Home Again: Discharge and Recovery – the Integrated Way

2000 patients and 20000 bed days later… (or goodbye to delayed transfers of care aka DToC!)

My last WIHSC blog in October 2015 told of a new service in South Kent stopping delayed transfers of care (DToC) by giving all the support needed (assessment, drugs, transport, home care) through specially trained teams of nurse-supervised Personal Nursing Assistants who get people out of hospital as soon as they are declared fit for discharge. It was a very new service that has really taken off since then with 9 hospitals in Kent and Essex now taking part. The upshot is that 2000 patients have had between them 20,000 days supported at home who would otherwise have been languishing unnecessarily in hospital beds. The most important outcome is patient well-being and satisfaction, but I am sure you can do the sums in terms of savings in the cost of bed days to the NHS. This number of patients is of course way in excess of the total number of people experiencing delayed transfers of care in the whole of Wales…

Similar in style to the Buurtzog Home Nursing  service in Holland, the nurse-led partnership operating in Kent and Essex has gone into hospitals and brought out people experiencing DToCs who should be in their own home. Specially trained Personnal Nursing Assistants (PNAs), working with their ‘Guardian Nurse’, care for each patient in their own home for up to 5 days (or up to 6 weeks for non weight-bearing people). Real time information and communication is managed through the PNAs iPads and iPhones. 61% of patients don’t need any further health, or social care packages once they have had their 5 days support and continue with their own lives after the team have finished. Even those who go on to have a social care package really appreciate the home from hospital recovery service ( 99% positive Friends and Family score for all participants ). Some patients do go back into hospital; however, on average, there is a less than 5 % re-admission rate – which is quite a result.

What next?

Well, one of the Trusts is talking about Hospital At Home, with healthcare delivery at home under the clinical control of hospital consultants. Imagine not having to build more hospital beds yet being able to treat more elective patients, or people with specific conditions. Instead of a 4 day stay in hospital, one day for the operating procedure then 3 days recovery in a hospital bed, your recovery would happen at home with all the convenience of your home environment, but with constant nursing and Physio supervision by the Home Hospital team who would use remote telemonitoring, iPads and iPhones connecting the patient to the hospital 24×7. This could be the new way of caring for patients without the risk of hospital acquired infections, nutrition or hydration worries. What a revolution it could be?

Coming to a hospital near you , soon, I hope….

Written by Justin Jewitt, External Professor


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Walking Backwards for Christmas

Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

Glyn Griffiths is one of the noble band of WIHSC Associates on whom we rely for much of our work.  A pharmacist by training, and a highly experienced senior NHS executive by experience, Glyn takes a fresh look at the slow progress we have made in shifting care from hospital to community, and points out some home truths for the future.  By the way, if you find the title puzzling, you’ll have to read the blog…!

Walking Backwards for Christmas

I have recently been enjoying reading Anthony King and Ivor Crewe’s book “The Blunders of our Governments”. It is always perversely more entertaining somehow to read stories about how powerful people can get things badly wrong. It seems to make one feel a little more relaxed about the litany of screw-ups that decorate the career history of so many of us, and yet somehow many of us have survived to blunder another day.

The book covers a list of government initiatives over the decades which have patently and gloriously failed and it will not be hard for readers to recall many such initiatives. I will not steal the authors thunder by listing them all but it will not require a ‘spoiler alert’ to be aware that the Poll Tax, ID Cards and IT purchasing appear on the list.

Each blunder is analysed and I will leave individual readers to enjoy that analysis, and subsequent sections of the book describe some of the factors which fuelled, if not caused, the problem. It was here that I found myself recognising so many things I had come across in a lifetime in the NHS. Again I will not spoil a good read for you but I will take a look at one phenomenon which just spoke volumes to me – the section on ‘operational disconnect’.

So many of us believe that the right level to make a contribution, indeed the level to which we aspire, is variously described as developing strategy, crafting vision, or even shaping the debate. There are just so many phrases which allow us to feed our ego and believe that we are exerting the maximum influence on the future.

The chapter of this excellent book on operational disconnection immediately took my mind back to the days when commissioning first came onto the horizon in the NHS and our local commissioner took on that new role. At first it looked as if they were doing everything by the book. Time-outs abounded, senior figures cogitated and eventually their vision was made public. They would move as much healthcare as possible closer to the homes of the local population.

Indeed, to their credit, their work had gone further and they had developed both a strategy and a plan to deliver this lofty vision. The strategy was to strengthen primary and community care to cope with delivering the vision by moving money away from the secondary sector and reallocating it into primary and community care. The plan was to shift (let us say, to make the money sound vaguely real in today’s terms) £27m from secondary care over three years using the new ‘contracting’ process. Incidentally this sum was an entirely arbitrary figure arrived at because someone in a meeting said ‘it sounds about right’. How often, even today, has that phrase been heard in NHS meetings?

So what happened to the magnificent visionary plan? Well sadly I am ashamed to say that nothing changed at all, and I say that with a sense of shame because I was a part of the Trust’s contract team, who when it came to agreeing contracts created a picture of the devastating effects on secondary care waiting times and services that shifting money at that level would create. The poor souls who fronted up the commissioner team where at a complete loss and simply did not have the authority to agree what should be ‘reduced’ from the secondary care portfolio.

There was a gigantic operational disconnection at the level where change could really have happened. This example, whilst very old now, is not unique. King and Crewe cite a number of huge initiatives where policymakers are disconnected from delivery, and is peppered with quotes from civil servants like;

‘Ministers simply aren’t interested in operations.’

‘Always talk to the people who are going to have to implement a policy.’

So what could have saved us way back then? What did we not do? Luckily King and Crewe offer the answer in the form of a piece of military planning. It seems that military commanders when planning to move troops from point A to point Z routinely plan on the basis that they assume those troops have already arrived at point Z and consider what needs to have gone right – and what possibly might have gone wrong- in the course of the move from A to Z. In other words, they plan backwards from the desired end point. This really is not quite as bonkers as it initially sounds. For example, when the troops arrive at their destination will they be able to park their vehicles in a way that does not expose them to enemy aircraft? Who has the maps of the route and how can we get our hands on them? Who can tell us whether roads are passable in all weather conditions and who can tell us what the weather will be on the appropriate day?

Overlay on this the principle of Murphy’s Law: ‘If anything can go wrong, it will’; and you have on your hands a planning tool which can turn visions into realities.

Had we but imagined where we were going to deliver new community based services and who was going to use those services and crucially properly costed them then we may indeed have delivered more services closer to people’s homes. But we did nothing of the sort and so when contract negotiations took place all the secondary providers saw was a crude attempt to reduce their budgets.

Modern NHS planning is now based far more on good activity data and more transparent consequences but unless the journey as well as the destination is part of that planning then save your money and do not even buy a ticket for the trip!

Perhaps by now readers will have understood the rather strange title I chose for this offering. Choosing something so strange is based upon the editorial policy of the student newspaper I used to read back when dinosaurs roamed the earth and was an undergraduate. If the editor wanted to report on the elections for the Student Union Vice President in charge of Sandwiches then the article would be published under a headline like ‘Female Undergrad Molested by Hamster’. And yes we all read those articles and never found the hamster in question.

The title is that of a song written by Spike Milligan in 1956 and performed by the Goons. Yet another example of something that dates its author!

By Glyn Griffiths


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Not So Acute

Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

In this week’s blog, Professor David Hands explores the relationship between the language we use and the strategic tasks we face in healthcare.  He points out that the conflation of ‘acute’ with ‘hospital’ is fundamentally misleading, and distorts our thinking.  David is a Visiting Professor at WIHSC and has held a variety of chief executive roles in the NHS in England and Wales over many years.

Not So Acute

When the words and phrases we use to communicate ideas become obsolete, they must be abandoned. My favourite for retirement is ʻacute servicesʼ. We need more subtle and accurate concepts to guide NHS development.

The sloppy thinking encompassed by this phrase helps to perpetuate the myth that general hospitals are the only places where serious illness is managed and are therefore the most important component of the healthcare system. Other elements are diminished.

The description bears little relationship to any clinical assessment of the relative severity of illness. For example, a patient with a long-standing skin condition referred to a dermatologist is classified administratively as ʻacuteʼ whilst another, experiencing a severe psychotic episode, is not. Organisational descriptions should be more in tune with clinical reality and patient need.

The term is derived from the early hospital statistical returns when many patients, particularly the elderly, mentally ill, infectious and disabled, were warehoused in long-stay hospitals, classified as “non-acute”. The distinction is now as defunct as those hospitals.

Out-moded concepts impede multidisciplinary understanding of the organisational arrangements required to improve outcomes and cost-effectiveness. There are more useful models. For example, the WHO distinction between primary (or generalist) and specialist (secondary or tertiary) services is much more valuable.

According to the WHO definition, primary care includes both prevention of illness and the point of first contact with health services. Primary care is also critical to the holistic management of co-morbidity and chronic conditions and follow through from specialist treatment.

The relationship between primary care and specialist services is much more complex than the simple notion of “referral”. For example, specialist doctors became known as ʻconsultantsʼ because of their role in providing advice and support as well as accepting transfers of care.

The concept of primary care is also much wider than GPs. It includes a wide range of community-based professionals including pharmacists, dentists, optometrists, podiatrists, therapists, nurses and those in public health. Conceptually, as the point of first contact, it should also include paramedics and hospital-based accident and emergency services. The concept of primary care is understood in this broader way, the potential for strengthening its contribution and its relationship with specialist services becomes clearer.

Similarly, the concept of specialist services stretches well beyond the confines of institutions. Psychiatry, paediatrics and geriatric medicine are generally recognised as requiring a strong community base or orientation. Most medical (as opposed to surgical) specialties also have a significant preventative component. Surgical specialties require specialist facilities but, now that almost 70% of surgery is possible on a day-case basis, traditional hospital beds are not critical. When patients go home quicker, the contribution of GPs and community staff is.

The distinction between primary and secondary services is helpful but the boundary between them requires tailored refinement and re-definition. Changing patient needs and medical technology require the explicit development of a range of collaborative, vertically integrated, health systems to respond to different types and levels of need. The roles and responsibilities of every component of each system, in relation to the overall goal of improving both individual and community health, needs careful re-definition.

The focus needs to shift to the evidence-based ways in which each specialist service can be re-orientated to better support re-organised primary care, including changes in location where appropriate. Similarly, the responsibilities and organisation of primary care in relation to specialist services needs to be spelt out.

Much work has already been done to define protocols and pathways but these tend to be limited to prescriptive guidance on patient referrals and relatively linear treatment processes. A more fundamental multi-disciplinary renegotiation of roles, relationships and responsibilities, referenced to a hierarchy of health outcomes, is required. This requires significant effort and sustained development support.

The adoption of more relevant concepts can assist development of better structures, systems and processes. However, there are other obstacles and disincentives. The internal market promoted fragmentation and perverse incentives to increase inappropriate specialist referrals and hospital admissions. It must be abandoned. Similarly, payment systems which reward activity at the expense of quality and outcomes will need to be replaced by outcome-orientated performance management supported by programme budgets.

Having already ditched the market in favour of more appropriate population-based health authorities, Scotland and Wales are in an ideal position to move quickly towards integrated health networks. England has more (dis)organisational baggage but the recent advent of ʻvanguardsʼ and ʻnascent health systemsʼ offer the possibility of change. When there is a widespread consensus that an in-patient hospital admission indicates system failure, we will know we have achieved success.

By David Hands

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A personal reflection on the structural changes in health and social care in Wales

Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

This week’s blog is by another long-term friend of WIHSC, Tony Garthwaite, Senior Fellow at the Institute. Many readers will remember Tony as a leading figure in Wales’ Social Services, when he was Director of Social Services and a Corporate Director in Bridgend, and led a fundamental review of the future workforce needs of Social Services in Wales. This week he looks at what is needed to effect a similarly fundamental reconfiguration of health and social care here, and does not seek to avoid controversy. Tony will be speaking at WIHSC’s 20th anniversary debate in Cardiff City Hall on 26th November.

A personal reflection on the structural changes in health and social care in Wales

WIHSC’s 20th anniversary provides a timely opportunity to offer some personal reflection on the history and impact of structural changes in health and social care in Wales since 1995.

There seemed to have barely been time for the changes of the 1990 NHS and Community Care Act to have bedded in when in 1996 along came local government reorganisation and the creation of 5 strategic area health authorities. Health partners wondered how they would manage different relationships with multiple smaller authorities having previously enjoyed the relative convenience of co-terminosity on social services issues with the 8 Welsh counties. Social Services directors bemoaned the loss of scale in their strategic capacity brought about by the creation of 22 councils and wondered what risks the advent of relatively unproven unitary status would bring. The latter proved to be surprisingly beneficial in most cases as services like housing and environmental health were able to engage with social services under one organisational umbrella. The capacity issue, however, remained a problem as authorities competed for staff and lost much of their ability to appoint single specialist staff. Multi-tasking soon became the norm at the individual and organisational levels; not an entirely negative notion but dependent on logic prevailing over expediency when the combinations of functions were determined.

Along came devolution and co-terminosity returned to the central stage with the replacement of the health authorities by local health boards in 2001. Suddenly, far from being the problem, 22 was now the magic number. Trusts remained unaffected and new relationships had to be formed, accompanied by different platforms of power and influence. The commissioner/provider split was still there but in reality with very blurred edges. Derek Wanless’s reports helped galvanise thinking that prevention was better than cure as a strategic objective but the ramifications of any collective organisational change for health and social services were mostly treated with scepticism and fear.

Clear red water then flowed and the market split in health was subsequently abandoned in favour of the current 6 integrated health boards. Currently, a Local Government Bill opens the opportunity for mergers of local authorities while disagreements about the right number dominate the debate.

Through all of this change and uncertainty, health and social services leaders have been expected to navigate a path to ever greater integration. I’m not a fan of structural solutions to problems, and the research generally supports my position, but if we are to find a sensible way to achieve integration at scale and pace

maybe the time is right for health and local government to be organised on the basis that has some logic and rationale. The ingredients for this appear to be coterminosity and a scale which can provide a sustainable strategic response to the huge challenges ahead. This would suggest a reorganisation of local government on the NHS footprint – as controversial an idea as any other configuration but at least one that we can all understand.

By Tony Garthwaite, Senior Fellow, WIHSC


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Politics out of health – The impossible dream?

Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

Our series of ’20 blogs for 20 years’, marking the Institute’s 20th anniversary, concluded last week with Jeff Collins’ blog, ‘Words’. But the debate on health and social care policy is, of course, far from over… So, without a pause, we continue to publish blogs written by WIHSC’s friends and collaborators. This week, Mike Ponton, one of our Visiting Professors, goes back to a question raised by Jack Evershed in Blog 13 – is there a better, more timely way of making tricky decisions in healthcare than the current arrangements? Mike has worked in health policy all his working life, rising from basic administrative roles at the start of his career, to being a Chief Executive and senior civil servant, and currently Independent Member of Hywel Dda University Health Board.

Politics out of health – The impossible dream?

According to Dr Alan Rees, Vice President Royal College of Physicians for Wales, health policy will clearly play a central role in the campaigns of all political parties in the forthcoming National Assembly for Wales elections. He believes the debate should be depoliticised and asks all political parties to support the RCP’s Future Hospital model.[i]

Professor Frank Dunn, President of the Royal College of Physicians and Surgeons of Glasgow has also called for the removal of politics from NHS in Scotland and suggests running it by an executive body including members of different political parties.[ii] He believes there remains a substantial political dimension to the NHS and the resultant conflicting information undermines the confidence of the public, patients and staff in the NHS. He suggests that even when NHS Plans are well thought through and have professional support – they will be mothballed if there is any electoral risk.

But will it ever be possible to take politics out of health in Wales when many see such debate as an essential part of democracy? Bambra et al have pointed out in the past that health is political because power is exercised over it as part of a wider economic, social and political system. In their view, changing this system requires political awareness and political struggle[iii]. As a fundamental component in our modern complex society, unsurprisingly the NHS has become a major political and election issue.

Local Health Boards, which have regularly faced awkward and high profile political criticism or opposition to their plans, have been told to work closely and more effectively with politicians in order to win their support. That may be easier said than done, particularly in view of the generic fickleness of politics and the pendulum nature of political opinion.

Depoliticising health has become a fashionable theme. It is understandable that thoughts are turning to ways of curing the blight of the apparent aversion of politicians to making courageous, difficult, yet necessary decisions on health futures. The Welsh Government’s recent Green Paper[iv] seeks to provoke a discussion on taking the heat out of difficult decisions.

The NHS is in deep trouble. Whatever approach we adopt, if we are to avoid its continuing decline we need to find more effective and pragmatic ways of speeding up the decision making process.

 By Mike Ponton, Visiting Professor

[i] Focus on the Future – Our action plan for the next Welsh Government, Royal College of Physicians, 2015

[ii] Agenda: Time to take the politics out of healthcare, Professor Frank Dunn CBE is President of the Royal College of Physicians and Surgeons of Glasgow, 2015

[iii] Towards a politics of health, Bambra et al, Health Promotion International, Vol. 20 No. 2, 2005

[iv] Welsh Government Green Paper – Our Health, Our Health Service, 2015

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Words by Jeff Collins

Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

We end our ‘20 blogs for 20 years series’, to mark the Institute’s 20th anniversary, with a suitably iconoclastic side swipe at what may be thought to be the essence of academia – Words. Jeff Collins provocatively argues that, quite often, we need fewer of them. If we are really serious about co-production, Prudent Healthcare, and all the other topics which these blogs have illuminated, then Jeff’s refreshing honesty may be a good, practical place to start. As head of the Red Cross in Wales, and as a former head of the Probation Service here, and a former submarine commander, he knows a thing or two about bureaucratic obfuscation.. and unnecessarily long words! 

Although this marks the end of the ’20:20’ blog series, it’s not our last blog. Tune in next week for another thought-provoking snippet…


Why so many words? Think about it! You have produced a four page document and you then spend another hour reducing it to two pages only. For the purposes of this exercise everyone earns £25k [£15 per hour and 25p per minute]. So that extra hour has cost your organisation £15.

It is generally accepted that most people will take four minutes to read a full page of A4, at a cost of £1. Hence if your document is going to be read by 200 people then your extra hour has saved the organisation in terms of staff time [200 x £1 x 2pages] £400! That’s a pretty good return on £15. But, and probably more importantly, in that hour you will have refined the language, cut out the jargon, and reverted to “plain English”. The result may just be that 200 people really do read it, and maybe even understand it. Come on be honest when was the last time you attended a meeting having read and understood all the papers, and how many emails do you really read and digest. The bad news is that if this needless and convoluted use of words is prevalent at a management level then what’s the score with those who work for you?

There are no prizes for the volume of your document, so the next time you write that report take the ‘lean’ approach and reduce the word count. You never know, people may actually even read it!

By Jeff Collins 


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Home Again: Discharge and Recovery – the integrated way by Justin Jewitt

Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

In this week’s blog in our ‘20 blogs for 20 years series’, to mark the Institute’s 20th anniversary, Justin poses a suitably provocative challenge: getting people discharged from hospital is actually quite simple, if we are prepared to think differently about how it’s done. If some health and social care communities can do it, why can’t we all? Justin is a Visiting Professor at WIHSC, and his experience is in the private sector provision of services around health and social care.

Home Again: Discharge and Recovery – the integrated way

Ever wondered why a patient remains in hospital after the consultant has confirmed that they are clinically ok to go home? If you haven’t then don’t read on, it won’t matter to you.

If you are still reading (which I hope everyone is) it’s because of us, people, the system, everyone wanting to do the right thing (except making sure that the discharge will immediately happen).

Discharge teams don’t have enough assessors to get an assessment done for every patient when they need it (holidays, training, sickness, meetings etc) and occupational therapists have the same time challenges. The hospital transport system doesn’t do individual runs to suit the patient whilst the hospital pharmacy doesn’t open to suit every patient. By the time the whole system is in alignment ….it can be several days or even weeks. And then are the family members or responsible carer willing to receive their loved one home?

All we need to get an immediate discharge done, to suit the patient, is a small team of trained Healthcare Nursing Assistants, led by a nurse, who handle everything for the patients, assessment, pharmacy pick-up, home transport and looking after the patient for up to a week afterwards.

Impossible, it can’t be that easy, can it? Yes it can, and it is safer and cheaper than keeping the patient in hospital.

This service is being used in a hospital in South Kent; it works, patients love it, clinicians love it, social services love it.

Perhaps it will come to a hospital near you sometime soon…..

By Justin Jewitt








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A good death?

Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

In this week’s blog in our ‘20 blogs for 20 years series’, to mark the Institute’s 20th anniversary, Professor Siobhan McClelland reflects on an intensely personal experience to ask whether the NHS has yet got the end of life right for everyone.  Siobhan is an External Professor at the Institute and is Vice Chair of Aneurin Bevan University Health Board, and has experience and insight across an exceptionally wide range of health policy areas.  End-of-life care remains one of the most problematic areas for the NHS and social care, and has added relevance in an era of Prudent care.

A good death?

For most of her life my grandmother rarely troubled the NHS. From a sheep farming family in the Rhymney Valley she remembered life before the NHS. She wasn’t a big supporter of Nye Bevan “I always vote Liberal” but she valued his creation although she was fortunate to not need to use it much.

Until the last two years of her life … over one hot summer she developed a UTI and was admitted to hospital. Whilst the hospital was committed to treating her and getting her home as quickly as possible this began a rotating door of hospital admissions, GP visits and increasingly complex medication. She lived independently in sheltered housing but became increasingly more dependent on my mother for day to day care and support. She often fell and started to feel scared in her own home but determined not to leave it.

Following a fall during the Christmas period the paramedics took her yet again to the hospital. Before New Year in the early hours of the morning my mother received ‘the call’ to come to the hospital. She wandered the deserted site in her distress trying to find an open door. When she got to the ward she found my grandmother had died before she could get there to say goodbye.

My grandmother was 95. She had a good innings to use that rather unhelpful cricket analogy. There are lots of points to make about polypharmacy, integrated care and prudent healthcare and of course about our quality of life particularly in our later years. This didn’t happen in Wales but it could have and I know that many other people have similar stories to tell.

What remains with me though is that my nana died in a hospital quite possibly alone and certainly without her family around her. So while on this twenty year anniversary of WIHSC where we talk much of how we want to live we also need to talk about how we want to die.

Siobhan McClelland, External Professor USW and  Vice Chair of Aneurin Bevan University Health Board

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Is Prudence here to stay?

Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

In this week’s blog, Alan Willson calls Prudent Healthcare ‘the new show in town’ – the latest in a long line of policy initiatives designed to effect a step change in the way services work – and asks whether it will survive? This is the latest in our ‘20 blogs for 20 years series’, to mark the Institute’s 20th anniversary. Alan was until recently the pioneering inspiration behind much of the huge effort to improve healthcare systematically in Wales, and with Jonathan Grey has clearly made change happen in this vital area.

Is Prudence here to stay?

Happy 20th birthday to everyone at WIHSC. Congratulations on surviving and thriving. You seem to have learned the secret of longevity. Thank you for your excellent work and especially thanks to Marcus for your values AND scholarship – you personify your work.

And happy 20th-ish birthday to the Welsh me. I arrived in 1992 from the London NHS so we have had a similar upbringing in Welsh healthcare.

What have we learnt? Back then, we had too much demand for not enough money and we thought the answer lay in more primary care and better disease avoidance. The familiar ring of the problem and the solution means we could have done better. We can’t be criticised for being short of ideas but our failures have been in failing to understand how change happens. There have been recurring themes of simplistic, top-down solutions and flipping between opposing ideas. We do not learn, we give up.

Back in 1992, I must admit I was attracted by the idea of the Welsh Health Planning Forum. On reflection, it may have been the gravitational pull of all that paper. Its demise 20 years ago mimics that of Ozymandias although he is at least findable on Google. Since then we have been through commissioning, fundholding, innovation, locality-ism, programme management, deliverology and integration (horizontal and vertical) (no – me neither). And those are things we intended to do. In between, there were a lot of crises to contend with.

Prudent healthcare is the new show in town and the question is, is it different? Will it be more successful than what has gone before? Importantly, it is driven by what happens when people meet with carers and it is based on real need and value. It is also helped by an international movement with similar intentions. But it will need time and consistency if it is going to work and good luck if it is to stay away from crises. It will be a struggle and there will be failures as well as successes: that is what happens with learning.

The NHS needs its academic partners to support this learning. Prudence is a very worthwhile goal. It needs to survive 20 years and WIHSC can play a vital role in ensuring its longevity.

 By Alan Wilson



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To integrate, or not to integrate…? by Viv Sugar

Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy

It’s discussed endlessly, but we seem no nearer a consensus: should health and social care be formally integrated? This is the subject of Viv Sugar’s blog this week in our ‘20 blogs for 20 years series’, to mark the Institute’s 20th anniversary. Viv has a wealth of experience at the most senior levels in local government and across the public sector more generally, in Wales and throughout the UK. Different approaches to integration proliferate, and there’s much to learn from them all… but which is best?

To integrate, or not to integrate…?

In 1974 I was working in Teesside County Borough Council’s Health Department when our service was transferred into the NHS. With a highly regarded, innovative and creative service pioneered by the Medical officer of Health, Dr Paddy Donaldson and a progressive Minister of Health in Barbara Castle, I was optimistic about the future. But 6 months in, I had no definitive budget to work to, orders of sterile supplies were not arriving in time for our clinics and with complaints falling on deaf ears, I realized that the total focus of the new Senior Management was on the hospitals and not the community.

Why am I remembering that now? Because two recent experiences have shown me that forty years on, acute, community and social care services are still not as seamless as they need to be to ensure the best outcomes for patients and carers. Of course individual personal experience does not necessarily make a solid foundation for the development of public policy but recent experience of frail elderly relatives who live alone and a visit to Scotland have made me realize how much more we need to do. Liaison between hospital, GP, District Nurses and Social Services required some family intervention to make it work. Individually most of the staff, the doctors, nurses and carers were professional, compassionate and trying to do their best under great pressure and with limited resources. But there was a lack of clarity about who was “championing” the patient and finding a path through the maze of agencies, voluntary bodies and the complexity of the DWP and Council forms that had to be completed. At the most basic level who could be found to boil an egg when appetite was not up to coping with a Meal at Home offering?

A few weeks ago I visited one of the Scottish Councils who have formed a Health and Social Care Partnership with their local NHS Region. The Partnership Director reports to both the Council and the NHS Chief Executives and sits on their Management teams. In that area, clinical health professionals, social work services, housing services, care home and home care providers, voluntary and community services and representatives of people who use health and social care services are all working together as partners for change. The Partnership brings together local government services for children, families, adults and older people with Community Hospitals, District Nursing, Community Mental health services, Learning Disability services, allied health professionals etc. Their vision is of enabling everyone to live longer, healthier lives at home or in a homely setting. The focus is on prevention, anticipation and supported self- management. For older people they aim to deliver more care at home by increasing the number of integrated community teams in local communities around G.P. practices. Sharing information and increasing access through a single point of contact and sustaining independent living.

I was impressed but they stressed that they are only 6months in. And then they asked me what they could learn from Wales…..

Viv Sugar


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