Is health beyond the hospital the key to alleviating system pressures?

Matthew Taylor

Welcome to Health on the Line. We're recording this podcast from the Confed’s Health Beyond the Hospital Conference, exploring how we can work collaboratively to support people in their homes and the community. We're having this conversation, of course, as we approach winter, which is always a challenging time for the health and care system. 

NHS England has outlined some high impact interventions for this winter, intended to support greater flow and manage surges in demand. Some of the interventions focus on keeping people well at home and helping to avoid admissions to hospital, recognising the role that out-of-hospital care plays in delivering prevention, early intervention and admission avoidance. 

This edition of Health on the Line comes as we publish the next report in our series with Carnell Farr on the value of health investment. Today's report, Unlocking the Power of Health Beyond the Hospital: Supporting Communities to Prosper, looks at community care and the role community care plays in supporting system productivity, reducing long-term pressure on the acute sector, and as a crucial contributor to healthcare, as a whole and to a productive healthcare system. But despite knowing that investing in settings outside hospital works on so many levels, we haven't managed fully to realise the ambition to move resources upstream.

So this episode of Health on the Line will explore why that might be and what we need to do to change that position. 

Joining me in this conversation, we have Daniel Elkeles, who is the chief executive of the London Ambulance Service NHS Trust; Karen Jackson, chief executive of Locola; Miriam Deakin, director of policy and strategy, NHS Providers; and James Sanderson, director of community health and personalised care at NHS England. 

Can you give them a round of applause? We're creating that kind of Question Time vibe, although I don't want you to behave like the Question Time audience, if that's okay. 

Karen, I'm going to ask you first; Everybody knows demand is high across the whole of the health service, we all want to be better at addressing, reducing that demand by providing services in a community setting and at home. 

We know and our report today confirms that that's a cost-effective way of doing things. But yet, despite talking about this for many, many, many years, part of the long-term plan we haven't yet made the leap. And that's really the exam question for our conversation.

What is it we need to do to accomplish what we all know we need to do? Or put it another way Karen, sort it out. 

Karen Jackson

And the more I read this question over the past couple of weeks, the more I thought, well, if I knew the answer to that, probably I wouldn't be doing this. 

My name's Karen, I’m from Locala. I perhaps should explain Locala is a social enterprise, and big shout out to my social enterprise colleagues and voluntary sector people in the ring. And we provide community health services for children through to adults across West Yorkshire and Manchester. And I have a lot of my West Yorkshire colleagues in the room who are incredibly supportive.

So it's great to be here. Having sat through today and listened, I feel a bit of a fraud here because there are some incredibly skilled and knowledgeable people in the room. So I'm just going to give you a bit of a reflection of what I think some of that is. I'm going to start with; do you know it’s right hard. It's really hard this.

So having worked in the acute sector for 23 years, when I came into the community services sector, being one of those people who said if that lot out there could just sort themselves that we could sort this. It's really complex. There are an incredible number of moving pieces and we must never forget that they're not just the statutory bodies.

And I think sometimes we get to that space and we forget there is huge contributions from the voluntary sector, social enterprise, many other organisations who support people in the places that they live. I think one of the other things that we've got to do is move the culture. So I've got lots of stickers as I've made notes. 

We are in a culture that we've built for quite a long time, which is built around things that you can see - the hospital: you can see that, you can get your head around it, you can grasp it. General practice: we all get that. 

But what we don't talk about, are all the other services that support people where they live, that are really hard to see and really hard to describe, and we have to go on a journey with our colleagues, but also with our with our communities and our populations that being cared for in a place like your own home or the place that you live can be done in equally as skilled away with probably better outcomes than just sending you to a hospital.

And I think one of the other challenges that's crossed my mind is we spend a lot of money in hospitals, don't we? So for example, in my patch at the moment, we have a number of our hospitals that have additional beds open and additional staff being paid for, and those staff are looking after people who can actually go home. They don't need acute support. 

Wouldn't it be a great idea if we thought about using that money, although staff differently, we might not move the patients, we might not be able to get to that. But if we could care for them and support them in a different way, maybe we could change the dynamic and change the dialogue.

So there are some challenges in that place.

I also think, and this is a challenge maybe to our national team, perhaps we need to start counting differently because we do the things we count. Michael often says to me, if we're not counting, we just practising. And if you think about the things that we're really focused on, which are incredibly important, cancer waiting times, A&E waiting times, they are measures about the quality of care that we give.

None of them are directly measuring how we are supporting people in our own home. And if we want to shift the dialogue, maybe we need a couple - we don't need hundreds; let's not do hundreds - but maybe we need a couple that help us count so that the dialogue shifts. 

What I thought about was, what can we do in different places? What can we do locally? 

So I think there's an advocacy role for us all and we're all advocates in this room. We all know how important it is and unless we continue to talk about it in our places and our ICBs [integrated care boards], it probably won't get on the agenda. I'm very lucky to be the West Yorkshire Community Services Collaborative SRO.

I lead on discharge, I lead on personalised care. So I am able to go in the room. But we all need to do that because if we don't talk about it, it might not get on the agenda. 

We have some great examples, don't we? My colleagues in Wakefield are working very closely with colleagues from Canterbury in New Zealand where they had a burning platform; they had an earthquake, they had to fix it.

And I know we've got people in the room and we are actually actively taking that, but let's not redo that. They've done that. Let's not redo that, let's use that kind of stuff. And locally, I think as well, we need to work together and that's all of us, voluntary sector - everybody needs to work together with support of other colleagues who can help us patients, advocates, patients.

I can see Helen’s in the room from Healthwatch. And I think we need to do some stuff. I heard loads of examples today of stuff we can do that don't need money, that don't need great structural change. They need the will and the determination. So I think locally there are things we can do. We need to do them and we need to share and we need not to be ashamed to sharing and pinching.

Regionally, I think there are things that we need to think about as well. I, for example, need to keep our ICB honest in West Yorkshire. Very lucky to work in West Yorkshire. They've committed themselves to ten tasks we've made for community services that Beck has worked on. Very important, but we need to keep them honest. They've committed to that, so we need to keep them honest in that space.

And when we get into conversations about how we're going to use a limited pot of money, let's not talk about what we've not got. Let's talk about what we have got and how we're going to use it differently. And if we can't move it around, can we talk about maybe additional money we get? Can we use that money differently?

But let's not be afraid to have that conversation. Certainly in my ICB, the acute trust chief executives are really, really keen because they don't want hospitals full of folk who don't need to be there and actually are deteriorating and we're not looking after well. 

And I think that nationally we should be asking our national colleagues and I have warned about this. I think there are things that we that we need to be helping with, but also challenging. So I think we need to continue to make the case. We have to gather the evidence and the data - like the report that's come out today that says, come on, we need some help with this and some of it might need policy change.

So we need to continue with that advocacy. We need to do that together. We are much stronger if we talk together rather than each going separately. And we must continue to work in that way because we'll have more creative solutions. 

Some asks: we have to have the workforce. If we are going to support more people with complex needs in the place they live, we have to have the workforce. And that's not just necessarily registered staff. That's across all of our sectors to support people in a very different way. 

We also, I think, have to do something about the public and their understanding, because as this changes and moves that culture amongst the people we work with has to shift and we have to be able to explain how we can give extraordinary care to people in their own homes, that doesn't necessarily need a consultant referral.

Mr. Smith doesn't need to see you because district nurse or voluntary services manager. But that needs a national dialogue and the local and regional dialogue about that shift in understanding and thinking so that that's an accepted thing to do. And then we need the enablers, don't we? We need the digital enablers, we need the common data sets. We need the ability for our systems to speak to each other and move us along.

And I suppose I'm going to just leave you with, you know, what I felt in this room today is absolute passion for this agenda. And we can do some things that will move the dialogue, that will move the discussion, and perhaps we should do those and then build on them. So, thank you for the opportunity. 

Matthew Taylor

Thank you Karen that was a brilliant start to our conversation. 

So, panel, I'm going to ask you just to - Karen's going through all sorts of issues ranging from kind of data and to culture - just pick on one of the things that Karen identified that particularly resonates with you. 

James I’m going to start with you. I know you've been trying to do a lot around data, for example, you recognise the point that I think Karen made, which is we don't measure this stuff. It's quite hard to argue for it. But what was there particularly that Karen said that struck a chord for you? 

James Sanderson

So I really liked Karen's list of the things that we need to do because it's simple isn’t it; sort the money, sort the infrastructure, sort the politics, the culture, the people, the workforce, the data, the digital side. It's a good list. It's a good list. 

I think we have got a problem with the community data. We've known that for some time. We don't have really high quality datasets, unfortunately, although that's been significantly improving over the past year. And we have a good body of data that we are not necessarily exploiting in the way in which it can shine a light on the amazing community services that are delivered on a day-to-day basis.

When I look at the performance data of community services, I see some brilliant examples of really proactive support happening on a day-to-day basis and actually the performance of community teams, the efficiency of community teams is incredible considering the immense pressure that's out there in the system. So I think actually making that data more readily available, shining a light on it, is really important because that will demonstrate what we're dealing with.

I think the real challenge, though, is that actually when we're talking about people living with very complex needs in the community and we're talking about that care at home, what you've got is a level of complexity in regards to their care that actually isn't as easily measurable as some other aspects of the system. 

It's quite easy to measure flow and what happens to patients in a hospital, relatively easy anyway, and it's quite easy to measure the sorts of interventions that happen in more transactional healthcare settings. Whereas supporting people living with long-term conditions, when you've got multiple teams that are required to support them, whether that's across obviously the voluntary community, faith, social enterprise sectors, across statutory services, across social care, you've got a lot of people intervening in that person's life and I think that's always going to be a challenge.

Even if we can get data to its really clearest operational relevance, if we can get it to that state, I still think there will be gaps. And we just need to accept that the type of support that we're looking for isn't as easily manageable as other parts of the system. 

Matthew Taylor

Really interesting, thank you. 

Miriam. What was there in what Karen said that particularly chimed for you.

Miriam Deakin

Thanks, Matthew. So I was going to pick up on Karen's points around both culture and the workforce, because one of the areas where I feel we could accelerate is in terms of how we train and recruit and retain our workforce in community settings, in the broadest context. So thinking not just about the NHS but shoring up social care, paying carers appropriately, thinking about unpaid carers in the voluntary sector as well.

So in the NHS we've got a really good foundation for that in terms of the NHS workforce plan, which James would correct me, but I think really sets out a great aspiration for expanding community provision. We've just got to hold government’s feet to the fire on giving us the money and delivering it. But there's there's much more that we could do.

I think about where we train people regardless of whether they stay in a community setting so that clinicians start to understand the potential offered by community provision and also start to think about how we could manage risk clinically, slightly differently. 

So I was really interested that you picked up on workforce. We've got some specific shortages in the NHS, so think about district nursing, speech and language therapy, podiatry and so on.

So for me that's kind of the foundation I guess, of the work that we want to do in terms of expanding provision in those different settings. 

Matthew Taylor

Thanks Miriam. 

And Daniel, I'm going to ask you your own question in a moment, but before I do that, was there anything particularly that Karen said that chimed for you? 

Daniel Elkeles

So two things. Firstly, on the workforce space, I love the fact that the NHS always thinks of their own bit as separate to everybody else's bit. And one of the things that we have had going in London since October was the idea which said the best way of getting the urgent community response team to people who were fallen is why don't we put it with the ambulance service? So we now have eight cars which have a community nurse and a paramedic to go to all of the patients who have fallen but haven't broken their hip.

And apart from the fact that the conveyance rate has now massively plummeted to hospital because what you've actually done is expedite people into a UCR service really quickly. The workforce learning is huge. So some of the people in the room are part of this service. 

And we've made a video where you just listen to the paramedic saying, I didn't know all these things that community nurses can do and isn't it great? I've now got some of these skills and you have the community nurses saying, I didn't know the paramedics could do all of this and now I've got some of their skills. And you kind of thinking, sharing our workforce and doing skills exchange, it seems a really important way of how to solve the workforce crisis. 

And the second bit which came out of - we had an ambulance sector strategy day last week - and one of the ambulance strategy directors said you know, one of the USPs of an ambulance service is we’re really good at logistics and scheduling and what about if we shared that ability with our community colleagues in both mental health and community? Wouldn't we be able to get to lots more people more quickly because we know how to get there? 

And so you kind of think, hey, there is such a lot in the out-of-hospital space where actually if we joined ourselves together and said we're all actually here for patients, how do we take the best of what we've all got to get it more than the sum our parts? I think we’d do really well. 

Matthew Taylor

Great. Thank you. 

You appeared on an early edition of Health on the Line and we talked about a number of things and one of the things we talked about was kind of care coordination, access points. And one of the challenges in the health service, which is relevant to this debate is that we talk about the things that we want to achieve over the long term, and then we talk about the things that we've got to achieve now because of the pressure that we're under.

And that is part of the dynamic that has meant that we haven't achieved what is sometimes called the left or upstream shift in resources because politicians and the media and the public tend to focus more on what happens in acutes. And that as Malcolm X once said it's the hinge that squeaks that gets the grease, and it's often the acutes which are the squeaking hinges of the health service.

So one of the things we have to do is we have to find ways of addressing short-term pressing needs in ways that help to carry us towards where we want to get to in the longer term. And that's why I think this kind of conversation about how we work better together, particularly thinking about winter, oncoming winter, how do we do that in ways that prefigure the future we want?

And just to finish this incredibly long question, I think you were at the event as well. I was very heartened recently when I went to an NHSE event around winter preparation, where the two presentations, the best case studies were both not from trusts but from places; from Leeds and from Walsall, and they were very clearly multiagency presentations: local government, the health service, different parts, third sector working together and that was quite different it felt to me, quite interesting. That at an NHSE gathering it was place-based bodies that were the ones that they were putting in the shop window. 

So the purpose of this very long question in a way, is to ask you whether you think I'm right in saying that the way in which we tackle these very pressing issues of reducing conveyancing, getting people out of hospital quicker, single points of access, kind and help us in the longer term aspiration of shifting where we invest our resources.

Daniel Elkeles

So I could give you a very short answer.

Matthew Taylor

No give me a reasonably long answer because we've got another 20 minutes to talk about this. 

Daniel Elkeles

The short answer is yes, definitely. And it was totally inspirational hearing from Leeds and Walsall.

To get to the short answer, this is what I think I would say. So firstly, the report you published on community services today I think is totally brilliant. So, in my previous job where I ran an acute trust that took on community services, the investment we made in the community services, particularly since both the populations in Sutton and Surrey Downs had very large numbers of older people, made a demonstrable difference in reducing emergency admissions to hospital. So it's just more evidence that the report was right.

And then I couldn't help but notice in the report that my sector is so small in ambulance and 111, it doesn't even feature, it’s in the ‘other’ somewhere. But I suspect if we did the same analysis in our sector, you would see the ‘investing in care navigation’, part of the ones and the nines, would give you as good a return as you would get in the community services.

And before this session I went to the session the Red Cross-led on virtual wards and I loved the fact that they had done all these different patient personas describing different groups of people and how they experienced care. And that so plays into this whole strategy of care navigation. And in fact, our new strategy for the ambulance service, which we launched yesterday for London, and we said our first mission is to provide outstanding care to everyone in London, wherever and whenever they need it.

And obviously that means get there very quickly, if someone is very sick. But most patients who phone either the ones or the nines in London aren't very sick. And actually the right thing to do for them is to do a detailed assessment of their needs and work out what exactly is the right care that that person needs. So you need to give a ‘tailored response’.

To give a tailored response means both you need access to lots of alternative answers that aren't ‘go to A&E’, but you also need a lot of care navigation with the people to understand what are the different alternatives and how to get people referred into them. 

And there are so many examples just in London of us doing that.

So, 15 per cent of all the people who phoned the nines in London and now it's called ‘hear and treat’. So the end products of their call is a telephone assessment with a clinician where the definitive advice is given on the phone. 

Courtesy of some changes in the framework we work in, there's this thing called ‘category two segmentation pilot’. So category two is the biggest volume of disposition that if you phone 999, and about half the patients we're now allowed to phone them back to do an assessment. And the consequence of that is 4 per cent of the patients, they don't get an ambulance at all. We are getting them an alternative response. 

I mentioned our community joint response calls, but we also have mental health joint response calls. That's 350 patients a month where the complaints rate hospital was well over half and is now 15 per cent. We've got loads of phone-a-friend schemes equivalent, so that's where a paramedic in the person's home can find a geriatrician or they can phone a stroke doctor or they can phone an A&E doctor and say, What would you think I should do with this patient?

And more often than not, the answer isn't not to take them to a hospital. It's put them into an outpatient appointment or this can go to SDEC [same day emergency care] or, you know, a different response. 

And then if you think of 111 as a whole, basically it's a giant care navigation service. So a third of people who phone 111 end up in a clinical assessment.

And in London, we've now got to a quarter of the patients where the answer is self-care, and only 8 per cent of patients send an ambulance, which is the lowest in the country, which just shows you that the volume and calibre of clinicians we have doing it is huge. So we've got GPs paramedics, midwives, community staff, mental health staff, we've now got pediatric nurses.

It's a huge growing set of skills and that's how I think you get to the winter. So I really like the ten high impact interventions that NHSE have come up with and I think they will make a real difference. 

But when it gets really tough and it's going to get really tough where every service says I am full, and the question is what do you do?

I think the best thing we can do is work out exactly what is the right need for the patient and get that patient’s need met right the first time in the right place. And I think that's how you get the finite capacity we've actually got - of beds and people - used to its best effect. 

So I would really, really welcome a focus on, yes, the ten high impact interventions, but let’s really think about care navigation too.

Matthew Taylor

So that's fascinating. 

And James, I'm going to come to you in a moment with a question around kind of what's happening in NHS England in this area, but you don't have ambulance services in your remit, do you? 

So when you hear Daniel and you see we see and hear these connections, what more can we be doing to ensure that the ambulance service is a full part of this conversation?

James Sanderson

I think it's really clear. I mean, all parts of the system have to work together in a very different way. I think the bizarre siloing that we've had in health and care systems for many years is clearly a significant barrier to working in the way in which we all now know is right. And listening to Daniel's outline, what is happening in London, obviously gives us hope that it can be done.

And the ambulance service being an integrated part of the way in which community teams work, sharing those resources that that integrated team of multi-disciplined professionals has got to be the right focus to support people with the level of complexity that I was saying earlier we've got to meet. 

Matthew Taylor

And Karen, I don't think you spoke about the ambulance service in what you said. As a service provider, what's your experience of working with the ambulance service and do you sense the potential that Daniel's talking about? 

Karen Jackson

Yes, so in West Yorkshire, in our community services collaborative, our ambulance service are part of the collaborative. So despite it being called a community services collaborative, there are lots of other folk around the room because we simply are not an island and we've tried to do that by setting the bar about who is involved in supporting people where they live.

And the ambulance service clearly are despite the fact that they might move some of them to somewhere else. And they've got a huge amount of experience to impart to all colleagues in the system, be they district nursing colleagues or the voluntary sector about how to support people properly where they live. 

They're critical. They're central. Certainly in West Yorkshire, because the Yorkshire Ambulance Service, they're stretched an awful long way and getting they've organised themselves to be able to service each place. And I could see that being a stretch. But they are absolutely central.

And we are starting to think about how do we use paramedics in our - let's call it the UCR service - but in our rapid response service and how do we actually deploy them in there, even if they're employed in the ambulance service. So they might not have a blue light and rushing around with the pants on fire, but actually they are responding really quickly to support people where they live. And that kind of rotational experience for a paramedic is deemed to be quite important. 

Matthew Taylor

Yeah really interesting. 

So, Miriam, you work for our competitor organisations, so I’m going to ask an incredibly hard question in order that you might show yourself up and reveal the fact that the Confed…. no, I’m not really.

Miriam Deakin

It might go the other way Matthew

Matthew Taylor

That is true, actually. Yeah. Okay. 

What I was going to ask was, you engage with the community sector as a whole. We jointly host that, Confed and Providers. There's a lot of variation in the quality of relationships isn't there. And of course, you know, one of the challenges for the ambulance service is you've got to deal with multiple ICBs, you know, in Yorkshire there’s three or four, in London you've got five.

And I know that's a real issue. And I think in Yorkshire they've devolved so that they've got an ICB lead in each post which seems sensible but also creates its own kind of challenges. 

So what's your perspective on the one the front on the challenging geography of this and the fact that it is very varied?

You can speak to some community trust leaders who will talk in glowing terms about how they’re working with the ambulance service, and in other places it's not nearly so good. 

What does that tell us more broadly about the relationship between national, and devolution, and local policy? 

Miriam Deakin

Yeah, thanks Matthew that is that is quite a hard question, but I think at the root of that, we should acknowledge the huge variation there is in provision and infrastructure, but that's particularly the case for community services, I think.

So we've got a patchwork of different levels of voluntary sector capacity in different places. We've got our community interest colleagues. In some places you've got a standalone community trust or you might have community services integrated with mental health or acute. So the kind of pattern of provision I think is quite variable. And then that's overlaid clearly with this range of relationships.

So I think we need to take all of that into account when we're thinking about accelerating change. It's going to be horses for courses in different areas, I think. Important that we get underneath where certain systems might need more investment, be that in intermediate care or in community beds or in more provision in people's homes, which is the direction we're all moving towards.

And that that comes into the conversation, doesn't it, both, I think with ICSs but also with NHS England when we're talking about allocations and ultimately with government who are really holding the purse strings in terms of what they want to invest and where. 

I do think it's quite an interesting question when we thinking about the pace and scale of change though, and something we probably have to factor in. People are going to be moving at different speeds, I would say, that doesn't mean that we're not all moving towards the same goal. 

Matthew Taylor

And brilliant answer if you don’t mind me saying so. 

And Daniel, I don’t want to put you too much on the spot, but how do you deal with the complexity of the relationships across multiple ICBs and multiple community trusts? 

Daniel Elkeles

Well, I'd like to say we had the answer and we did it really well. But I think we're still learning. And I think one of the things we need to learn at is when do you actually need your ICSs to work together because there can only be one answer to the problem? 

And when do you say it doesn't matter because a local answer that's bespoke to a borough is totally the right thing for that population. And I have to get my organisation to not work at a regional level. Not even work perhaps a borough level, but work with a PCN. Right? So we haven't quite sussed, I suppose, the trusting relationships that enable us to have the mature conversation, where we can agree on what scale the right answer has to happen at. It would be great if we spent a few months working that out.

Matthew Taylor

I had a really good conversation with the place leader in Greater Manchester who spent five minutes explaining to me the unbelievable eye-watering complexity of the institutional kind of architecture, but then said to me, you know, there is no way you can make this simpler. In the end, it is all about the quality of relationships. So we could spend loads and loads of time jiggling things around to make them look neater, but it will still rely on the relationships.

So why don't we just get on and make the relationships work? I think that's a really well made point. 

So James, NHS England going through an incredibly challenging period of change, political scrutiny and pressure inevitably growing with the general election around the corner. A kind of perception externally, that NHS England has sometimes has a feeling of being an acute-oriented organisation that it’s leadership has kind of an acute sector background in particular. 

How do the kind of arguments we've been articulating today, how much do you feel those arguments are being heard in NHS England, there’s time to hear those arguments? Do you think you're winning the arguments yourself within the organisation and what can we expect in the future? 

James Sanderson

So I think there's a real difference between what I recognise is the conversation - the national conversation is about the acute sector, and that's been the case for many years.

But the positive thing is I think we have a real consensus across health and care leaders that we need to move to the type of model that we're talking about. And I think that consensus has come with a sort of combination of pressures, because we know that the downstream pressures are creating, huge challenges that aren't sustainable.

We know that the demographic shifts that we have with people living longer lives, but with greater levels of complexity, are something that needs a new way of thinking to approach it. And I think we know that the way in which we spend money needs to be looked at and we know that preventing ill health and deterioration is much cheaper than dealing with it when it happens.

And we also know that the demands of the public have shifted as well, that actually people have got a growing sense of wanting to be cared for close to home in their communities, perhaps away from that traditional model that's been there. 

And whilst there's a lot of developments in all of those areas, I think all of those areas are creating that consensus.

So I'm really positive about the way in which we're now able to embrace this new way of thinking in the NHS. And we started to do that with the shift that we've made for the preparations for winter. So last year we were very successful because of the brilliant work of community teams right across the country, of mobilising urgent community response services, setting up at very, very short notice in many areas acute respiratory infection hubs, and that supported over three quarters of a million people in the community.

The majority over half a million people have been seen face-to-face, avoiding hospitalisation, avoiding enhanced treatment for those people. So that gave us a great example, I think, of how the mobilisation of community services could support a different way of working. 

What we need to do now is we need to take that from individual initiatives that were a winter response and make sure it's part of the way in which we do business on a day-to-day basis.

And this isn't a shift as a pressure release valve, we should have urgent community response. Even if Daniel’s ambulances are sitting idle on the side of the road, it's not the right thing to do to send an ambulance to somebody that doesn't need it. So I think we've got to make that shift now from these things, like urgent community response, being a mechanism to support winter, to actually just being a day-to-day operational reality. 

Alongside that - because that's only one shift - once we've shifted all of that activity away from the acute sector, hopefully we release pressure from the ambulance service as well to enable them to deal with more complex cases, we then need to start looking at that same group of patients and finding out ways of getting to them before they fall into that crisis moment in the first place.

And that's where shifting further upstream into working proactively with certain groups of people is the next big shift that we need to make. 

So, I suppose the consensus for me is on the idea that we've got to move a lot of activity out of the acute sector into the community. We've then got to organise the community slightly differently into integrated teams that we've spoken about, and there's some great examples of, so that those integrated teams can support people in a different way.

And then we've got to make a third shift, which is doing that much more proactively. 

I'm really positive that that can be done, but it is complex. Back to the beginning of the conversation, there's lots of areas that we need to address in order to make this right, but the circumstances that are presented demonstrate that we've got to do something very, very differently.

And the really positive thing and the positive thing about the report that you’ve published today, demonstrates that it is possible and it is happening, just not everywhere yet. 

Matthew Taylor

Yeah. So Karen, you referred to this in your answer earlier, but James is fighting the good fight for us within NHSE. But if you had Amanda or Richard Meddings here and you had to make one ask of NHSE, what would it be?

Karen Jackson

One?

Matthew Taylor

Yes you’re allowed one. 

Karen Jackson

So, in the NHS plan and in all the documents we receive, it talks a lot about supporting people in the places that they live. But then when we get things that come down in terms of supporting us to do that, maybe moving the money around or making some at risk decisions where we've all got enough data to do something and so we think we're going to do it, and it's a bit of a risk… 

The planning narrative, I don't think matches what it feels like on the ground narrative. And so something that says it is important is in every plan that we've got and we know that it will make a significant difference. The report you've done today, the £1 and the 40, all that, but something that demonstrates that it's really and truly been heard and there's some action that's going to make a difference.

Because there is a disconnect between the planning narrative, which is all properly intentioned, and actually what translates onto the ground.

And I think that would make a huge difference in us believing that it’s been heard and it’s been supported in a very different way.

Matthew Taylor

Thank you. And Daniel, not wanting to capsize your career, what would you say about it? 

Daniel Elkeles

So I was just thinking of how to not give a career limiting answer. [Laughter]. So I suppose my plea to NHSE was would be: Please, could you think about patients as opposed to think about silos that we work in? Because I think James has just given a brilliant example of the silo answer to the problem. So you said that the way of relieving pressure on the ambulance service is take some work away to give it to the community services.

That's great, if the community services had loads of spare workforce, but they don’t. Whereas the answer I gave to ‘how do you get to frail elderly people?’ is to say, well, I've got the skill set and the community's got a skill set, why don't we put them together? And I find it really hard to get up the food chain to understand that you don't have to compete in silos.

What you have to do is get clinicians to say, What's the right care for this person? How do we get a good model for that? And that's where all the innovation comes is when you get clinicians focused on how do I solve this problem for a person. Right? 

And so my plea is, please, can we have more focus on patient groups and specific issues and less focus on the different silos that we’re all beautifully aligned in. But I hope I hope I still have a job!

Matthew Taylor

Yeah, well, there's a lot of people nodding, so you've got lots of friends, even if you haven’t got a job. 

Miriam, I'm going to ask you to respond to what James said, but also to pose the question I was going to ask earlier so that we can turn to questions; you engage with community sector, one of the reasons we've organised this conference was a sense when you and I meet with community trust leaders that community trusts aren't understood, that their voice isn't as loudly heard, that it's a complex sector with community interest companies, with, many combined issues and community trusts. Some combining community mental health. 

What do you think the sector needs to do to make sure, because part of the responsibility has to lie with us; we cannot always say, well, NHS is acute dominated, and that's partly because the acute is a bloody good at getting their act together. You know what does the sector need to do to get its voice heard more strongly to do that. 

Miriam Deakin

Yeah, I mean I think going back to one of James's earlier points that there is more the sector can do to get its act together on data and kind of making a case for itself. And we hear a lot of enthusiasm from the community sector to do that. I do also think that the dial is really shifting in the dialogue with NHS England. So we actually do see Amanda, I think, put community services more at the heart of more of what she says. 

There is probably further sort of room to go on that. But I think the community sector has got better, I think, at engaging in those conversations and also in bringing into conversations with - not just James's team - but others at NHS England, some of their expertise. So we see that I think in some of the hospital-at-home initiatives where trust leaders are kind of helping bringing their frontline expertise and kind of helping to inform policy more. 

So that really is what the Community Network, which we jointly hosted, is there to help do, is to help provide that clearer voice, I think, for community providers at appropriate levels within the system. So the dial is definitely shifting. And again, as colleagues have said, there is a lot more enthusiasm for different ways of working from acute sector colleagues and other colleagues in the sector as well.

So that is something we should embrace and harness, I think. 

Matthew Taylor

Great. Thank you. 

Well, what I'm going to do is I'm going to take five questions from the audience. There's a roving mike that's going to come to you. Well done, sir. Oh, wow, look at this. See, this is what comes to being at the front. I did warn you, I’m going to take five points. 

Unerringly, it’s an overwhelmingly female audience, and all the five people at the moment are men. So that’s not going to happen. We’ll take the five questions and you have to forgive me if you’re not called. And then, panel, I’m going to ask you to just pick one or two of those questions to respond to in a kind of closing round up.

Okay. So could you please clearly introduce yourself for the record? 

Speaker

Hello, I'm Harry Sultan, I’m the next director from West Yorkshire ICB, responsible for citizens and future generations. 

So you've talked a lot about wanting to move out of the acute sector, into the community, but currently 80 per cent of healthcare placements are in the hospital. I'm also a medical student and I will barely see the outside world beyond the hospital after my undergraduate training.

So how do we shift that dial to ensure that the clinicians of the future are adapted and educated to this world of out-of-hospital care that's been talked about? 

Matthew Taylor

Brilliant, I think that's both a point and a question. And thank you. 

I was going to say I'm desperate for a woman, but that doesn't sound great, does it? [Laughter]. We’ll go with that lady over there. Sorry, it's my age, Dad jokes, can't resist them. 

Speaker

Pleased to oblige. My name is Lauren Walker, I'm an occupational therapist and I work for the Royal College of Occupational Therapists. 

There's been some really stimulating, encouraging conversation today, some really great examples of collaborative working. One of my reflections is that a lot of those are focused on medical and social interventions, which are of course incredibly important.

But there's been very little conversation around rehabilitation. We know from the new Intermediate Care Framework that therapist-led rehab in communities is going to be a big part of the future, which is very, very welcome. So I’m interested to know what the panel’s views are on that and how we can ensure that rehab is front and centre of how we deliver support and care outside of hospitals?

Matthew Taylor

Great - and the gentleman there in the third row back. 

Speaker

My name is Harry Peacock. I'm working as a programme lead for Home First, but I've also spent many years as a carer. 

And my point is: unpaid carers are the real workforce for people staying at home and receiving support at home. And I wonder how we get that further up the agenda.

I know some great work's been undertaken around carers’ contingency planning and raising the profile of carers, but I don't think we can underemphasise the role that carers play and I think we really need to think through what our approach is going to be in terms of how all the organisations wrap around that person - whether it's care navigation, whether it's an ambulance response - and how we support carers in doing that.

Matthew Taylor

Yeah, I'm not going to answer the question, but I completely agree with that. And we've called at the Confed for a different, a more ambitious conversation with patients, carers and the public. And I think what is interesting with the community sector is, that really is the place where it's clear the care is a partnership, in a way that probably isn't the case for other areas quite so much, so fascinating question.

Fiona, who's next? 

Speaker

Johnny Marshall from the National Association of Primary Care. I've been a GP for 30 years. 

This is probably my 30th pre winter conversation about what we're going to do with this winter, which sounds very similar to the other 29 and very much and understandably it's very sort of service based. 

I just wonder whether this problem is ever going to be solved unless we find the time, the space, the money to invest in both the proactive elements of preventing people getting unwell in the first place and tapping into that huge asset that is the community itself in the way that Daniel is talking about, thinking about what people need. 

Not as patients, but as people. What do they really, really need and how do we activate them? I’m a patient activation person is incredibly powerful to ensure that they don't need so much of our support. 

Matthew Taylor

One more woman, please. Yeah, if you go back. Brilliant. And I've got a gentleman here that’ll have to be it I’m afraid. Yep. 

Speaker

Hi, my name's Sarah Haines. I'm a physiotherapist. I'm currently working in our community mental health transformation in middle/north Hampshire. 

And my question is around the idea of the skills exchange is really exciting, particularly as an allied health professional who qualifies in an area that can work across all sectors. So, I'm not limited to physical health, mental health, children, adults, you can work across all of that range.

But also how do we ensure that a lot of the focus at the moment is on how we support that, joining up of our physical health, community and acute services and moving out of acute physical hospitals.

How do we make sure the mental health side is not forgotten and that we look at that whole joined up pathway to ensure that we consider everybody’s health, not siloing it still into physical and mental health. 

Matthew Taylor

Right sorry to all those I haven't been able to call but I'm going to have to turn to the gentleman here as the last question/point.

Speaker

Thank you. My name is Peter Amreeka and I'm managing director of Icon Health Care Management Consultancy, previously with the board of the Southeast London CCG as chair of the Primary Care Commissioning Committee and before that with the Health and Wellbeing Board of Lewisham for five years. 

I joined the NHS in 1970 and had a career involving, I think about seven Secretary of States changing the NHS all the time. 

I was very interested in Karen's first point about the culture and how that culture is promulgated by the department of health in the shift that is being considered. We hear there's going to be, I think, 40 new hospitals by 2030? £20 billion are being allocated for new hospitals? I just wondered in the information which the Department of Health and Social Care push out, why do they continually emphasise that the improve payments in the health and care is centered on hospitals and capital monies?

Should there not be a concurrent notification of improvement in community care and the shift that is being articulated now? So  that's my view and what is happening. And it's sad that it continues to happen all of these years. 

Matthew Taylor

Thank you. Well, thank you for that. I'm going to come to the panel and I'm going to give you a minute to each to pick a couple of those points. 

Just on the capital point, I think that it's a well-made point when we talk about the problems of capital in the health service, the need for more capital investment, I do think you're right. We too often talk about it as if it's only an issue of hospitals and kit in hospitals.

You know, the primary care estate is nothing like where we want it to be, community mental health. So we do need to talk about the problems of capital investment across the board much more than we do. I completely agree with that. 

So I'm going to go left to right. Daniel, pick a couple of points. 

Daniel Elkeles

Okay. Clinicians need training and out-of-hospital care, couldn't agree more. I think that it would be great if every commissioner who was doing an undergraduate degree had a whole semester on mental health because boy, do we need to increase the mental health workforce and if we skill everybody up, that would be grand. 

I think on carers, when we go and see a patient in the home, we get the electronic patient summary record. Wouldn't it be amazing if a part of it was about carers so that the paramedic crew knew what it was, the caring environment they were going into? 

Focus on proactive care? Well, my organisation only does reactive care, but I think we could do way more reactive care for other parts of the NHS to free them up, to do the proactive care that they need to spend time on. 

Skills exchange? Our paramedics love it. So you say to paramedics, ‘Would you like to learn about this?’ And they say, ‘yes’. So I’m all for skilling up commissions to go outside the box. 

Matthew Taylor

Great. Thank you, Daniel. Miriam. 

Miriam Deakin

Let's start with a mental health point, just because it hasn't come up as much in our conversations and completely agree. So appropriate pathways for people, particularly in crisis over winter and at any point in the year have got to be really central as part of the solution. So Daniel's mental health cars, but really more support in the community, more helplines so that people are not ending up in A&E, which is probably the worst possible point for them at that moment in crisis. I completely agree with that. 

I completely agree with all the points around training and placements. I think there's a lot of work to do with royal colleges universities to really look at where and how people are trained.

And then just finally on the on the cultural point from the gentleman at the front, we are both from apolitical organisations, but it will be interesting to see which parties in party conference season focus more on the community sector and those that focus less. I would listen out for that.

Matthew Taylor

Interesting, interesting point. Thank you. Karen. 

Karen Jackson

Starting with carers. So in West Yorkshire we have a carers programme which I lead on with a great team of people and let's be frank, without carers or proxy carers that come from places like the third sector or our social impact colleagues, we’d fall over. So we have to invest and we have to go on the journey for the person, as much for the carer and to support the carers.

So you’re absolutely right and I want to mention young carers in this because not all carers are adults here. Some carers are children and they have extreme pressure which is very, very different. 

Harry, your points are well made about we need medics in the out-of-hospital space, particularly if we're going to look after more complex people and we need to be thinking about a rotation through those services that isn't just community. It could be in the ambulance service, mental health, etc.

In terms of rehab, rehab is absolutely critical to keep people well and supported in the place. The work that the teams do medically is one thing in the community, but actually the rehab to keep somebody supported in that place is fundamental to that position. So we have to invest in that going forward and we have to value those skills.

And the point that was made about we need to see the whole person, it was somewhere there about mental health. We have to see the whole person. And that means we have to skill all our colleagues in at least some of physical health, mental health, social wellbeing, etc.

The capital point I think is really well made and I'm going to speak on behalf of my social enterprise colleagues and voluntary sector who provide a significant amount of community services, I think it's about 30 per cent nationally. 

We don't get access to NHS capital, so we have to find that ourselves and our organisations, I'm incredibly proud of social enterprises for the work that they do, for the social impact and the difference that they're making communities, but also for the fact that they find their own capital without access, in a situation where we're being asked to respond to NHS contract needs.

So I think that's really important to recognise too. And a huge thank you to all of you out there who do that work. 

Matthew Taylor

Thank you, Karen. James.

James Sanderson

What a great set of questions. And most of them were statements really that I found myself agreeing with. 

Back to data, we've got to get community services more visible by presenting the data and make it exciting for people to want to work in them and take up training places in community services, I think that's a core point.

Allied health professionals; we need more of them and the workforce plan thankfully targets extra recruitment of OHPs, including occupational therapists. I think we've got to change the public perception in many ways. 

The point about spending and capital, I think there is a real challenge. What do the general public want the government to spend money on?

And if you ask them, it would be hospitals, it would be more doctors, it would be more beds. And actually we know that those things are not necessarily the things that we need to invest in to provide the health service that the public want. So I think there's a big cultural shift publicly and that will then support politicians making the decisions that they need to make and only can make.

And then finally, I think in terms of what people need, that's more about delivering a personalised care service, asking people what matters, developing services wholistically around their needs, looking at them as a whole person. It's great that we've got 8 million people that've been supported by personalised care interventions, but that's a very small number when you compare it to a million appointments every day, just in general practice alone, let alone what happens in the community and in hospitals.

So we've just got to continue with that quest to roll out more personalised care. 

Matthew Taylor

Thank you, James. 

So thank you for attending this session and thank you for listening to Health on the Line. 

Can I just ask you to thank our wonderful panel, Danielle colleagues Karen Jackson, Miriam Deacon and James Thomson. [Applause]