Robert Hill Consulting Why place-making matters to NHS Trust chief executives Masterclass for NHS...

Robert Hill Consulting

Why place-making matters to NHS Trust chief executives

Masterclass for NHS chief executives

May 7th 2008


Thirty years ago when councils were councils they…

• Ran their own services – street cleaning, parks and highways

• Managed their own housing stock

• Controlled the schools

• Managed the old people’s homes

• Looked after children in care homes

• Regulated the buses


Today it is more than likely that…

• A contractor will deliver the waste collection and other services

• A housing association will manage social housing

• Schools will organise and manage their own affairs

• Old people’s homes will be run privately or by not for profit organisations

• Children are fostered or adopted

• Bus routes and timetables are determined by bus companies in competition with each other


Why did things change so much?

• Councils were not that efficient

• The quality of service was often not as good as it should have been

• Councils were limited in the amount of capital they had to invest in updating facilities

• The rise of consumerism resulted in people wanting more say over the services they received

• Public funding was tight

• And there was politics – and the belief in a smaller state


But although councils do less they oversee more

• Economic development and regeneration are key issues for most councils

• Childcare duties have become a major new responsibility

• New regulatory roles have been added – e.g. health and safety

• Local authorities are now important players in tackling:

– crime and disorder and anti-social behaviour

– global warming

• Councils are expected to improve outcomes – e.g. education, childhood obesity

• Local government for the first time has a power to promote economic, social and environmental well-being of their area

• Councillors have powers to scrutinise other agencies – including the NHS


The term ‘place-making’ reflects these changes

• The principal role of councils is now seen in terms of place shaping

– “My description of place-shaping reflects my view that the ultimate purpose of local government should be to take responsibility for the well-being of an area and its communities, reflecting its distinctive identity, and promoting its interests and future prosperity. It involves a focus on developing the economic, social and environmental well-being of the local community and the local area. It therefore requires councils to take responsibility for influencing and affecting things beyond their more narrowly defined service responsibilities.”

Sir Michael Lyons


What does this mean in practice?

• Local authorities work with other public agencies and community organisations – through a Local Strategic Partnership (LSP) – to:

– Develop a vision and strategic priorities for a place which they set out in a Sustainable Community Strategy or Community Plan

– Negotiate up to 35 improvement targets with central government – covering issues such as anti-social behaviour, worklessness, child poverty, educational attainment, substance abuse and child obesity – that are formalised in a Local Area Agreement (LAA)

– Tackle tough cross-cutting local issues through thematic partnerships – some of which have a statutory role (for example, Crime and Disorder Partnerships)


Government policy

• Recognition of limits to the top down delivery approach

• Increased drive for efficiency

• Need for different type of engagement with local people

Economic policy

• Need to build skills base

• Quality of life and leadership affects inward investment

• Infrastructure co-ordination

• Links between worklessness, poverty and disadvantage

Societal challenges

• Population growth and migration

• Climate change

• Changing family patterns

• Entrenched social problems

• Rising consumer aspirations

Local challenges

• Building cohesion and social capital

• Gaining consent for major changes

• Joining up across agencies to:

– Provide personalised services

– Relate vision to physical plans

Why the emphasis on place-shaping?


Why place-making should matter to hospital chief executives

1. Hospitals are essential players in a place

2. Place-making makes sound business sense

3. Place-making supports efficiency

4. Place-making responds to complex local challenges

5. Place-making helps to improve public health

6. Place-making relationships are essential when reconfiguring services

7. Place-making enables whole-system change and personalisation

8. Place-making will be a key component of world class commissioning

9. Place-making fits with the membership dimension of Foundation Trusts

10. Place-making partnerships underpin emergency planning and responses


1. Hospitals are essential players in a place

• Hospital trusts as value-based organisations have a corporate responsibility to a place. They are :

– Often the biggest employers in a place

– Major purchasers in the local economy

– Drivers of inward research and economic regeneration

– Influencers of local patterns of transport

– Big producers of carbon – waste, energy, travel

– A key focus of community activity

“As an organisation employing 8,000 staff and with an annual spend in excess of £300 million, Central Manchester And Manchester Children’s University Hospitals NHS Trust has considerable economic and employment leverage in the local area. Many of the electoral wards that make up our local community suffer some of the highest unemployment rates in the country. There is a correspondingly high incidence of social deprivation – all of which has a negative effect on psychological well-being, health status and morbidity. As one of the City’s largest public sector employers and providers of healthcare, the Trust has a duty to do all that it can to address these deficits.“


2. Place-making makes sound business sense• The demographics of many areas is changing fast – hospitals need

to understand and be part of the process of planning for change

• Hospitals are continually developing their assets – planning and place-making frameworks are being integrated

• The volume of A&E visits and emergency admissions (and hence the work of the rest of the hospital) are affected by factors such as:

– Levels of crime and how they effectively they are dealt with

– The effectiveness of local care pathways for long-term and chronic conditions

– Local road safety

• Collaboration with local authorities, FE colleges, universities and the LSC is needed to deliver the appropriate local balance of skilled staff for hospitals

• Hospitals benefit from sub-regional plans and bids for regeneration which are increasingly place-based

In the last three years Nottingham University Hospitals NHS Trust has submitted around 25 planning applications for different sites


3. Place-making supports efficiency

Both local government and the NHS have been set a target to deliver 3% efficiency savings between the 2008-2011. Place- making provides the basis for strategies that will help to deliver this and improve outcomes for users: on the supply and provider side and via joint prevention strategies.

Source: National Evaluation of Partnerships for Older People Projects: Interim Report of Progress – University of Hertfordshire, October 2007


4. Place-making responds to complex local challenges

Partnership working provides a framework that enables health, social and economic policies to be developed and implemented in a way that is mutually compatible and reinforcing

Source: The role of public health in supporting the development of integrated services – CSIP and Integrated Care Network, May 2007


5. Place-making helps to improve public health

Intervention Relative effectiveness

Walking bus Not cost-effective under current assumptions

Travel SMART Not cost-effective unless joint costs spread over health/transport objectives

Active after school Not cost-effective under current assumptions

Orlistat in adolescents Cost-effective

GP intervention Cost-effective

Multi-faced school-based minus PE Cost-effective

Gastric banding Cost-effective

TV viewing Cost-effective and cost-saving

Multi-faced school-based + PE Cost-effective and cost-saving

School-based fizzy drinks reduction Cost-effective and cost-saving

Family-based targeted Cost-effective and cost-saving

Targeted multi-faceted school-based

Cost-effective and cost-saving

TV advertising Cost-effective and cost-saving

Source: ACE-Obesity: Assessing Cost-effectiveness of obesity interventions in children and adolescents – Department of Human Services, State of Victoria 2006.

The most cost-effective public health interventions require place-based partnership working


6. Place-making relationships are essential when reconfiguring services

Example

• The Independent Reconfiguration Panel acknowledges the rural nature of the [West Suffolk] area under review and recommends that the PCT establish a specific Transport Review Group comprising health organisations, the local authorities, local community transport providers and local people to identify necessary improvements and developments arising from the introduction of the new model of care.

• The Panel recognises the importance of open and transparent communication from all involved to enable these recommendations to be successfully implemented. Necessary trust and respect need to be established. The Panel recommends that the PCT establish appropriate involvement, engagement and communication strategies to address these issues, using where appropriate, external specialist advice and facilitation as well as making full use of locally available knowledge and expertise. Source: IRP

Attempting to reconfigure services without involving other stakeholders is a certain recipe for conflict, delay and frustration – and very often results in failure.


Walsall Transformational Change Programme

Commissioners: Walsall tPCT, & PBC clusters

Providers: Walsall tPCT (community services), Walsall Hospitals Trust, Walsall Social Care & Inclusion, West Midlands Ambulance Service, WALDOC (OOH GPs), Third Sector Providers

Population: 253,000

Programme Aims

Outcomes

Measures

To develop a whole systems benefits realisation framework and dashboard across the Urgent Care, LTC and 18 Weeks Referral to Treatment programmes, ensuring that:• Programmes of benefits led transformational change are delivered• The PCT grows capability to deliver change and realise benefits Programme Delivery Outcomes• The 18 week RTT target will be met in December 2007• Sustain 18 W RTT target by development of new VFM

pathways by April 2009• Reduction in hospital beds to support PFI development by

October 2007• LTC VFM pathways delivering care closer to home• Delivery of new Urgent Care Model Capability Outcomes• Benefits and measures will be agreed across all three

programmes• A benefits dashboard and realisation framework will be

developed • ISIP will be mainstreamed

Examples of Programme Delivery Measures:• Patient experience using patient diaries• Cost of redesigned pathways• Business efficiency measures e.g. 18 weeks RTT Capability Measures• Measurement of capability using maturity model assessment• Baseline 1-2 Target of level 4 by April 2008

7. Place-making enables whole-system change and personalisation

Partnership is fundamental to delivering whole-system change

Source: http://www.isip.nhs.uk/case-studies/case-studies-theme


8. Place-making will be a key component of world class commissioning

Example

2. Work with community partners

World class commissioners will take into account the wider determinants of health when considering how to improve the health and well-being of their local community. To do this effectively, they will work closely and develop a shared ambition with key partners, including local government, healthcare providers and third sector organisations.

These relationships are built up over time, reflecting the commitment of partner organisations to develop innovative solutions for the whole community. Together, commissioners and their partners will encourage innovation and continuous improvement in service design, and drive dramatic improvements in health and well-being.

Source: World Class Commissioning: Vision – Department of Health, December 2007

A number of the 11 key organisational competencies required to deliver world class commissioning require effective partnership relationships and working. Partnership is at the heart of undertaking Joint Strategic Needs Assessments.


9. Place-making fits with the membership dimension of Foundation Trusts

• The membership dimension of Foundation Trusts and the duty to engage with local communities parallels developments with other services and LSPs:

– From April 1st 2009 councils will be under a duty consult and involve local people and to respond to petitions

– The government is encouraging moves to develop community ownership of assets and participatory budgeting

– The police service is subject to a community call for action

– A new White Paper on empowerment is expected this summer

There is potential here for some innovative joined-up thinking that takes community support for the NHS and civic engagement to a new level


10.Place-making partnerships underpin emergency planning

• Better support to the bereaved and survivors – Giving people the information they need – Practical and emotional support – Compensation and financial support – Sharing of information – Health services– Treating the dead with dignity and respect – International response

• More resilient telecommunications networks – Public telephone networks – Emergency service communication networks– Underground communications

• Providing timely information to the public • Keeping London moving safely • Crisis co-ordination arrangements

These were the areas identified as needing an improved response in the wake of the 7/7 attacks. The scale of partnership working needed to address them cannot be suddenly switched on, but needs to be grounded in the every day reality of place-based partnership focused on meeting the needs of local people

Major accidents, terrorist incidents and natural disasters, such as flooding, require intense multi-agency planning, systems and training


What does place-making mean for hospital CEOs?


Leaders have choices on how they engage with place-making

We can characterise leadership behaviours towards partnership working in a similar way. The aim should be to move more PCT and local authority leaders in London towards understanding the implications of a full leadership role

Leaders stand outside partnership working and refuse to involve their organisation in collaborative activity.

Outsider

Player

=

=

=Leaders are supporters of and contributors to partnership activity but not yet committed to playing a full leadership role within the partnership.

Observer

Leader =

Leaders support partnership activity but more as passive onlookers than active participants.

Leaders model collaboration and are fully committed to the values and aims of the partnership and to resolving differences within the partnership.


• Thinking strategically• Communicating well• Developing a shared purpose• Being honest in relationships• Respecting others’ achievements• Facilitating group processes• Involving others• Understanding impact of change• Leaders learning from each other• Mediating conflict

• Setting direction

• Commanding authority

• Being accountable

• Championing an institution

• Persuading through vision

• Understanding different organisations

• Making trade-offs

• Modelling collaboration

Leadership of an institution

Leadership in a partnership

Leaders need new skills for place-making

Leading partnerships means fostering the skills on the right-hand side of the chart

Source: Achieving more together: adding value through partnership – Hill, ASCL January 2008


Leadership of place-making partnerships operates at several different levels

Strategic leadership

Community engagement

Executive delivery

Professional co-ordination

Operational support

These factors need to be balanced otherwise you end up with a smaller space in which to act and/or a lopsided partnership

Robert Hill Consulting Why place-making matters to NHS Trust chief executives Masterclass for NHS...

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