"We're facing a perfect storm," says Dr Nadim Fazlani, Liverpool GP and chair of the city's clinical commissioning group (CCG).
Councils are facing huge budget cuts, he adds, and these are adversely affecting northern cities like Liverpool. "Then you have the welfare reforms and their impact on communities and health," he says. "We couldn't continue as before – we have to do things differently."
Fazlani has joined Cllr Roz Gladden, Liverpool city council's deputy mayor and cabinet member for health and adult social care, to explain the thinking behind the city's increasingly integrated services.
Gladden says: "It doesn't make sense to work separately these days. If someone's receiving support at home, my own view is that as long as they get what they need, they probably don't care whether their carer comes from the health service or the council. That service should be wrapped around the individual – so we are trying to move beyond organisational structures."
Gladden and Falzani arrived in their current posts at around the same time. Previously the shadow lead, she took over in 2010 when Labour won council control from the Liberal Democrats, while he balanced his GP work with roles in the primary care trust (PCT).
Shortly after the new council administration took over, the government announced plans to replace management-led PCTs with GP-led CCGs – and began its programme of public sector cuts.
So far, Gladden's departmental budget has dropped from £210m to £174m, and in three years' time will be £120m per year. Services have been cut and contracts renegotiated, with only the most complex cases prioritised.
Liverpool already had a history of co-commissioning but adversity pulled the two bodies closer together. As well as taking up statutory positions on the city's new health and wellbeing board, the CCG – which spent two years in shadow form before last April's launch – also took the unusual step of inviting Gladden and department director Samih Kalakeche onto its governing body.
In Liverpool, the added ingredient since 2012 has been the elected mayor, who has ultimate responsibility for health. Inaugural mayor Joe Anderson launched an independent commission into health, which reported in January and backed his calls for deeper integration. Priorities include tackling alcohol abuse, which is said to cost the city £288m a year. Minimum unit pricing for alcohol is a distinct possibility for Liverpool, even if the city ends up acting alone.
Gladden says: "The mayor has challenged us to work together and with our other partners to reduce the huge health inequality which exists in Liverpool. We have completely changed the way we work in the past three years. In my team we are really trying to promote independence and keep people active for as long as possible."
Both agree the integration journey has at times been challenging. At all levels, staff have had to look beyond their own workplace culture and learn to collaborate. The goal is that GPs, district nurses, social workers, care workers and others become equal players in a system which prioritises service recipients over organisational politics.
Radical changes so far include rethinking the way private care homes are organised. Whereas before a single home could have a mixture of social care and health beds – with separate specifications and contracts – they are now jointly commissioned. Instead of some beds being visited by a nurse and others by a social worker, today community matrons work within the homes. GPs team up with social workers to do session work and everyone saves time.
The CCG and council also jointly invested in putting social workers in A&E, to signpost patients on to other services such as drug and alcohol support – a particular issue on busy weekend nights. They say the move has cut readmissions to acute services by 40%, saving money.
Another change has been the introduction of neighbourhood working. Instead of being organised centrally as before, social services now work in divisions structured around GP catchment areas.
Falzani explains: "We are trying to mirror services around communities rather than organisations, because we think it makes more sense.
"It can be very confusing for those who need health and social care – there can be many different assessments for the same problem and we have to ask what is the point in wasting people's time and our limited resources.
"What we hope to see going forward is one pathway across health and social care and back again so that for the patient it should be irrelevant which organisation is providing it. That is the aim."
And if something does not work, they will hear about it. Whereas the PCT had little contact with patients, GP commissioners and councillors work on the frontline and hear what is going on in their communities.
"I think we tend to take a longitudinal view because we work in our communities for a very long time," he says. "I've been there 25 years, Roz for years too – and the same with many of our colleagues. This means we understand what is needed in these areas. And if things aren't working as they should we will certainly be told about it."
Written by Ciara Leeming for the Guardian, to a brief agreed with Liverpool city council and Liverpool clinical commissioning group. Funded by Liverpool city council
