Wigan: Integrating Health and Social Care

Mensnes Park, Wigan

Since 2011 Wigan council has been fundamentally transforming the way it operates. As part of improving outcomes for local people, council leaders were keen to work with local NHS partners to create an ‘integrated care organisation’.

This was new territory for the Council and health partners, testing organisations’ compatibility to work together, given they come from fundamentally different cultures and arrangements.

In the early days the organisations had different opinions about what such a body might look like, how it would operate and who would lead it. The council’s ambitions of transforming the whole system at pace concerned the local NHS clinical commissioning group (CCG) and the acute hospital trust. Despite many conversations little progress was being made, and there was a great deal of frustration on all sides.

TRANSFORMING RELATIONSHIPS

However, over the last three years, there has been a dramatic transformation in those relationships, and what the partners are achieving together. In what is now known as the ‘Healthier Wigan Partnership’ (HWP) there is strong mutual trust and partners are energetically driving forward integration together. A ‘care alliance agreement’ is in place, and there is a clear shared sense of purpose, with agreed longer-term outcomes and staging posts.

A key turning point came when the partners agreed to give up trying to agree an overall organisational model, and instead to focus on progressing integration on the ground: “learning by doing, adapting and tweaking”.

The key strategic leaders also participated in the ‘accelerating transformation change programme’. This enabled them to better understand each others’ behavioural propensities, their impact on system working and how to unlock unhelpful and ‘stuck’ behaviours. It helped them to work with each other on a personal level much more successfully.

ACHIEVEMENTS

• Services are being integrated around seven ‘service delivery footprints’ (SDFs) with aligned primary care networks and leadership
• The integrated commissioning committee (ICC) oversees all health and social care commissioning activities to ensure they support the overall system plan
• All health and adult social care budgets are either pooled or aligned
• Health and social care issues are being tackled in a joined-up way, using an asset-based approach that supports independence and wellbeing.
• Community nursing, adult social care and reablement services are integrated and operating in the SDFs
• The new integrated complex care and community response teams are reducing pressures on the hospital’s accident and emergency services (A&E), supported by the local ambulance service
• GPs are centrally involved as ‘anchor points’ in the SDFs, on the HWP Board, and on the ICC
• Community mental health services are aligned to SDFs and the next stage is further integration with physical health services
• The scope of the partnership’s work has extended from out of hospital care to now include in hospital care
• Partners are working through integrated governance arrangements and propose to strengthen their connections further with joint system support teams around business intelligence, portfolio management, finance and other areas.
• A co-designed refreshed ten-year transformation plan, ‘Healthy, Happy People’ was launched in December 2019
• A population health management approach is being taken, including paying attention to prevention and early intervention.

OUTCOMES

Ten years ago many health outcomes in Wigan were getting worse, with the gap between Wigan and the England average was widening.

Now many performance indicators are demonstrating that both the council’s and the HWP’s approach is improving outcomes:

• The demand for A&E from over 75 year olds has flattened despite the rapidly ageing population
• The demand for ambulances has reduced by 12 to 15 a day
• Rates of delayed transfers of care are among the lowest in England
• 91% of older people are still at home 91 days after discharge from hospital, significantly more than the England average of 83%
• Rates of emergency re-admissions from care homes are lower than the England average
• Local residents’ ‘healthy life expectancy’ has increased dramatically in recent years, much faster than most comparable places
• Rates of premature mortality from cardiovascular diseases and cancer have fallen faster than the England average
• Over the last few years smoking rates have halved from 30% to 15%
• The rates of physical exercise increased from 48% in 2012 to 55% in 2015, while the England average did not change.
• The rate of improvement in care homes has been the third highest nationally
• Wigan has the fifth best detox rate in England
• There are no difficulties in recruiting in key areas like social work and health visiting

KEY LEADERSHIP ACTIONS

The key leadership actions that appear to have helped the HWP move forward so dramatically appear to be:

Building mutual trust by:

• Having “honest conversations”, surfacing tensions, and working through them purposefully
• Appreciating other organisations’ constraints, concerns, pressures and strengths
• Appointing an experienced external independent chair trusted by all parties
• Encouraging leaders to reflect together on the impact of their behaviours
• Identifying key shared issues and working together to develop solutions

Agreeing shared strategies by:

• Acting as leaders of systems
• Agreeing a powerful unifying vision
• Starting small, learning by integrating services on the ground, then adapting and scaling up successes
• Ensuring key politicians and key clinical leaders support the approach

Delivering results by:

• Being brave, determined and tenacious
• Investing resources
• Engaging managers and staff in delivering the vision, encouraging joint working across as many functions as possible
• Attracting a critical mass of people in key roles who support the vision

CHALLENGES

• Demonstrating integration works when many aspects will only impact in the long term
• Coping with NHS bureaucratic requirements and the commissioner/provider split
• Governance and accountability issues when the council’s community services moved into the acute trust

THE FUTURE

The partnership leaders now feel they can build on a firm foundation of mutual trust, a clear vision, and mechanisms for delivering it. However, there are issues about how they scale up and spread successes while maintaining an organic approach.

There remains much to be done. They want to do more to develop the SDFs’ distinctive identities. There are still many pressures on A&E services that need to be addressed. More work needs to be done on integrating mental health services further into the model. And, at some point, it may be necessary to agree an overall organisational model for health and social care integration.

ADVICE FOR OTHERS

All the leaders stressed the hard work involved in integrating services. They also emphasised the fundamental importance of developing mutual trust. As one said:

“Don’t underestimate the impact of culture: history, myths, the back story, the imprint of what’s gone before. But it’s less and less a factor the more you build trust.”

Some suggested that there are different ways of integrating services, depending on local factors, but similar approaches are likely to help. As one said:

“Integration can be done in every area, but it can’t be replicated. The context is important, the history of the relationships, and what the local community is like. It’s best to learn from others, and distill the key ingredients.”

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