The last time I wrote about a different system was after a visit to Catalonia, where it was 42 degrees and sunny. Since then I’ve been to Ashton-under-Lyne to visit Tameside and Glossop CCG, which was hazy and wet but just as rewarding.
Having been in serious difficulties with poor performance and mortality rates, out-of-control finances and difficult internal relationships, the local system has reversed its fortunes and found a new sense of direction. As well as doing better on length of stay, emergency department waits and more traditional NHS performance measures, there have also been some marked successes across a range of other areas, including on return to work rates and on indicators on the health of young children.
There are important lessons here for national policy-makers and local leaders – notably about how success depends on the local context and a willingness to try new approaches. There are a number of interesting aspects to their story, but three struck me in particular.
Shared objectives for the whole local system
The CCG and council have a shared set of objectives for the system, which encompass economic development; education and skills; infrastructure and resilient communities; and health and wellbeing. The health objectives are integrated into these.
There is a heavy emphasis on prevention, early intervention and social determinants of poor health. These seem to go beyond rhetoric, and are having a direct impact on how local services work.
Developing a place-focused provider
A change in leadership at the Trust, as well as the integration of acute and community services (including very close working with local social care staff, mental health services and pharmacies), have had a significant impact on the local system. Co-locating staff has helped, and an organisational development programme seems to have been vital. Services are delivered through five neighbourhoods, which have clinical directors who are local GPs and who have foundation trust contracts for that part of their work.
They have developed an asset-based community development approach to population health – with a focus on at-risk groups, the extensive use of social prescribing, and coaching and self-management education. There are targeted programmes for supporting people with mental health problems into work, and also to reduce rough sleeping, provide early support for patients, and to promote Shared Lives (where people live with approved carers).
Other notable developments include:
- creating a telephone and digital support hub, primarily for care homes (similar to the one in Airedale and which is also used as the contact point for urgent GP referrals and digital outpatients)
- intensive support at home that allows ‘step’ and ‘step down’ programmes to operate well
- creating integrated extensivist and frailty services
- targeting long-staying hospital patients.
It’s a cliché to comment on the importance of leadership, but there are nonetheless some aspects of the model that are worth noting.
The chief officer of the CCG is also the chief executive of the council, and both organisations share a finance director and have closely connected commissioning arrangements. The development of a financial framework for commissioning has allowed money to be moved around imaginatively – supporting the Trust to reach its control total and helping to unlock capital that has supported important service redesign.
Similarly to other places that have made progress, there is a small leadership team with a history of working together. Being part of the Greater Manchester devolution has also helped.
Policy conclusions: different approaches needed
Even areas that look similar can hide important differences, so we always need to be careful about making assumptions that models can just be copied elsewhere.
The pressing financial and service delivery problems that compelled Tameside and Glossop to take action were important. They are also clearly defined distinct communities, with a sense of identity the model could coalesce around (Glossop is in a different local authority, but this was accommodated). As in Wigan, political stability and a supportive, pragmatic approach by local councillors also enabled difficult decisions to be taken – which other councils might be too risk averse to attempt.
Developing integrated services and commissioning approaches requires a lot of effort in rewiring financial and governance arrangements behind the scenes, and needs the support of councillors and NHS performance managers for potentially risky transactions.
Devolution in Greater Manchester has also provided a source of development funding not necessarily available elsewhere – this was used to allow the model to be developed more quickly. It has also provided a degree of air cover for innovative local decision-making.
The sudden arrival of primary care networks also shows how a centrally designed policy can cut across local models in unintended and unhelpful ways, such as by leading some GPs to move their attention towards PCNs instead.
Nonetheless, I was struck by the high engagement levels of a wider group of people, and the extent to which frontline staff that I met understood the direction of travel.
The time and effort required to make such progress means we should not overpromise about the short-term potential of this sort of model, but we can be optimistic about the longer-term impact – even if different places will need different approaches.
Edwards N (2019) “Local lessons: what can we learn from Tameside and Glossop?”, Nuffield Trust comment.