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Bottom up, top down, middle out: transforming health and care in Greater Manchester


In April 2016, control of Greater Manchester’s £6 billion combined health and social care budget was handed over to local leaders as part of the first devolution deal of its kind. Since then, local NHS and local government leaders, clinicians and wider partners have been working together to develop services suited to the needs of the 2.8 million people who live in Greater Manchester.

There is a great deal of work going on at the Greater Manchester level, led by The Greater Manchester Health and Social Care Partnership – a body made up of the 37 NHS organisations and councils in the region. But not everything is being done at this level. Ten ‘local care organisations’ (LCOs) have been created, bringing together organisations from each of the 10 boroughs to design and implement local service transformation. All are working to integrate care and improve population health. The LCOs have received investment from the Greater Manchester transformation fund and have developed and agreed local transformation plans. The focus now is on putting plans into action.

Chris Ham and I recently attended a meeting of the LCO network, which brings leaders from the 10 localities together to share progress and learning, identify issues and interdependencies at a Greater Manchester level, and support each other through the process of change. We came away both impressed by progress being made and energised by the enthusiasm shown.

Reflecting on the day we were struck by both diversity and unity. Each LCO is developing an approach to suit its ‘place’, built around the needs and strengths of the local population and the assets from within the health system and beyond. Progress is varied, and some LCOs are further ahead than others. This is to be expected given the different starting points and priorities in different areas. For example, in Salford there have been pooled health and social care budgets since 2014, and health and social care services are closely aligned through the integrated care organisation.

There were also many similarities, and a unity and clarity of vision reflecting the overarching Greater Manchester strategy. Core elements include:

  • multidisciplinary neighbourhood teams – in Wigan, more than 500 staff from adult social care and community nursing teams have come together into integrated teams

  • population health management through segmentation and targeted interventions – Manchester LCO has introduced a ‘high-impact primary care’ model offering intensive support to people with the highest levels of need

  • community-focused models that centre on community and primary care services and minimise hospital use – in Tameside and Glossop, a nurse-led telemedicine service providing specialist advice to care homes is starting to impact on the use of other services.

A further common thread was the prominent role of local authorities and, in many cases, the voluntary sector – for example in Wigan, where there is a well-established focus on asset-based community development.

Different routes are being taken to achieve these changes. Some LCOs have focused on aligning structures and leadership – there are new contracting arrangements, governance structures and alliances forming in some localities. For example, both the Stockport and Manchester LCOs have begun procurement processes for large multispecialty community provider or accountable care organisation contracts. Others have started by developing new delivery models, with plans for structural and governance arrangements to follow. Many are doing both.

There was a strong recognition that the relational and behavioural aspects of transformation deserve as much, if not more, attention than technical and structural aspects. Pursuing change by taking a structural route can seem relatively straightforward compared to the complex and often messy route to forming new relationships. But effective relationships between partners in a local system are essential to enable new ways of more integrated working to be implemented and sustained. Paying attention to the factors necessary for collaborative leadership – including the development of a shared vision, having frequent personal contact, and surfacing and resolving conflict – is a critical piece of the puzzle. Representatives from the Tameside and Glossop LCO attributed much of their progress to the development of an aligned vision between the local clinical, managerial and political leadership, and regular face-to-face contact between them.

Much of the strength of the Greater Manchester model lies in its recognition that different changes require action at different levels. There is a focus on what should be done ‘bottom up’ from within each locality, and what elements would benefit from a more ‘top-down’ approach. The ‘top’ in this case is the Greater Manchester footprint, where the direction is collectively agreed and some elements can be standardised to ensure consistency and allow economies of scale.

And the LCOs are also using a third approach – middle out. Leaders from the LCOs can work together to learn from their peers, adopt and adapt each other’s models and take collective action when this is the best route forward. The LCO network, and similar networks elsewhere, offer a vehicle for building from the middle out, sharing and spreading learning from those developing models of care across the country.