The Centre for Progressive Policy (CPP) conducted research to explore the hypothesis that geographic misalignment of institutional boundaries negatively affects health outcomes by increasing the risk of coordination failures.

In order to measure the extent to which different institutions are fragmented across local authorities, CPP has created the first health and social care Fragmentation Index. The Index produces an alignment score for each local authority based on their misalignment with institutions relevant to the delivery and/or accountability of health and care.

• For each point a local authority moves down the Fragmentation Index, there will be around 5% more unplanned admissions to hospital.

• If the local authority you live in doesn’t geographically align with the CCG, Delayed Transfers of Care are, on average, 32% higher.

• In a local authority where the different bodies responsible for healthcare do not geographically match-up, there will be around 15% more unplanned admissions to hospital and 30% more people will be delayed in being discharged from hospital.

All local authorities are then given an Index score ranging from 0 (least fragmented) to 10 (most fragmented).

You can view the Fragmentation Index within CPP’s latest health report, Beyond sticking plasters: An inclusive, whole-systems approach to health and social care.

The top five most fragmented local authorities are:

• Buckinghamshire
• Cumbria
• Derbyshire
• Hertfordshire
• Surrey

The top three least fragmented local authorities are:

• Gloucestershire
• Isle of Wight
• Somerset

CPP found that combined authorities face a coordination challenge as they cover large and complex areas and health systems. Analysis shows that nine out of 10 combined authorities experience a higher than average rate of unplanned hospitalisations, while four out of 10 experience a higher than average rate of delayed transfers of care (DTOC).

Charlotte Alldritt, Director of CPP:

“The creation of health cannot sit within the boundaries of NHS services alone. CPP’s new research has shown beyond doubt that if the agencies looking after someone’s health are fragmented and don’t work together there will be adverse consequences. Place must quickly be recognised as the determining factor of health and CPP will continue to work with multiple agencies to ensure there is greater emphasis on place as a determinant of health.”

Andy Burnham, Mayor of Greater Manchester:

“CPP’s analysis has shown that housing is one of the most important factors in variation in life expectancy. We need to consider radical new ways to narrow this inequality.”

To measure the consequences of misalignment, CPP first explored the relationship between the Fragmentation Index and unplanned hospital admissions for long-term conditions where hospitalisation shouldn’t be needed. The analysis shows that local authorities with greater system misalignment face higher rates of unplanned hospitalisation which is presumably because they find it harder to coordinate support for these individuals in the community.

Second, CPP explored the relationship between the Fragmentation Index and Delayed Transfers of Care (DTOC). Delayed transfers can either mean delays from hospital to a care home or “step down” facility or delays from hospital to home. Both may require significant coordination between hospitals, adult social care providers and the local authority (amongst other potential stakeholders). Our analysis shows that local authorities with a higher degree of misalignment also face higher DTOC rates.

Overall, geographic misalignment across institutional boundaries results in unnecessary hospital admissions and once in hospital, such misalignment makes it harder to go home. This can have serious consequences for the health and wellbeing of individuals.

Beyond sticking plasters: An inclusive, whole-systems approach to health and social care has found that the importance of place in delivering health and social care is being increasingly recognised. However, the use of different definitions of place and boundaries across institutions creates challenges in delivering the place-based coordination and accountability necessary to improve health outcomes.

Different geographical boundaries can apply to each of the following institutions all of which are relevant to the delivery and/or accountability of health and care:

• Clinical Commissioning Groups (CCGs)
• NHS England Regions, 14 local offices
• Health and Wellbeing Boards which are, by design, coterminous with local authorities
• Sustainability and Transformation Partnerships (STPs)
• (Mayoral) combined authorities (in some places)
• Parliamentary constituency

Not all local authorities with high degrees of misalignment experience poor health outcomes against these measures. Surrey is an example of a relatively large local authority with a high degree of institutional misalignment but experiences low rates of unplanned admissions and DTOC. Similarly, there are well-aligned local authorities that experience poor health outcomes. Blackpool is an example of a local authority with relatively well-aligned boundaries, but experiences high rates of unplanned admissions and DTOC.

Notes to editors

Definition of unplanned hospitalisation: This indicator measures how many people with specific long-term conditions, which should not normally require hospitalisation, are admitted to hospital in an emergency. These conditions include, for example, diabetes, epilepsy and high blood pressure. This outcome is concerned with how successfully the NHS manages to reduce emergency admissions for all long-term conditions where optimum management can be achieved in the community.

The Centre for Progressive Policy (CPP) has embarked on a 12-month inquiry into the future of health and social care in England. Our first report Diagnosis Critical, published in June 2018 identified the link between the underfunding of health services and declining constitutional standards of care. Since then we have undertaken a comprehensive programme of engagement with members of the public, policymakers and politicians across the main parties. This interim report presents research from the inquiry’s first six months and sets the direction for our final report due in May 2019.

Our findings and programme are informed by three overriding principles:

1. Good physical and mental health must be a key pillar of any inclusive growth strategy, and this is health in the widest sense of the word, not just healthcare. The NHS plays a significant part in this debate but is not the only delivery mechanism.
2. Place must quickly be recognised as the determining factor of health – but before this can happen a common definition of what this means needs to be created.
3. The system needs to change; increased funding cannot be used for marginal efficiency gains or merely to help health and care delivery stand still.

Here we set out new research using publicly available data, with key findings including:

1. The nation’s health, as measured by life expectancy, is stagnating. Life expectancy among older women in areas situated in the bottom four deciles of deprivation saw flatlining or falling life expectancy. It is likely that rising place-based inequality is driving the overall slowdown in UK health improvements.
2. The use of different definitions and boundaries across economic and social policy institutions and public services agencies creates challenges in delivering the place-based coordination and accountability necessary to improve health outcomes. CPP’s new Fragmentation Index shows that people who live in areas where the different bodies responsible for healthcare are geographically misaligned are more likely to end up in hospital and find it harder to be discharged if they do. Specifically, we find:
3. For each point a local authority moves down our Fragmentation Index, there will be around 5% more unplanned admissions to hospital.
4. If the local authority you live in doesn’t geographically align with the CCG, DTOCs are, on average, 32% higher.
5. In a local authority where the different bodies responsible for healthcare do not geographically match-up, there will be around 15% more unplanned admissions to hospital and 30% more people will be delayed in being discharged from hospital.
6. The challenge posed by misaligned institutions and structures may be exacerbated by recent NHS policy developments. The emergence of regional teams and regional geographies covering both NHS England and NHS Improvement functions are intended to promote integration, but they may add yet another layer of complexity to already complicated and fragmented local health systems.
7. The NHS cannot solve health inequalities in isolation. Employment, education, skills and training, access to better quality housing and other public services are integral to health and the relationship between health, wealth and income inequalities.
8. Addressing health inequalities requires cross-departmental action and resourcing as well as improved coordination at a local level. If better health is the goal, then place-based investment and coordination in education, skills and training, increasing access to quality housing and active labour market policies to reduce unemployment and low pay may be just as relevant as more funding for local hospitals and GP surgeries. Cross-departmental strategies in central government do not do enough to make collaborating easier or more effective while funding and accountability incentives are not sufficiently aligned to allow for integrated ‘whole place’ approaches to supporting health at a local level.
9. The long-term failure to think holistically about health is having a particularly detrimental impact on adult social care. Adult social care is failing with declining standards, insufficient funding and significant inequality in access and provision. CPP analysis of Care Quality Commission (CQC) data shows that in some local authorities only around half of care homes are rated as good or outstanding when it comes to safety whereas amongst the top 10 local authorities this rises to over 90%. There are even greater variations in terms of the availability of residential care.
10. Local differences in care provision help underpin the health inequalities outlined in this report. Our analysis finds that a lower proportion of good or outstanding care homes and a higher number of older people per care home are both strongly related to areas having a higher avoidable mortality rate.

Contact details

Thomas Hauschildt, Communications Manager, CPP

020 7070 3370

THauschildt@progressive-policy.net

Rachel Shortte, Account Manager, ZPB Associates

07834 523 001

Rachel.Shortte@zpb-associates.com

About CPP

CPP is a new think tank committed to making inclusive economic growth a reality, led by Charlotte Alldritt, former Senior Policy Advisor to Nick Clegg. By working with national and local partners, our aim is to devise effective, pragmatic policy solutions to drive productivity and shared prosperity in the UK. Inclusive growth is one of the most urgent questions facing advanced economies where stagnant real wages are squeezing living standards and wealth is increasingly concentrated.

CPP believes that a new approach to growth is needed, harnessing the best of central and local government to shape the national economic environment and build on the assets and opportunities of place. CPP is independent and impartial. We are not aligned with any political party and are a not-for profit organisation. We are fully funded by Lord David Sainsbury, as part of his work on public policy.

For more information or to interview Charlotte Alldritt, please contact Rachel Shortte at ZPB Associates: rachel.shortte@zpb-associates.com

CPP Health and Social Care Advisory Board

Charlotte Alldritt, Director, Centre for Progressive Policy

Siva Anandaciva, Chief Analyst, The King’s Fund

Professor Mike Bewick, former Deputy Medical Director, NHS England and Independent Chair Mid and South Essex STP Joint Committee

Jo Bibby, Director of Health, The Health Foundation

Sir Cyril Chantler, Honorary Fellow and Emeritus Chairman UCL Partners Academic Health Science Partnership

Maureen Dalziel, former Chair, Barking, Havering and Redbridge University Hospitals NHS Trust

Pam Garside, Fellow, Judge Business School, Cambridge University

Sir Ian Gilmore, Professor, University of Liverpool and former President, Royal College of Physicians

Paul Jakimciw, Digital Health Expert

Alex Kafetz, Managing Director, ZPB Associates and Independent Member of the National Information Board

Tim Kelsey, CEO, Australian Digital Health Agency

Stephen K. Klasko, M.D., M.B.A., President and CEO, Thomas Jefferson University and Jefferson Health

Professor Peter Kopelman, Vice-Chancellor and Emeritus Professor of Medicine, University of London and former Principal, St George’s

Dame Julie Moore, Professor of Health System at Warwick University

Professor Sir Mike Richards, former Chief Inspector of Hospitals, Care Quality Commission

Professor Sir Terence Stephenson, outgoing Chair, General Medical Council and Nuffield Professor of Child Health, Institute of Child Health, UCL

Geraldine Strathdee, former Clinical Lead for Mental Health, NHS England

Margaret Willcox, Past President, Association of Directors of Adult Social Services

ENDS