Building understanding between the NHS and local government - in conversation with Kath O'Dwyer

There can be few clearer articulations of the central aims of integrated care systems than that offered by Kath O’Dwyer, chief executive of St Helens Borough Council and the Liverpool City Region LA CX representative on the Cheshire and Merseyside ICS.

Kath said: “Our patients, residents, service users, whatever we want to call them, don’t care whose logo is on our payslip. They just want an integrated solution to their problem, where they don't have to tell their story 400 times, and that everyone in the system talks to each other and works together.”

Kath has over 39 years' experience in local government working across children’s services, adult social care and public health. She is also the former National Director of Social Care for Ofsted.

Last week we sat down with her to discuss relationship building and effective collaboration between local authorities and NHS providers in the context of integrated care from the local government perspective.

That kind of genuine partnership working can be anything but straightforward. When ICSs achieve full statutory footing in July, it will mark the beginning of a whole new relationship between local authorities and NHS organisations. Achieving the public health goals of integrated care will depend heavily on that relationship working smoothly.

The NHS has worked with local government since its inception in 1947, but this time it’s different – this time the relationship is guaranteed in law. The partners in any ICS come to the table with very different cultures, different expectations, and different priorities.

Success will depend on being open-minded, on forging strong working relationships, and on resisting the temptation to make assumptions about how others work and what their goals are.

This work has been underway for some time, of course, so what’s the local government perspective on how successful it’s been?

Kath O’Dwyer is well placed to comment. With nearly four decades of local government experience working in eight local authorities, she is a former director of children’s services and people services, incorporating adult social care, public health and children’s services and has spent five years working on sustainability and transformation planning (STPs) and integrated care systems (ICS) with NHS colleagues.

O’Dwyer says the partnership approach, after STP issues were addressed, got off to a good start with trust and effective communication: “There was a lot of really good engagement with politicians and councils [and other partners]. We had each other's mobile numbers, we'd text each other if we thought somebody needed to know something – it was a very integrated and collaborative set of arrangements.

“When they announced the national appointment process for the chair interviews and for the chief exec interviews, I sat on the panel representing local councils. It was a real positive that local authorities were engaged even to the point of recruitment.

“But then the government announced that there wasn’t just going to be an ICP [integrated care partnership]. We weren’t just going to have a partnership board, there was going to be an ICB [integrated care board] as well, focused on the NHS statutory responsibilities. That felt like a bit of a shift, resulting in a bit more political and partner suspicion, with people thinking ‘well actually, is that the board that's going to make all the decisions and decide about the money and decide about anything that matters? Will the partnership board just be a talking shop, and what powers is it going to have? How is it going to make a difference – will it really be doing things differently to deliver true integration and address long standing health inequalities?”

There has also been some scepticism about the status of social care in the new systems – not helped by the allocation of statutory roles in integrated care systems. Kath says: “All of the statutory roles have been advertised in each of the systems. Directors of finance, directors of nursing, medical directors – all have been advertised under national job descriptions. But where does care fit? This is a health care partnership. Under which of those statutory offices does care fit? If you look at the job descriptions, nursing care is clear but not wider care – children and adult social care is not really referenced anywhere. This is a real missed opportunity to put integration of health and social care and health inequalities at the heart of the system.”

The director of public health (DPH) representative on integrated care boards is often a non-voting role. Kath says: “Local authority chief executives have voting roles, and they manage their DPHs, so you could say it's through that route. But actually, there's no DPH or DASS expertise in many of the ICS core teams. If this is truly about integration and health inequalities, then that's a potential omission.”

The way to ensure close collaboration, according to Kath O’Dwyer, is to embed expertise into ICS core teams. She says: “Often, the NHS doesn’t really get local government and its governance and politics because they've never had to. But we've all been reared on it. So three years ago we suggested to the chair and the chief exec of the HCP at the time, that they might want somebody in their core team that was a local government expert. So they recruited a recently retired local authority chief exec for three days a week to be their internal advisor around all things local government. It paid real dividends.

“I think that, at least in part, this is why we developed a political assembly. Because we've had somebody right at the beginning of the conversation in there shaping things, not something written by somebody who has limited knowledge of these aspects and then sent to us for comments, but actually somebody in there helping to shape and develop it.

“That worked so well, and I think that model is what needs to happen with social care and health inequalities. There has been a suggestion to the Cheshire and Merseyside Health and Care Partnership that we create a director of adult services (DASS) advisory role in the ICS core team – a statutory officer in local government realms –as a conduit, an advisor and resident expert. And I think it’s a good idea.

“There needs to be a DASS and maybe also a DPH embedded right at the beginning of all the conversations within the ICS, shaping a truly integrated world that will really deliver something different as a whole system. Otherwise there is nobody in the core team required to have any expertise in social care or public health.

“Integrated care is a massive opportunity to really do things differently, to commission differently, to deliver differently, to focus on true integration and really, for once, make a positive impact on health inequalities. We need to make sure we don’t miss this opportunity by just doing what we always done, but under a new banner.”

Cheshire and Merseyside is one of the biggest ICSs in the country serving a population of around 2.7m people. There are two boards, the ICB and ICP. There are 15 voting members of the ICB, a statutory NHS body, of which two voting members are from Local Authorities and two from primary care, who all directly input into the range of duties the ICB has. The ICP bring together a much wider representation from local government and from the VCFSE sector.