Why place-making matters to NHS Trust chief executives

1
Why place-making matters to NHS Trust chief
executives

• Masterclass for NHS chief executives
• May 7th 2008

2
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 peoples homes
• Looked after children in care homes
• Regulated the buses

3
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 peoples 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

4
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

5
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

6
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

7
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)

8
Why the emphasis on place-shaping?
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
9
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

10
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 Childrens
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 Citys largest public
sector employers and providers of healthcare, the
Trust has a duty to do all that it can to address
these deficits.
11
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 AE 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
12
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
13
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
14
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
The most cost-effective public health
interventions require place-based partnership
working
Source ACE-Obesity Assessing Cost-effectiveness
of obesity interventions in children and
adolescents Department of Human Services, State
of Victoria 2006.
15
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.
16
Place-making enables whole-system change and
personalisation
Programme Aims

• 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

Partnership is fundamental to delivering
whole-system change
Outcomes

• 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

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
Measures

• 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

Source http//www.isip.nhs.uk/case-studies/case-s
tudies-theme
17
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.
18
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
19
Place-making partnerships underpin emergency
planning
Major accidents, terrorist incidents and natural
disasters, such as flooding, require intense
multi-agency planning, systems and training

• 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
20
What does place-making mean for hospital CEOs?
21
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

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

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

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

Leader
22
Leaders need new skills for place-making
Leading partnerships means fostering the skills
on the right-hand side of the chart
Leadership in a 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

• Persuading through vision
• Understanding different organisations
• Making trade-offs
• Modelling collaboration

• Setting direction
• Commanding authority
• Being accountable
• Championing an institution

Leadership of an institution
Source Achieving more together adding value
through partnership Hill, ASCL January 2008
23
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