Good morning everyone. What I’d like to do is give you Plymouth’s experience of developing a place based approach to whole system change. We’ve don’t that through our integration programme and I’ve got to say, just as a starting point, this has been the most exciting and challenging piece of work that I’ve ever been involved in. I’ve just found it so interesting. My responsibilities mean that for the Local Authority in Plymouth, I’m covering the whole of Children Services including education, all adult social care, our links to health as well as community safety housing and leisure. So as you can see it’s very wide. It’s enabled us to look at things in a very different way and to look at things in a whole system approach.
So, just a bit of context and setting the vision, we’ve had a really clear vision for Plymouth. We’re the fifteenth largest city in England. Population is around about 264,000 and we’ve set our stall out on one of growth, so we’ve been looking at how you bring more housing, more people, more jobs and more investment into the city, because we want to make it a place where people want to live, work and play and we’ve developed some sectors that we really want to expand and one of those is our health and care sector. So we’ve got a very large hospital in Plymouth, Plymouth Hospitals NHS Trust. We want to make sure that there were jobs in there that are the high end jobs, there’s research, as well as a lot of the normal sort of jobs you get in the hospital but at the same time, we’ve been trying to do a whole system approach, by developing in one of our secondary schools, a new studio school that is a health and care studio school and the Chief Operating Officer from the Trust is the chair of governors at the school, and the idea is to start to get young people interested in a career that is in health and care of the future.
So we’ve taken things very much as, let’s look at our whole system. What can we do at all different stages. And although we’ve got vision for the city, we’ve also got a number of really difficult local challenges, probably the same as many of the challenges you’ve got in your city. This is our bus stop of our life expectancy, developed by our director of public health, because we’ve got a of two halves. On the leafy suburb side of the city, the east, very nice places to live, life expectancy much higher than on the west of the city, which is very deprived, with high levels of domestic abuse, drugs, alcohol, mental health, issues that from my children’s services work, we’re constantly looking at how we can do things differently, lot of long term conditions amongst people living in those communities. So we use this bus route as the one to explain that. We’ve got about twelve years life expectancy difference across the city.
So what did we do? We decided first of all as part of the vision, that we would start with initially a Plymouth plan but you can see now it’s a joint local plan because it involves two of our neighbouring districts, and what we did there was we said we only want one plan, we don’t want any other plans in the city. So we got rid of them all, we had a bonfire of plans, and this was the single strategic plan for the city. Everything’s in there and you can see the themes cover health and care education and learning. We tried to do this in quite an innovative way. We had a conversation with our citizens about what mattered to them, around all of those things.
So some of the things that we did, we took a sofa on a tour of the city. It turned up in the hospital, in schools in the city centre, in our leisure centres. We had a conversation with the public around one of the themes and it was to say “what is it you want to see in the city, how do you want to see the city develop?” That plan now, not only contains the themes for the city but it covers all of our planning requirements, about how we will use land across our area and the two neighbouring councils.
The next thing we did was, you probably all know in your areas, you have to set up health and wellbeing boards. Well we decided that our health and wellbeing board was not going to be the traditional council committee. So we’ve only got three elective members on it. We’ve got all of our providers on there, we’ve got housing, police and crime commissioner, health watch, a whole range of voluntary and community sectors. We wanted it to be something different, and we spent the first year in development and we actually did systems leadership with our health and wellbeing board.
We actually did some stuff with The King’s Fund, and the leadership centre and we did a particular piece of work focusing on alcohol and the impact in the city. But what that enabled us to do was to think about how we were going to do things differently and we could continue our conversation with the public. You’ll see up there, the sofa engagement comes up again. So the whole of the health and wellbeing board went out with the sofa, in different places to talk about health and wellbeing. So there was a point where I was in one of the local neighbourhoods in the little shopping centre with one of our pharmacists, one of our GPs and myself, one of the local councillors and we just had a conversation with whoever was walking by, who wanted to sit on the sofa and have a conversation about what was going to matter about health and wellbeing. It just started a different engagement and set things in a different way.
We then used the health and wellbeing board to drive our health and wellbeing strategy, which you can see there is Thrive Plymouth. Thrive Plymouth is about the four lifestyle choices that pulls the four diseases in the city that create the 54% of deaths across the city. And what we did was, we then with a conversation again with the public, we’ve had a four year programme with the first year we worked with businesses, second year with schools, third year with communities and this year a focus on mental health. That’s led by our director of public health, but again whole system approach to it, and everything was about how do we change the culture? How do we do things in a collective way? So our health and wellbeing board, which is probably different to many other health and wellbeing boards, was actually really important in driving our change they still are, but I’ll explain in a minute, some of the things that we needed to do to move that on.
What the health and wellbeing board did for us, after they’d done the systems leadership was, they set the challenge around integration. They said they wanted to see integrated commissioning, integrated deliver and integrated health and wellbeing, and they gave us a challenge to do it by April 2016 and this was in 2014. We actually delivered it a year early in April 2015 and that was because they set such a good strategic ambition for us, and the whole of the health and wellbeing board got behind it, we were able to take all the different organisations in the system with us, we’re now beginning to see some of the benefit of it. That was April 2015, we would say two and a half years on, we’re still only just beginning to see some of the things that we wanted to see delivered coming to fruition.
One of the things that we did during that development was just prior to the setting up of the health and wellbeing board, I’d taken the adult social care department through a transformation and we had put personalisation and putting people first in the centre of the transformation programme. So some of the things we did at that point was we had acquisitive enquiry events with different groups of service users. So for example, we had a theatre group come in with a group of our learning disability clients, and we used that to develop what our personalisation approach would be. How would they want to use personal budgets? How would we change care across the city? And it was really helpful having those conversations before we went into the whole system change, because it meant we began to move the adult social care department before we went onto integration. We took some of the waste out the system, because we took out whole end to end review approach, where we looked at things in a very different way.
So what did we do when we actually set up the integration? You’ll see our logo there, one system, one budget, so we think our integrated commissioning has helped us drive all the changes that we have done. We put in place a single budget, and I’ll explain about that a bit more in a minute, but we also devised four commissioning strategies, and they were across the complete life cycle. So there’s one for wellbeing, one for children and young people, one for community and one for specialist and enhanced care, because we were saying everything was in and through those you’ll see things like mental health, running as a theme through them. They weren’t separate. Everything was about, what do you need in a system for whole person care?
The other thing that we set up with the system design groups you’ll see mentioned there, we used these to begin to look at how we would change the system. So I’ll give you two examples around those; one was around mean which is around making every adult matter. We brought together a group that were looking at homelessness, mental health, alcohol and drug abuse and we brought together the providers with service users. A lot of the providers were from the voluntary and community sector and the charitable sector and what we said to them was, here’s the budget we’re spending, how would you use that differently and how would you re-shape the system? And they helped us do it. It was co-produced and we developed a completely different system. We’re still on that journey, we haven’t completed it yet. We started that one first and two and a half years in we’ve still got more to do.
The one I’m probably the most proud of is the one we did with some children and young people. We used our young safe guarders to help us think about how would we put in a different system for emotional health and wellbeing of children in secondary schools. We co-produced it with our secondary schools and the secondary schools put money back into the system from dedicated school’s grant to enable us to employ more CAMHS workers, access to counselling for those young people in the secondary schools, and again we started to change the system. The young safe guarders, when we launched it, they were the ones out the front and they talked to a room that was bigger than this room, and explained what was important to them and what they wanted to see. So we put the voice of young people at the centre of everything we do.
The other things we concentrated on were things like governance and performance, because as you know, if you don’t do that, you’re never going to be able to demonstrate some of the changes that you put in place.
At the same time as we set up the integrated commissioning, on 1 April 2015, the city council transferred the whole of its adult social care department into a community end trust community called Livewell Southwest, to create the integrated community health and social care provider. Two and a half years on, we’ve got some success from that, we know we’ve got to go a lot further. It’s not yet delivered everything we wanted, but it has delivered more than we’d hoped for in some of the areas.
The budget, we believe helped us drive all of that. What you’ll see here is the mechanism that did it. We decided driven by the health and wellbeing board, that we wanted everything in one budget, cradle to grave, prevention to acute. So the whole of the city council budget that was my responsibility, and the public health budget, and the whole of the CCG budget for Plymouth, bearing in mind we’re in a CCG that is wider than Plymouth and involves Devon as well, and we created the net pool and align fund of £462 million. It’s just under £700 million gross and our accountants came up with some really clever ways of doing it because you can’t pool everything. Even under a Section 75, you can’t pool everything, but we got it all in. Everything’s in there and that’s created different conversations to enable us to change the culture about the way we do things.
So just some of the things I thought it would be useful in terms of the learning, one of the things we had to get was absolute political consensus because when you go to political local leaders and say to them, as a director, you recommend them putting all their money into a pool fund that the CCG are going to hold and you’re trooping 172 staff out, that’s not an easy conversation to have with local leaders. And we did that, in a council, where we switch virtually every three years. So our challenge was, how do we take the councillors with us? And you’ll see from there, we’ve gone through a number of changes, and we had to get a political consensus. That’s the two leaders of the council there, and I’ve probably worked for those now for the last fifteen years and I’ve worked for them virtually every three years of the switch and we had to take them on that journey.
That message about putting the city first and the citizens living in it, that became the mandate and they realised how important it was and we’ve got absolute cross-party support. It’s sometimes easier for local authorities to take their cabinet with them on those sorts of journeys, but we needed to make sure all the backbenchers came with us as well, so we used scrutiny to do that, and we helped the backbenchers who sit on our scrutiny panels on the journey.
Every time we went, the whole system went to those meeting so there would be the Chief Exec of Livewell Southwest, public health, myself and the CCG as well as other officers. We were trying to say, this is a whole system approach, do you want to do something different for your citizens?
When we got to the end of this, the scrutiny actually came with us to the cabinet and recommended to the cabinet that we should do what we were proposing, which meant that again, we had all the backbench support with us.
The other bit of work that we did, which we felt was really important, was we needed a conversation that was different between the GPs who were of course the clinical commissioning side, alongside the elective members. We did all of that in development sessions. We took them to that wonderful place that we’ve got there which was Lady Aster’s home and we had very informal discussions there, to create the trust that was needed for the GPs and the politicians to say this is right for our city. We’d also do things like we had a number of big events in the city, MTV crashes, national fireworks, we always invited our partners from health to those events, so that the dialogue was constantly about what do we do differently for the city. It was all about the importance of relationships. It’s the biggest thing we’ve learnt from our journey; get the relationships right, get the trust right.
We also said to our politicians, you need to understand what health does, so we took them on lots of visits. They went to our A&E department, I took one of the cabinet members into A&E with the Chief Operating Officer of the trust on a day when there were no beds in the majors, they were queued up. There was ambulances at the door, it was absolutely packed to the rafters and the cabinet member turned to me at the end of the visit and said, I know why we’re doing it now. Absolutely clear why we’re going on this journey. We’re doing it to make things better here. Exactly the same with the mental health acute. We managed to get a place of safety put in there by us all working together. The people it’s helped the most are police because the police have no longer got adults in the cells on Section 136’s. They think it’s the best thing that was ever achieved. We think it was the best thing for the people who were ending up in the place of safe. So it’s about again, seeing things through other people’s eyes all the time.
When we were trying to do things, we realised that when you were talking to the public, that what you needed to do were use different people at different points. So we never had a situation where it was just a politician or just a GP or just one of the managers talking. We did videos with everybody in. We’d always get a quote from the GPs alongside the politicians. Everything was done to show that it was joined together and the language was becoming the same. What’s really difficult on that, and our learning is, as you get changes, as you move along, you’ve got to keep going back around the loop again because of course people move on and if they’ve not been on that journey with you, you’ve got to go back around and explain why you’re doing things, take people on the next stage.
The CCG governing body, bearing in mind that was covering the whole of Devon and Plymouth, when we went to that to present the case, I took the politicians with me and they spoke to the governing body as to why they thought it was right to create the integrated fund, and the difference that made, you could feel afterwards the non-exec directors talking to the politicians. It just began a different conversation.
The other thing we did was, we moved all the commissioners in together. So, we have what we call Floor 2 in Windsor House and you wouldn’t know who was health and who was city council. We’ve got a director of integrated commissioning who’s got one foot in both camps. He’s probably got the hardest job out of everything that we’ve asked anybody to do, because he’s trying to understand the cultures in the CCG and the city council and manoeuvre his way through how you make those teams come together and act in a different way.
We had development sessions before we went into that and what we wanted that group to do was co-produce everything. So of course, we needed them to be able to work with health watch voluntary and community sector. They were going to be the people that went out and had the conversations with the public, service users and carers and they need to be able to do children’s commissioning, so they had to be able to talk to children and young people as well.
So, where we go next. We realise integration is such a journey. We’re so proud of where we’ve gone in two and a half years and then the STP came along and the STP for us covers Devon, Plymouth and Torbay and so of course, we’ve had to go right the way around the loop again because you’ve got three local authorities, two CCGs and we were just working on Plymouth which we thought was pretty important, but now we’re having to look at it in a very different way again. We don’t want to lose any of the gains that we’ve got from the work we’ve done and we want to help transfer that across the wider Devon, but inevitably you’ve got to go round the loop again because it’s different issues.
So some of the things we’re facing now, primary care fragility in the city, we now talk a lot about the A&E four hour wait, around RTT problems, around workforce, around delayed transfers of care and with everything we’ve done, we are still one of the ones that’s in the CQC targeted review because our delayed transfers of care and A&E four hour wait are really, really challenging. So next week CQC arrive in Plymouth to help us look at what we do next, even though we’ve done all the stuff that I’ve told you about, that we’re really proud of, it’s not enough.
We’re now looking at an accountable care system for wider Devon. We’re looking at local partnership delivery, which will be our bit across the Plymouth system and we’re looking at how we develop a fully integrated system now that will have acute community health and social care and primary care, all in one system. We need to go the stage further.
So where now? Going back around the loop again to take us on the next stage of the journey, and the thing that drives everything for us is putting the person at the centre of it, all we’re looking for are better outcomes for the people of Plymouth and if that means looking at it on a wider basis, that’s what we’ll do.
Thank you very much.