tending to see people as citizens and community members.60 And the two
systems have very different relative strengths, with local government good at
market shaping and accountability, and the NHS is good at processing health
information to aid patient care and clinical leadership.
These cultural differences have somewhat inevitably resulted in longstanding
and ongoing difficulties in communication and understanding between the two
systems. Almost two-thirds (65 per cent) of survey respondents cited cultural
differences when asked for reasons that wholesale integration of health and
care services nationwide has taken so long to develop. One HWB Chair told us
that the failure of individuals to understand the work of other bodies - they cited
the example that they had discovered some doctors have never met a social
worker - can forge an environment of distrust and ignorance of the broader
picture. And this was underlined by Communities Secretary Eric Pickles who has
said there is an "enormous" [amount of] "distrust and arguments between local
authorities and the NHS."61 This distrust and poor communication is another key
element in delayed transfers of care.
This failure to effectively communicate can also take a technological hue, leading
to a lack of healthcare information sharing between services and partners.
One interviewee said: "[The fact that] we have no integrated information
system is bizarre". The result is, as another HWB Chair told us: "Not really
knowing and tracking people through their lives [resulting in] people coming
in having previously not seen us and then needing lots of care immediately".
Indeed, our survey of local health leaders confirms this with 52 per cent of
respondents saying that relationships between relevant partners are one of the
main underlying causes of delayed transfers of care.
Predictably, such different cultures can also make change management across
the whole system even trickier than usual. The more organisations involved
(and in some local authority areas it can easily be dozens), the more different
processes and specific corporate cultures that have to be aligned, and the more
complex any change attempted.
The institutional and historic separation of the NHS and local government has
resulted in fragmentation of healthcare provision at the local and national
level resulting in significant barriers to integrating services. At the national
level leaders have faced a tough challenge, managing wide-reaching change
throughout the NHS while themselves split across Department of Health, NHS
England and Public Health England (Plus Monitor, the Care Quality Commission
and national Healthwatch).
Although the structural changes were introduced for sound reasons, attempting
to radically reform the shape of the NHS to make it more locally and clinically
led, some local health leaders found the fragmentation a challenge. Nearly half
of our survey respondents thought that the impact of changes to the NHS were
a reason for why wholesale integration of health and care services nationwide
had taken so long to develop. Fragmentation has been observed as a significant
problem at the national level as well. In a recent interview with the Guardian Sir
Bruce Keogh, medical director for NHS England, said: "Too many patients find
the NHS fragmented [and] confusing. They find that they get pushed from pillar
to post, they feel like a ball in a pinball machine at times."62
Local government and health authorities are not structured along the same
geographic lines - in the jargon they are not co-terminous - and this was another
60 Localis, In sickness and in health
61 Wiggins, K, "Hunt: NHS has
'responsibility to help councils"
LGC (31 October 2014)
62 Campbell, D, "NHS cannot cope
with ageing population, warns
top doctor" The Guardian (19
Chapter 3 - What Is The Diagnosis? Or Why Are We Failing Our Elderly?