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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.

3.3.2 Fragmentation

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

(September 2013)

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

January 2015)

Chapter 3 - What Is The Diagnosis? Or Why Are We Failing Our Elderly?



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