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Pooling Power
Health Service Journal – 17 December 2009

One solution to the cost-cutting era looming over the NHS could be the Total Place programme, in which local public sector budgets are co-ordinated for greatest impact. By Mark Smulian

Demands for more efficient spending are easy for ministers to make but less easy for staff on the ground to achieve - governments usually assume there is a bottomless pit of money called "waste" - but the parlous state of public finances has moved the issue from aspiration to necessity.

Total Place is one exercise that might provide an answer. Its 13 pilots involve pulling together the budgets, powers and expertise of some or all of the public sector in these areas to tackle agreed problems. Initial findings have been sent to the Treasury and will inform next year's Budget.

Most pilots have some health element to them, and all require those involved to think beyond their traditional organisations and budgets. It's uncertain how far Total Place will go but, for the moment at least, the government has a lot of hopes riding on it.

Prime Minister Gordon Brown last week launched the Putting the Frontline First programme as part of a drive to find 47bn of savings in the next four years. He said: "Our task now is to develop government to work in partnership with individuals and communities to deliver the services people want in the way they want them and to preserve them in the face of all the challenges this new era presents."

That is largely what those in the Total Place pilots believe they are doing, finding not only the promise of savings but also the chance to redesign services around users, rather than around the somewhat arbitrary boundaries between public sector budgets.

Phil Swann is programme director for the Dorset pilot, which includes health, local government and the fire and police services in the county and adjacent Bournemouth and Poole. Its theme is older people's services, chosen because of the high number of unplanned hospital admissions of elderly people at an annual cost of 122m.

"Admissions to hospitals have shot up. Hospital acute services are a bit like the M25 - if they are there they will get used to capacity - so we need to look across budgets," he says. "Hospitals are open 24 hours a day and the alternative preventative services generally are not, and people have confidence in hospitals and so do their GPs, so people are pushed to them. "It's a bit like the argument that people trust their cars but they don't trust public transport so they don't use it. Preventative services have to become trusted and build confidence in themselves."

Potential savings

Mr Swann illustrates this with the tale of Betty, an 86-year-old who lives alone, becomes nervous at night, dials 999 and gets admitted to hospital for a few days at an annual cost to the NHS of some 19,000. There are plenty of "Bettys" in an area favoured for retirement. But under Total Place, using part of the budget to support a local group to provide a contact service has meant Betty has not been admitted to hospital since it was formed.

"You have to think on the level of Betty about how older people can be helped in their homes," he says. Mr Swann says the scale of potential savings is still being explored "but if you take the 122m cost, and that we think 30 per cent of older people in hospital should not be there, you can see the sort of savings possible from providing better services outside hospitals".

Leicestershire County Council's Conservative leader David Parsons is an enthusiast for Total Place but does not think the government has followed its own logic by removing budget "ring fences". The county is working with Leicester City Council, health and police partners on alcohol and drug use. Mr Parsons says: "Total Place has already given us some knowledge. It has shown that ring-fencing does not work, for example we are trying to fight alcohol abuse but a lot of the money is only for drug addiction, yet 60 per cent of arrests in the area are for alcohol.

"We have also come up against multiple performance management regimes for the police, health and local authorities and are trying to harmonise those. If we succeed and there is less abuse of alcohol, and so fewer people admitted to hospital or arrested, there will be savings, potentially huge ones.

"Total Place is potentially a very powerful tool but the big thing is the intellectual leap that will be needed from 13 pilots doing something to the whole of the public sector doing it."

Alcohol and drugs were chosen because the PCTs and councils had good relationships and wanted to tackle something together of immediate concern. This harmony is not reproduced at national level, says Mr Parsons, who also chairs the Local Government Association's improvement board and represents it in Whitehall meetings.

"I'm quite clear that government departments have got to come out of their silos and the biggest challenge in that is health," he argues. "Most government departments are up for it, but the Department of Health talks about its latest internal management change as though that were the answer. It still seems to be rather top-down."

Drugs and alcohol are also the focus of the South Tyneside, Gateshead and Sunderland pilot, which will seek to co-locate police, probation and health services to minimise duplication of efforts to prevent relapses; place health teams in misuse "hotspots"; and jointly procure services or products required to support this work.

In Croydon, NHS Croydon interim director of strategic commissioning Jessica Brittin has found that "although Total Place came about for financial reasons it allows us to do something different with our services because you can look at what you are getting from different budgets". Ms Brittin said its focus on children aged zero to five has allowed "a chance to involve the community in services so that you are looking at families as a whole and providing what they need, rather than what we think they need. Too often we can decide what the problem is when the user knows better."

Frequent flyers

She gives the example of a teenager who gave birth, after which the baby and teenager were both cared for by the girl's mother, who was also caring for elderly parents.

"This woman was caring for three generations but she had no official source of assistance because it was looked at as a teenage pregnancy, not as the needs of the whole family. Once we could bring all our budgets to bear we could help her." In this way, Ms Brittin says involvement in Total Place has changed the way she thinks about problems.

In Birmingham, three PCTs are working with the city council and other partners on better ways to use the 7.5bn invested annually by the public sector. Among the fields being explored are learning disabilities and mental health, drugs and alcohol work, where it is hoped to cut the numbers of so-called "frequent flyers" into accident and emergency departments, and work on supporting children at risk of entering gang culture.

Richard Kenny, the city council's head of strategic development, says: "We think that central government could help us by starting to think in terms of a Birmingham budget, a simplified public sector performance management framework, and simplified accounting officer arrangements to enable greater flexibility over investment choices within the city - the issue is how far are they prepared to go?"

Bradford's public sector has focused Total Place on keeping elderly people with mental health needs from hospital, offenders from prison and young people from care. Alison Milner, the city council's assistant director for communications, explains: "Older people with mental health needs leaving a general hospital can feel lost or overwhelmed because of the complexity of their needs and the silo delivery of support from multiple agencies.

"A lack of co-ordinated health and social care support services often means they experience longer stays in hospital and have a greater likelihood of admission into long-term care." Bradford's Total Place group found that a single assessment process for both practical and psychological support needs is required and would give more emphasis to "spend for the benefit of the service user, rather than the individual organisation".

Total Place raises complex questions about who is in charge of spending what in each area, and will involve new ways of working, but the chance for better savings and comparatively painless pending cuts could be great.