This year has seen a significant shift in the way the sector works in collaboration with wider health organisations and the community. Under the Health and Care Act 2022, 42 integrated care boards (ICBs) were established on 1st July 2022, replacing clinical commissioning groups (CCGs). Each ICB has a constitution setting out the Board membership and governance arrangements for the organisation. As required by the Act, clinical commissioning groups (CCGs) worked with designated ICB leaders, to engage with key local stakeholders to develop their constitutions.
Previously, the clinical commissioning group (CCG) in County Durham matched the local authority boundaries which certainly helped with integration. Following the change on 1st July 2022, the Integrated Care Board for the North East and North Cumbria (NENC) assumed commissioning responsibilities. The NENC area covers 13 local authorities from the border with Scotland to Staithes – a distance of 133 miles. It includes rural areas, cities and some areas with stubborn health inequalities. This was a major shift in commissioning and presented all partners with the dilemma of how to keep a local, place-based focus and work at scale. However, by working together in County Durham, we are moving towards a solution that is based on our strong track record.
County Durham Care Partnership
Here in Durham, we have been working at integration for a good 10 years. Most colleagues know each other really well and solve problems together every day. Our integrated model is the County Durham Care Partnership, which brings together NHS and social care organisations such as County Durham and Darlington Foundation Trust, our Integrated Care Board Durham County Council and other health and care providers in a true collaboration. This united approach has helped to drive our ambition to further develop system-wide integrated models of care.
Our vision is about putting people at the centre of everything we do, moving away from a hospital-based model of care to a new way of working, based on collaboration and partnership. We want to provide more care in people’s homes and their community and, at the same time, break down barriers between services. This means joining up the work of general practices, community services and hospitals to meet the needs of people requiring care and finding new, more efficient ways of supporting people. This could be population-based prevention initiatives or developing provision for very complex health or care services.
Of course, this is never as simple as it sounds. Different financial regimes, workforce terms and conditions, national targets and policies make operational integration a real challenge. One simple but important example is paying for care. NHS services are free at the point of use and based on clinical need. Social care is charged for depending on savings, income and eligibility criteria.
In County Durham we have formed Teams Around the Patient (TAPs) which are made up of social workers, GPs and their teams and NHS Community Services Teams. There are three different sets of pay scales, pension arrangements and holiday entitlements, some of them set nationally.
What we have done in County Durham is recognise these differences but focus on improving customer experience through streamlining pathways together. We have concentrated on what we can change rather than what we can’t, including shared IT systems with GPs, co-location, joint senior managerial posts and shared points of access.
Regional opportunity
Although the NENC Integrated Care Board is huge, it realised the importance of working at place. The Board has committed senior staff resources to work at a place-based level and takes an active role in
place-based partnerships. The Board has committed to co-producing a Joint Committee for Health and Care in County Durham and we are working on this together.
The Integrated Care Board has been in place for less than 100 days. It is in a period of transition but is moving at pace to work out what should be done at scale and what should be done at place. We already arrange many services at scale. Highly specialist cancer care, cardiology, mental health and children’s care are some examples.
We also know that working across this large geography means that one size doesn’t fit all. Ideas can be developed at scale, but they need to be tailored for local implementation. In a place as large as County Durham, we often have to tailor services within our county to work for our local communities as it is so diverse. The partners in The County Durham Care Partnership recognise that, too. Many of them work across larger geographies and have learnt how to gain efficiencies of working at scale, but also how to be part of very local teams.
The change to the Integrated Care Board means we can work at scale. We must not forget that most care is delivered in people’s homes and communities. It is a huge privilege to work in the newly developing Integrated Care Board and to see recognition of the importance of place-based care, but most importantly, to work for both health and social care.
Successful working
In health and care, we are surrounded by colleagues who want to do their best for people, push boundaries and make a change. Turning good ideas into a reality can, however, be a challenge due to either the different processes and procedures in place at different organisations or the availability of funding.
There has been a logical way to address this in Durham; we created roles that span organisations. For example, I am employed by Durham County Council and the North East and North Cumbria Integrated Care Board and I work in a commissioning role. In my role as the Joint Head of Integrated Strategic Commissioning, I feel equally accountable for the success of all of the members of the County Durham Care Partnership. This makes a huge difference to how I view things and how we work as a partnership. Mine is just one example of how these cross-organisational roles work. We have found from doing this that staff are more focused on our population and less focused on individual organisations.
For tangible proof of the reality of what happens when strategy is converted into action, we need only look to Barnard Castle – an attractive market town set in beautiful Teesdale. In the Richardson Hospital we have co-located community services, social care, therapies, mental health, out-patients, a community hospital and GPs all working together to serve the same population. When we were there in hot weather everyone was sharing ice creams – a sure sign that integration is working.
In 2021, it took just five working days for the Council and the NHS Trust to set up a vaccination centre in the Civic Suite of County Hall. We vaccinated over 11,000 people and supported each other with a shared determination to protect the nation from COVID-19. It was great to see council staff, librarians, leisure assistants and facilities managers working alongside clinical colleagues. The task now is to translate that level of shared determination into ‘making strategies’.
On the horizon
Our NHS Trusts, social care and GPs already have integrated working arrangements in place, but we are entering a new phase, opening a new chapter in our story.
Our ambition is to deliver outstanding care for our residents. Bearing in mind the challenges we face – demand, complexity, workforce, estates, finance – the only way we can do this is through closer working. In County Durham, this means working together with our Integrated Care Board in a Joint Committee arrangement. We are realistic about our different governance arrangements, quality and inspection frameworks, HR rules and planning timetables but we don’t let them stop us. Therefore, by December 2022, our councillors and senior leaders expect to be working in a shadow Joint Committee sharing resources to deliver outstanding care.
Sometimes it is good to have a fresh view of the area in which you work. Sam Allen, Chief Executive of our Integrated Care Board, has visited the County Durham Care Partnership. She gave us great encouragement and inspired us to intensify our collaborative working. We are often so busy managing day-to-day operations, waiting times, outstanding reviews, and staff rotas that we forget about the progress we have made. Sam heard about some groundbreaking clinical innovation we are doing with Durham University and heard some uplifting patient stories. She was kind enough to give us some feedback and said, ‘I was blown away by the digital innovation, integration and partnership working. Truly impressive and so much to be proud of!’
Michael Laing is the Director of Integrated Community Services at the Durham Care Partnership. Email: [email protected] Twitter: @CDCarepartners
Sarah Burns is the Joint Head of Integrated Strategic Commissioning at the Durham Care Partnership. Email: [email protected] Twitter: @CDCarepartners
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