CAN’s response to “Engagement Document: How we work together at a more local level in our Integrated Care System (May 2021)” by Norfolk and Waveney Health and Care Partnership.

CAN has been gathering the views of other Norfolk VCSEs on the Integrated Care System (ICS)’s vision of place-based working, to inform its response to the engagement document “How we work together at a more local level in our Integrated Care System (May 2021)”. Given the potential impacts future changes may have on residents and stakeholders, it is important to get this right and build a good foundation for the ICS system based on the whole system’s needs.   

CAN’s Response 

It is important to recognise that there were no VCSE or residents representatives included as part of the steering group developing the Norfolk and Waveney vision for place. This represents a fundamental failure in process. The VCSE sector has long called for the inclusion of all key system partners in early development work and that models should be built with residents at the centre from the start. 

The consultation is limited to identified stakeholders. Whilst this is progress from previous iterations of structural changes where there was no engagement, it still represents a deficit on what we would regard as appropriate engagement.  

We agree with statements that have been made that few residents or organisations have a direct interest in how things are structured, what is often referred to as ‘the wiring’. They do, however, care deeply when such structures result in care being delivered in a different area or in a different way. Whilst these subsequent service changes may be consulted on, often in our experience the outcomes of these consultations are pre-determined by the already agreed structures. Putting users at the centre of our services means designing structures by framing the process through engagement and questions that are important to them. 

Noting the limitations of the engagement process, and based on the conversations we have had, there seem to be two tracks of thinking in terms of place-based models going forward. 

• Adjust as little as possible. People have just about got used to our existing boundaries and begun developing the relationships necessary to deliver our ICS ambitions. This would suggest keeping to the previous CCG boundaries. 
• Minimise the number of different boundaries that exist. This would suggest moving to make different boundaries coterminous (both NHS but also Social Care operational areas).  This would suggest a model built around the district boundaries. Although with local government reorganisation on the horizon the suggestion would be to hold off implementing any changes until the outcome is known (working with the status quo until then). A district option also helps send a strong signal that the ICS is not simply another NHS driven and dominated restructure.   

General Points 

• We fully acknowledge that wherever boundaries are placed, issues of borders and overlap are inevitable. It is therefore important to invest in the capabilities to work across boundaries effectively. 
• Where organisations operate across multiple areas as a result of system decisions, consideration needs to be given to additional resourcing to ensure they can invest effectively in the relationships across all those areas equitably. 
• Many organisations already operate across multiple areas, this does generally add complexity. It is important to base decisions on the level of complexity across the system as a whole not on the complexity for individual providers. 
• How boundaries are set gives a strong cultural signal as to the priority and relative importance of different elements and organisations. If, as in one of the proposals, the boundaries are set based on the acute footprints the message sent will be the system is being built around acute care. This is the antithesis of the stated strategic goals around prevention and greater community-based care. This message will create a credibility concern in the ICS’s commitment to these goals. 
• We note the importance placed on the wider determinants of health within the locality documentation. The literature highlights that health care providers are a minority component in determining health outcomes. This suggests a structure built to support the health of our population should not be built around health care providers. 
• Our experience, as well as a lot of research, identifies that when it comes to place-based/community models, what is important is that they are identified and resonate with residents. At a place level, this would tend to support more established recognised boundaries such as districts. At a neighbourhood level this will most often be parish/village/town/ward. This highlights the fundamental issue that is the structure of the PCN’s as the ‘neighbourhood’ building block. There was no wider engagement on the PCN models. They were built around private sector primary care practices. In a number of cases their size and shape create considerable accessibility issues (Swaffham and Downham) as well as overlapping geographies and demographics that are not coherent in terms of a place-based approach  (Great Yarmouth and Northern Villages). Whilst there are economies of scale that mean a true community-level approach to ‘neighbourhood’ is unlikely to be feasible, not having a community/resident centric model to this base building block is an insecure foundation on which to base the ICS.  
• Accountability is a critical issue. There needs to be greater clarity on how structures will be accountable to residents and wider system partners. There should be clear, effectively communicated mechanisms in place to influence decisions and raise concerns. Whilst this includes formal consultation and complaints processes, an accompanying more informal on-going relationship-based approach will result in better system outcomes. These structures also need to have meaningful independence, feedback from service users particularly around primary care raises a problem in that any issues raised will be reviewed by those concerned.  This could create a perception that they will not be meaningfully addressed and that raising concerns may result in more negative service experience going forward. It should also be underlined that good feedback and response mechanisms are a critical part of continuous service improvement.  
• We note the suggested use of the maturity matrix to determine delegated power. Our experience of these being based on self-assessment is they often significantly overestimate capacity, especially if there is an incentive to do so, and particularly in terms of the effectiveness of partnership and engagement work. This approach therefore should include validation by resident and VCSE partners.   
• We support the concepts that form should follow function and subsidiarity as enabling better care closer to home - again the lens for this analysis must be resident experience and outcomes. This should be formally enshrined within any decision matrix.   
• Further thought needs to be given in terms of how to structure parallel activity with non-place based communities or non-contiguous areas of common/similar need. For example, how might a focus on the health for different ethnic groups or on areas of highest deprivation be structured across the system.