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How we bridged our town's east-west healthcare divide

Practice-based commissioners in Crawley are working with their local government in a health and wellbeing partnership to tackle health inequalities, as Dr Amit Bhargava explains

Practice-based commissioners in Crawley are working with their local government in a health and wellbeing partnership to tackle health inequalities, as Dr Amit Bhargava explains

One of the key success measures for our PBC locality commissioning group in Crawley, West Sussex, is the incremental reduction

in health inequalities and increase in wellbeing of the area's population. We aim to progressively disinvest from as many hospital-based services as possible in favour of community-based services.

By increasing spending on preventive services we hope to measurably improve the health of our population. We have a three-year delivery plan.

Last year (2007/8) we had £2.5m of freed-up resources (FURs) from our total commissioning budget of £150m, which we believe came partly through the increased emphasis on local partnership working.

This joint working engages many players, commissioners and providers in our town in a dialogue-and-delivery plan that is mutually beneficial – a true symbiotic relationship with a common purpose. PBC and the wider Crawley Health and Wellbeing Partnership has aligned many of its business plans and workstreams and delivered integrated care.

The challenge we face

Crawley is a densely populated town of some 100,000 people 25 miles south of London, in the north-east of West Sussex and close to Gatwick Airport.

It is a 60-year-old ‘New Town', organised into 13 distinct neighbourhoods, with medical and commercial services in each. It is vibrant, ethnically mixed – with ethnic minority people making up 15.5% of the population – with high employment, great leisure facilities and co-terminus local authority services.

There is an east-west divide in the town, with a history of underinvestment that has led to relatively poor public services in the poorer areas in the east.

We also have the lowest per capita spend on health in West Sussex yet one of the highest needs. Health inequalities, mortality (5.5 years difference between patients in the most affluent and deprived wards), exercise rates, obesity, healthy lifestyles and prevalence of chronic diseases are all worse in the east of town.

The use of emergency beds is also highest in people from the areas of greatest deprivation.

There is a rapidly growing elderly population, especially the over-85s. Some of these older people are living on as little as £28 a week and suffer fuel and food poverty, and they are also the greatest users of unscheduled care.

We also have an increasing number of hard-to-reach ‘not heard, not seen' – comprised of immigrants, migrants and shift workers with specific health, preventive and social needs that are unmet.

With this background of place, people and needs we needed to find a local, sustainable, deliverable, measurable and integrated solution, focused on people with the greatest need, alongside a rebalancing of investment from partners.

Health and Wellbeing Partnership

Crawley's Health and Wellbeing Partnership was formed two years ago and has rapidly evolved, demonstrating its strong commitment to partnership working and supporting the modernisation of health, wellbeing and social care services. It sits alongside the Local Strategic Partnership.
The members include our PBC group, Crawley's community nursing services, the acute hospital Surrey and Sussex Healthcare Trust, social services, West Sussex county council, Crawley Borough Council, the Citizens Advice Bureau and other voluntary and charitable organisations.

It was clear that we were very often directing resource to the same client group separately, but for the same purpose, in a disjointed way. So it was in our mutual interests to work together. There was no cost involved in setting up the partnership and it has enabled all the different pots of money available within the different partners to be used more efficiently and effectively.

The partnership has two components – health and wellbeing – with some elements distinct and some involving shared programmes where people can move from one to the other seamlessly. Both have the same ultimate aim of improving health and wellbeing.

Health This component involves acute, primary, community or mental health services working with social services, with some local government and voluntary services forming integrated teams around GP practices and registered populations.

The patients covered by this initiative mainly have long-term conditions (LTC) and the integrated teams work to prevent them from getting acutely ill, support them to manage their conditions at home and in the community and help them to remain well.

Wellbeing This part of the programme has a dedicated office, a partnership manager and team.

Its programmes include increasing participation in physical activity, reducing health inequalities and raising life expectancy in Local Neighbourhood Improvement Areas, developing a ‘menu' of activities for referral and signposting by primary care professionals, frontline staff and employers using a dedicated website, self-determined personal programmes and plans, and workplace health.

Early steps: walking the talk

We started with a good base of cohesive PBC, good general practice and community teams, and willing ‘can do' partners. Our areas of work have included:

A joint commissioning group The PBC group, PCT, Crawley Borough Council and county council social services meet regularly to work out a joint commissioning plan. This has been challenging because of the different ways budgets and numbers are crunched in different agencies. For example, if we each chose to look at how much we spent on the elderly infirm there was no like-for-like between us.

For the PBC group the expenditure was spread across prescribing, different diseases and so on whereas social services would point to their nursing home expenditure. There were also issues with individuals going back to their organisations and finding there were rules preventing them from moving things forward.

While we work through organisational rules and behaviours we have found areas where we can have some early wins such as the disability facility grants (DFG) example (see box page below), workplace health and a LES to tackle obesity.

Care plans for the high-risk

Crawley PBC group has put together a business case based on the Improvement Foundation's unique care model to provide extended integrated care.

This will involve GPs and practices working with an extended integrated team of community nurses, managers, social services, debt counsellors, wellbeing managers, psychotherapists and others to provide

co-ordinated care to the top 20-30% of people with LTCs. This group will be identified using a predictive analytical tool, for which a tender process has begun.

Links with the Sussex Sports Partnership – funded by the PCT and local council – have meant securing funding for a three-year full-time worker to address physical activity in the workplace, improve workplace health and productivity, and direct working-age adults to preventive services.

Website The launch this month of the wellbeing programme's website will enable direct, easy access to up-to-date, user-friendly information about the programme and links to and from a range of other public or voluntary sector sites.

The website is designed to be welcoming, positive and happy. A referral system and back-end database has been developed to ensure cohesive integrated working takes place with cross-referrals and data transferred between agencies including GPs and social services.

Workplace health There is concern among Crawley GPs that bad workplaces are a major cause of physical and emotional harm to our patients, with 30-50% of our sick notes being related to workplace issues, mainly stress-related.

We have been working with the borough council and public health department for some months and have launched a project whereby, through an agreed web-based electronic form, the GPs will feed back to the council details of the business and the clinical reason that is causing harm.

We are also identifying five pilot businesses to see how we can improve the health and wellbeing of their staff. Working-age men are least likely to engage with GPs for preventive services and carry the risk of undiagnosed hypertension, diabetes and so on. Our intent is to take this service to local businesses.

Overcoming challenges

It was always our absolute intention to make the Health and Wellbeing Partnership a strong and locally relevant partnership with clarity about our work, the resources needed and locally agreed targets. We have learned from the experiences of similar endeavours of the past.

The need and benefit of local partnership working was incontestable and widely acknowledged. The challenges we have had some success with are:
• Getting senior decision makers around the same table frequently and consistently. The commitment had to be more than good intentions – we had to be there in person to continue conversations, resolve tricky organisational issues and lead from the front.

• Moving from principles of joint working to real work programmes, with real money and real people. This took the most time, as people found organisational boundaries, rules and historic behaviours reasons for prevarication. Having senior decision-makers onside, including local politicians, really helps by keeping them involved in smoothing the path.

• Getting the organisations to agree to targets and delivery dates and linking this to investment. Open and transparent books and discussions help – there's nothing like a bit of competition for the moral high ground.

There are a large number of national policies for health and local government which support this work. Understanding these and using them in decision making is really important, as aligning work programmes to policy makes it easy for the accountable leaders to say Yes.

The most important and the most difficult issue for us was to have accountable and responsible people with power locally in Crawley. The seats of power in West Sussex are dozens of miles away from us and all the accountable leaders are based there.

Local devolution of decision-making is key to speed, successes and keeping workers engaged.

Finally there is one key point to bear in mind. Many hugely important joint ventures like this fail because people give it up as ‘too difficult' around the midway point. Persistence by the believers makes or breaks the success.

We have many good people who drifted away but came back when they saw progress was being made. Now our meetings are well-attended with great debate.

Dr Amit Bhargava is chair of the Crawley PBC locality and the NHS Alliance PBC co-lead for South-East Coast SHA

Many partners drifted away but came back when they saw the progress that was being made.

Turning words into action

The Health and Wellbeing Partnership realised installation of home adaptations would facilitate early hospital discharge and help keep people with chronic diseases safely at home.

Crawley council returned £12,000 of disability facility grants in the previous year and received a very disappointing Audit Commission report on the use of DFGs.

The grant has strict rules attached to it about whether the recipient is in private or public housing and is means tested. It could sometimes take weeks just to get an initial assessment done by the occupational therapy service and many weeks and months before the adaptations were fitted.

We agreed an aspiration that OT assessments would be carried out within 48 hours and that adaptations should also then be fitted speedily.

Crawley Council has a working group of officers and councillors that is currently looking at delivering these aims.

The council is also undertaking a lean thinking exercise in relation to both DFGs and the aids and adaptation service to improve process efficiencies and the customer experience and service.

Making a partnership succeed Dr Amit Bhargava (left) with partnership development manager Malcolm Bray Dr Amit Bhargava (left) with partnership development manager Malcolm Bray

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