand that the best of our organisations integrate into our management people who use services, people who work in our services and people from our communities. This balance of interest, knowledge and experience is critical to the way that VCS organisations operate and how they stay attuned to the needs of the people they serve.
VCS organisations tend to have flatter hierarchies, with workers having broader responsibilities and more freedom of action to innovate and bring about change and respond to the needs of people who use services. We involve people who have or are using services and members of the our communities as volunteers.
Finally, we know that values matter and we try to work with other organisations that share our values and ways of working, as this is a critical way of ensuring the safety and quality of services. Informal networks of trust between workers can make services seamless and smooth rather than relying on complex protocols and agreements.
As part of the LLLB programme there are provider alliances in North, Central and South. The ones in North and South are at a very early stage but the one in Central has made considerable progress. It consists of the major health service providers: Central Manchester Foundation Trust: Manchester Mental Health and Social Care Trust; Go To Doc; and the GP Provider Organisation; and the local authority. Macc and Manchester Carers Forum are part of a board with commissioners that oversees integration in Central Manchester which includes these providers, but are not part of the alliance as they are not providers. The hope is that the providers work together to deliver services in an integrated way. For the public sector this is a new way of working and is one of the most innovative achievements of LLLB.
People Powered Services
Another thing we understand in a profound way is the centrality of the experience of people who use services (including carers). This knowledge makes it difficult for us to put people in a box, as an illness or a condition or a “protected characteristic”. We tend to understand how the different parts of individual’s lives interact.
Services that do not engage with people who use services will devise the wrong services. This is generally understood by people who work in public services and there is much talk about co-production and co-design, both of which are commonplace in the VCS, so much so that we don’t recognise we are doing something that the public sector finds difficult.
However, co-production and co-design are often mistakenly understood as being just a different process, a meeting to which different people are invited. VCS organisations understand that it is much more than this, it is about creating a culture with people who use services at the heart of the values, it is about a workforce that identifies with and feels part of the community it serves. Without this culture shift then co-production and co-design tend to be tokenistic.
As well as involving people who use services in design, and in their own services, there are a wide range of other ways of building in the views of people who use services through active feedback on services, through advocacy, through supporting users organisations, through supporting organisations that represent equality groups, through building a network of feedback that promotes continuous development of services. VCS organisations are experts in doing this.
How Communities Work
Anyone who is part of a locally based community association understands the complex web of social networks and organisations and environment that work together to form a community. It’s an eco-system where each part affects other parts and it’s easy to break things and far harder to build them and the history of an area has a critical part to play in its future.
There are some communities in Manchester that are in a bad way and have been for decades. These are the communities with low employment, poor housing, few voluntary sector groups and few social connections. These are the places where ill health is bred and if Manchester is to lose the disgraceful status of having the lowest life expectancy in England this is where life has to get better.
Pouring money into specific conditions, such as diabetes or heart disease, may prevent some hospital admissions and provide a better quality of care but it will not stop people getting ill in the first place. The long-term solution is improving the lives of people living in the most disadvantaged communities is in Manchester.
The voluntary sector understands how to do this through encouraging and supporting local action and involvement, from building on the skills and qualities of people living in those areas, by helping them to build a better place for themselves. The public sector needs to understand how it can assist that process rather than accidentally undermine it and we can help.
Part of the LLLB plan is to open up their estates so that local people can use them and we know how to manage community buildings. LLLB also wants to encourage GPs and other primary care staff to use voluntary sector services and we can help them to understand how to be part of an eco-system of a community rather than an outsider for example, through employing local people and using local volunteers.
Conclusion
Transforming our own organisations is difficult enough, transforming public services on the scale that LLLB envisages is monumental, however we have to help where we can afford to, and try to forgive public services for their inability to change or understand as quickly as we would want them to or their tendency to ignore what seems obvious to us. Some VCS organisations in Manchester have understandably decided to withdraw from interaction with public bodies, find their own funding and provide their own services as public services have failed their communities, but many continue to hope that system change is possible.
The role of Macc, together with those VCS orgs that have the resources and the willingness, is to offer what we can in facilitating the process of transformation.