Committee evidence: primary and community care (House of Lords)

Good afternoon, everybody. It is a great opportunity for me and Mark to be able to update the committee on where we are. As you say, we have been on a path towards ever greater integration for some time. The answer to your question is yes, and it is getting closer all the time. It is an evolutionary process, possibly, rather than a dramatic event, but in the six years that I have been mayor I have seen in Greater Manchester the increasing sense of one public service, of people working as one team around individuals, families and communities in places. That has been the direction of travel for a long time.

The integrated care system reform codified how we had been working for a long time. I see signs of it going even deeper. Mark will probably talk more about the five-year plan that was signed off by our integrated care partnership on Friday. It is very much a health in all policies vision. At the very basic level, when we are thinking about supporting people, it is looking at health in every possible way from the early years right up to active ageing.

So the answer is yes, and it is not just at the Greater Manchester level. We have developed a locality model, a place-based model, where you take, say, a population of 30,000 to 50,000. We have worked up from those building blocks, so the integration happens at that locality level as well as at the Greater Manchester level higher up. We are becoming closer all the time.

I can see a day when the organisational boundaries will simply not exist in the way they do at the moment. We are not there yet. We are walking rather than running. We have to move at a pace that is right for everybody, but the path that we are on is ever greater and closer integration. We could talk to you this afternoon about things we have already done in the last few years that are different, for instance the health-based approach we have taken to homelessness, or the way we have sought to redesign our support in the early years. On every level, we are taking a highly integrated approach.

When I spoke to the Public Services Committee, I was describing what we had done on school readiness, which had been a very big focus for us pre pandemic. In particular, we fostered integration, which is the subject of this inquiry. We believed very strongly, and still do, that all professionals have to have visibility of important data. In the context of early years, it was the Ages and Stages Questionnaire that is carried out by health visitors. At the time that we were looking at it, in 2018, it was a paper-based system, so only the health visitor could see, at age two, for instance, the names of kids who were unlikely to be school ready if everything stayed as it was. We have done a very specific piece of work here to digitise the Ages and Stages Questionnaire. I think—Mark may correct me if I have got this wrong—that it has been implemented in about four of our boroughs so far, but certainly the intention is to roll it out more widely.

I would stress to the committee how important this is. Based on the data we have from the reception class of 2022, levels of development have gone quite seriously backwards during the pandemic years. Those kids were two during the first lockdown. If you think about it, as we go into reception year 2023, those kids would have been one, and then, into 2024, those were the kids who would have been born in lockdown.

How we now see what the needs of those children are, and how we now start putting extra support in place so that they are school ready or certainly have a better level of development when they arrive at primary school, is a really serious issue for the country. That is a tool that we have developed, which is probably going to come into its own for us now because we really need to think differently about how we support those young children.

More broadly, I refer the committee to the Greater Manchester care record. In the pandemic, we introduced an integrated care record for our residents. This is a health and care integration, so that you can see all the interactions that health and social care are having with a resident. I have a testimony from a GP who says that it is improving the quality of care when a GP can see all the different interactions that a patient has had with the system, giving them a more rounded picture perhaps than they have had before.

These systems remain very important to us. It is not so much the tech that we need to get excited about, but more the concept of a health professional at any level of the system being able to have visibility of the important data on a particular child or resident. It is work in progress, but there are some really good things there to inform the committee.

It is good to see you, Hilary. I do not think that I have ever found any barriers here, in that there has been no resistance beyond, say, pockets of people who do not want to work in a more integrated way. The vast majority of people in our system support the direction we are going in, so there are certainly no local barriers to what we are trying to do.

The barriers, as I have experienced them, tend to be in IT systems, but, more than that, data and data sharing. The control of data remains a really frustrating issue. There is often a cautiousness in people’s minds, which I understand, but there is always a much greater benefit to be had from the sharing of data. I gave the example of those kids. It is clearly in everyone’s interests for people to see the kids who need support at age two, rather than for that data to be held back. Those data and data sharing issues remain challenging.

Estate is an issue. I am proud—as I am sure you are, Hilary—of the LIFT infrastructure that went in during our period in government, with modern health facilities in communities. There has been an underutilisation of those facilities, and sweeping away the restrictions in the way they are financed would allow much more integration where there are not the estate challenges that we have. Those are barriers that I would flag up.

That is a good question. The answer that falls straight off the tip of my tongue would be not to dip your toe. Do not talk the talk of integration and then hold back. If you are going to do it, do it properly, because the more you do it and the more deeply you dive in, the greater the returns.

Mark referenced the Lancet, and I appreciate Baroness Wyld’s point that others might see it differently. It is clear to me that we were making rapid progress on school readiness pre pandemic and going more quickly than England on that issue. We were going more quickly on levels of physical activity, which was linked to the way we were working with our leisure services and thinking about health and leisure together.

One of the big reasons why we achieved that change was linked not necessarily to older people living longer but to the work we did on homelessness, where we reduced deaths of people in their 30s and 40s on the street because of some work we did there that was health service-funded. I remember very vividly, in the early days, being in the office where I am talking to you from now and asking the health service in Greater Manchester to help me with a scheme called A Bed Every Night, where we wanted to provide somewhere for everybody to go every night. The initial reaction from the health service was, “Well, no, we don’t fund hostels or places in accommodation”. I said, “But you’re going to leave my office and walk past people whose health is being catastrophically damaged by sleeping rough, so surely it is a health issue. It can’t just be that smoking and obesity are health issues and rough sleeping isn’t”. To be fair, Mark’s predecessor thought about it, came back and said, “You’re right about that”. Since then, the health service in Greater Manchester has funded A Bed Every Night.

I mention that, because it is an example of the health service diving with us into a difficult issue and being a real partner, as we have now started to unpack the mental health and addiction issues of homelessness.

My message to other people around the country would be not only to talk the talk but to walk the walk and dive in properly. Take the lanyards off, as Mark said. Consider yourself one team and your loyalty to be to the residents of your locality or of Greater Manchester, not the organisation you work for or the professional discipline you have.

As I look around our primary care networks, there are some examples now of that mentality beginning to flourish. It cannot be done overnight, but, in parts of our system at its best, you are seeing a place-based approach that is becoming more and more organisation or professional discipline blind, which is where we want to get to.

Q69 Lord Watts: Good afternoon, Andy and Mark. Can you touch on the investment side? You touched on it in terms of the estate. Do you have control of the way in which the estate is funded? Do you have a plan for identifying the blockages? Do you have the ability to build and change things in a structural sense? You have talked about some of the service levels, but what about the estate itself? Do you have a plan? Do you have the resources? Is that limiting what can be done in Manchester?

Baroness Redfern: I have a subsequent question for Mark regarding data sharing. It might put you on the spot, Mark, but who do you think is holding it up, so that we can get better data sharing?

It is a good question. I can see Mark wanting to come in, so I will not hold the floor for too long in answer. It is not that people are completely abandoning their institutional responsibilities. When Greater Manchester was developing this way of working, there was a BBC news report that showed people taking their lanyards off. It was symbolic more than requiring people to walk around without a lanyard. It was an attempt to say, “Look, your loyalty is to the public, not to an organisation”, and I do think that is an important ethos to build into integration. “Why are you integrating?” That is the question. “What is the purpose of integration?” It is to better serve the public. It is recognising that the silos created by Whitehall departments often get in the way of serving the public or create conflicting pressures or tensions that are unhelpful.

At the Greater Manchester level, we have tried to create a space at the locality where people can genuinely act with a little more freedom, work together as a team, and be a little more entrepreneurial in getting to the root cause of an issue that is holding a particular person or family back. We are trying to give a bit of permission to work outside the tramlines that are often laid down by organisations or departments.

I hope we have not given a misleading impression of it to the committee. People still have accountability for their roles, but we are asking people to work and think a little differently at the local level.

Mark, I can see you came off mute before. It sounded like you had a very important thought.

I think I am correct in saying that we have 65 primary care networks in Greater Manchester, and we are beginning to see some truly innovative practice in those PCNs. One that I visited, which the committee should take a look at, is Healthy Hyde. This is a primary care network that has quite seriously embraced work on health inequalities. To answer your question, it is inspired GP leadership that is driving forward the Healthy Hyde project.

What you then get is a networking of organisations and individuals around that leadership. It is not so much a management structure but a request for a certain way of working, where people start to pull in the same direction. It is often very strong GP leadership at that locality level that then builds that sense of team and gets all organisations and people pulling in the same direction.

I would not want to overcomplicate some of this stuff. Going back to the question about whether Greater Manchester has really made a difference to life expectancy, it is not surprising that you might make more of an impact in supporting people if all public services and professionals face in the same direction and start pulling in the same direction. That, in its simplest expression, is what is happening. It is happening most in localities where, rather than an appointed leader, there is inspired leadership, often from a GP or sometimes from a local authority employee.

It is connected. I will elaborate on why, and go back to my time in the Department of Health. I mentioned to Baroness Armstrong the investment in primary care. Tameside had significant investment in its primary care estate in the period post Shipman. It was one of the parts of the country with a high number of single-handed GPs operating out of terraced properties, and a very deliberate decision was taken to invest in the primary care estate. Healthy Hyde operates out of one of those buildings. It opened about 15 or so years ago, or maybe a little more.

It is also linked to the challenges that Tameside general hospital had. If you recall, it was a very challenged trust at times, going back 10 or more years. For all those reasons taken together, linked to inspired local leadership, particularly by the local authority chief executive, Steven Pleasant, and Karen James, the chief executive of the trust—Mark, you might want to pick this theme up—Tameside stands out in the Greater Manchester context for really having embraced integration in a more fundamental way, as I was describing to Baroness Armstrong, by diving in rather than dipping a toe. Tameside did that, possibly because of the challenges that it had been through with primary care and with secondary care in the preceding years. We would point to it as a model of good practice. Mark, is that a fair assessment?

We mentioned the acute system. There has been some scepticism, if I am being honest, in parts of the acute system about integration and whether it can make any difference to what comes through the front door of A&E or what ends up as pressure on hospital beds. When we talk about Greater Manchester, it sometimes sounds as though we are saying that it is identical everywhere; it is not. Some places are more advanced than others. Tameside stands out because the hospital, as part of its recovery strategy, embraced integration as a way of improving itself, and that makes it quite interesting.

Baroness Barker, as you correctly anticipated, the two boroughs that did not show the same improvement were Rochdale and Oldham. Those would be the places where our health challenges are greatest.

I come back to the central point that, if you create a sense of people pulling in the same direction, it is unsurprising that health should improve. In many ways, health is not created in the health service. It is created in homes, workplaces and communities, or it is not; it is damaged in those places.

We had the tragic case of Awaab Ishak last year, a two-year-old boy who, as you will have seen in the news, was killed by the damp in his home in Rochdale. This is where this journey goes next to become much more engaged at that level in understanding health, and how and where health is created. If you want to move the dial in Rochdale and Oldham, you have to get much more serious about housing standards. You have to start dealing with insecure employment and all the damage that does to mental health. That is where the journey goes next.

You can integrate services, and that can take you so far in providing a more seamless and joined-up experience to the public, which is good and absolutely what should be done, but if you want to improve health in the most deprived places you have to fundamentally get to grips with things that are making the job of the health service harder, which is employment, housing and all the issues associated with that.

There are two issues that fall out of your question, Baroness Barker, which I would like to unwrap. First, as I mentioned to Baroness Wyld, there is existing data that needs to be given greater visibility. The Greater Manchester system is doing that effectively through the work on early years that I talked about, by digitising the health visitor’s record, and through the integrated health and care record for all residents.

All integrated care systems across England should think about how you give the greatest level of visibility to all professionals working in the system, so that the data we already have is used better than it currently is and is not kept in a particular silo. That is one thing, and we are doing some of that.

There is also data that needs to be collected but is not picked up by national collection. Greater Manchester has worked to fill in some of those gaps. Let me give you two examples. First, on our teenagers, we began a survey, originally called life readiness, of year 10s and their thoughts, feelings and level of hope. One thing we asked them was, “Do you have hope for your future?” It was quite a powerful question to ask a 15 year-old. That produced data at a very local level, which told you something quite significant about different localities in Greater Manchester and what needed to be done to raise aspiration.

That has since evolved into something called BeeWell, which we are doing in partnership with the University of Manchester. This is a very sophisticated survey of our teenagers and particularly their mental health. It is a level of data that I do not believe exists anywhere else in the system. We decided that it was critical, if we are going to improve the health of the overall population, to understand how teenagers are thinking and feeling, and to act to support them.

A second example is our Big Disability Survey. During the pandemic, our disabled people’s panel conducted a survey, because it was clear to us that some of the issues that disabled people were experiencing during the pandemic were probably accentuated versions of issues that other people had, particularly with isolation. That survey has since carried on, and it gives us an insight that national data collection does not. It is more linked to people’s thoughts and feelings, which is often the most powerful data that you can collect.

Those would be two examples of how we have sought to fill in the picture. Whereas national data is often a bit quantitative rather than qualitative, we are trying to get that broader, more qualitative picture in our data collection, and those two surveys have helped us to do that.

This is, in many ways, where we have been at our most innovative on population health and quite energetic campaigns in this space. Mark mentioned Make Smoking History, which was a very hard-hitting campaign, but, more positively, I look at what we have done around physical activity.

GM Moving is an organisation that links players from across our system with an interest in the promotion of physical activity. Just to give you an example, they put it to me, in my early days as mayor, that I should give people permission to wear their trainers to work. We like our trainers in Greater Manchester, and that message was very well received when I said that everyone is free to. I would never take offence at somebody wearing their trainers in a meeting if they had been using them to walk to the meeting. It was called Active Soles and remains an ongoing Greater Manchester campaign on physical activity. I indicated before that we had real success on that front pre pandemic, and we could share the figures on that with the committee.

The GM Moving movement is still a really powerful thing and extends to health services. There is a great innovative scheme called Prehab4Cancer, and I would recommend it to the committee. It began in Salford but is now around the Greater Manchester system, where cancer patients who were about to undergo chemotherapy or radiotherapy undertook a quite rigorous physical activity course as well in order to get ready for the rigours of what was coming.

Rather than wrapping people up in cotton wool and the old idea of a patient having to sit in a room and not do anything for weeks, it was the opposite: getting people physically active and then helping them to deal with the physical and the mental challenges of treatment, because of the support to remain physically active. Prehab4Cancer won the mayor’s award at our Greater Manchester Moving awards. It is a very innovative scheme that almost points to a different philosophy of health and people not being patients but staying really active and strong.

One quick final example is the work we have done on mental health, particularly suicide prevention. We have a campaign called Shining a Light on Suicide. When it was first put to me as mayor, I was a bit unsure. I thought it was a bit too hard hitting, but in many ways that was the point. We had to go over that hump, if you like, and become more direct in our messaging on that. Shining a Light on Suicide is an example of a Greater Manchester campaign that is more impactful than some of the national campaigns. The football League Managers Association has backed us and has been doing work with us on it, and it has been really successful. This is an area where we have been very innovative with our devolution freedoms, and we have delivered some bottom-up health campaigns that have moved the dial quite a bit. Mark, I hope you will agree with that.

I could talk at length about social care.

I will not go down that path, then. We need greater devolution of Health Education England budgets and functions, so that we can do more ourselves on workforce challenges and rethinking workforce, on more blended roles between social care and health, and on new pathways for young people into the health and care system.

You may have seen that we had a trailblazer devolution agreement signed last week with the Government that gives us more control over post 16. If your committee could then empower us with more devolution of Health Education England functions, we would be in a good place to demonstrate how we could change. I know from my days as Secretary of State that workforce in the NHS has never been done particularly well from a top-down level and often misses the target. Bottom-up workforce development is the way to go in these integrated systems, and I would welcome recommendations in that sphere.

Yes, I will happily do that. Mark referenced the five-year strategy that has just been signed off. If we were to send that to the committee, that might be a good start. It is radical in the England context, because it is asking the system to think social rather than medical first, to all the things Mark was talking about before. That should be the first port of call, rather than a medical or clinical intervention. We can certainly provide more.