Councils need to build on their successes in integrated health care

A new report assesses joined-up health and social care and local government's growing role in providing such services. Photograph: Shannon Fagan/Getty Images

Another week, and another report provides a reminder of how local government is changing. The report In Sickness and in Health from the independent thinktank Localis reflects the growing recognition of local government's role – working hand-in-hand with health commissioners, healthcare providers and local communities – in driving better health outcomes.

However, the report also recognises many of the difficulties faced by those responsible for making this work in practice. To understand the opportunities and the challenges involved, it is important to understand the broader context within which these changes are happening.

Well over a year since Barnet's "graph of doom", councils face a further round of budget cuts and council tax freezes. Meanwhile, as demands on local health and social services grow, so do questions about whether patients and service users are receiving the quality of care they deserve.

Not surprisingly, the mantra that only radical transformation will do has become the meme of public service reform, echoing around council chambers, conference halls and management boards. But talk to those at the frontline and there are few better places to start than the interfaces – or, perhaps more accurately, the gaps – around how care is delivered.

The concept of better co-ordinated services, centred on the needs of individuals, isn't new. The Local Government Association suggested that rolling out whole place community budgets could save between £9bn and £21bn over five years. The fund for joint NHS and local authority commissioning is set to be £3.8bn by 2015-16. And there is comfort in what one Localis researcher, Gwilym Tudor, Jones said earlier this year about the "near feverish excitement" around uniting health and social care services. But questions remain as to why it has taken so long already and what will happen next.

The story of health and social care in England is often written as one of crisis, but it's important to remember how much of this is driven by another story – one of success.

Between 2001-02 and 2011-12 net NHS expenditure increased from £49bn to £104bn.At the same time, gross expenditure on adult social care increased to £17bn, a 33% rise over the same period.

The benefit of bringing these services together is an area of almost complete political agreement. But the reality is that the closer we get to integration, the clearer both the opportunities and challenges become.

Take away considerations of politics and funding and we are still left with organisations with cultures, practices and infrastructure that are as separate as their objectives are shared.

Health and wellbeing boards will be crucial to fixing this, providing the one vital place where the right people come together with a view across the whole and the remit to make change.

This summer saw the launch of the Local Government Association's support for health and wellbeing boards seeking to integrate care at scale. Working with partners, including NHS England, Monitor, the Department of Health and Integrating Care, this is about providing practical help to identify opportunities, overcome barriers and implement the new models of working that promise the biggest improvements for service users and organisations alike.

At the heart of the association's work is the recognition that many local authorities and their partners have already made good progress in bringing together services. Learning from what has been achieved, and making it the norm, is our best chance of meeting the challenges ahead.

Simon Morioka is managing director at PPL and senior adviser at Integrating Care.

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Copper build up in brain 'could explain Alzheimer's dementia'

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Article Date: 20 Aug 2013 - 3:00 PDT Current ratings for:
Copper build up in brain 'could explain Alzheimer's dementia'

New research suggests copper that enters the body at levels encountered in the average modern diet may be leading, eventually, to Alzheimer's disease - by reducing the body's ability to clear away toxic proteins in the brain, and also by encouraging the clumping of those proteins.

Copper is an essential trace element in the diet. With iron, it helps make red blood cells, and it is also essential for the health of the immune system, blood vessels, nerves, and bones.

Copper enters the body via many sources, including drinking water carried in copper pipes, and from foods such as shellfish, nuts, red meat and many fruits and vegetables, and also via food supplements.

But now a study that used cells from both mice and humans, led by Rashid Deane, a research professor in the University of Rochester Medical Center (URMC) in the US, shows that copper can also build up in the brain and disrupt the body's ability to clear away amyloid beta proteins before they form the plaques that are the hallmark Alzheimer's disease.

Prof Deane says:

"It is clear that, over time, copper's cumulative effect is to impair the systems by which amyloid beta is removed from the brain."

He and his co-authors, all with URMC, write about their findings in Monday's online issue of the Proceedings of the National Academy of Sciences.

Normally, the body removes amyloid beta from the brain with the help of a protein called LRP1, short for lipoprotein receptor-related protein 1. This protein, which lines blood vessels in the brain, binds with amyloid beta and escorts it out of the brain.

For their study, the team gave mice trace levels of copper for three months.

They found the metal collected in the cells walls of the fine vessels that feed blood to the brain.

The cells the copper collected in are an important part of the brain's defence mechanism, the so-called blood/brain barrier, which controls the substances that can pass in and out of brain tissue.

By collecting copper in their membranes, the cells were just doing their job.

But the researchers found that with time, through the process of oxidation, the copper build up in the cell walls started to affect the ability of LRP1 to escort amyloid beta proteins out of the brain. They saw this happen in both mouse and human brain cells.

In a further experiment, they then examined the process in live mice bred to develop Alzheimer's disease. They found the cells responsible for maintaining the blood/brain barrier could not cope: they became leaky, probably with age and repeated damage from toxins.

Had they not been leaky, the cells would have trapped the copper in their cell walls, but in the Alzheimer's mice, the blood-borne metal was able to pass unhindered through the blood/brain barrier.

As it met with brain tissue, the leaked copper stimulated brain cells to increase their production of amyloid beta.

The copper also had a direct effect on the toxic protein itself: it encouraged it to clump together and form the characteristic plaques of Alzheimer's disease.

Once amyloid beta forms these large clumps inside brain cells, the body's natural ways of eliminating it are overwhelmed and cannot cope: scientists believe this is how Alzheimer's starts and progresses.

In a final experiment, the team also found that copper led to inflammation of brain tissue, which may also speed up the breakdown of the blood/brain barrier and the subsequent build up of Alzheimer's toxins.

The levels of copper the researchers used in their experiments were trace amounts, about one-tenth of that set by standards for water quality from the US Environmental Protection Agency.

Prof Deane says:

"These are very low levels of copper, equivalent to what people would consume in a normal diet."

But neither he nor his colleagues are suggesting people change their diets or intakes of copper on the basis of these findings, which they say should be interpreted with caution.

The body needs copper, it is an essential metal. The effects shown in this study are due to exposure over a long period, and the key is getting the balance between too much and too little.

"Right now we cannot say what the right level will be, but diet may ultimately play an important role in regulating this process," Prof. Deane says.

Help with finding for the study came from The Alzheimer's Association, the National Institute on Aging, and a pilot grant from the National Institute of Environmental Health Sciences.

This is not the first study to implicate copper in a neurodegenerative disease. In 2011, another group of US researchers reported how copper affected a protein associated with Parkinson's disease.

Written by Catharine Paddock PhD
Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today Visit our alzheimer's / dementia section for the latest news on this subject.

Low levels of copper disrupt brain amyloid-ß homeostasis by altering its production and clearance Itender Singh, Abhay Sagare, Mireia Coma and others, PNAS. Published online 19 August 2013 (DOI: 10.1073/pnas.1302212110).

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How the NHS can build partnerships with other organisations

Meeting the challenge: commissioning support units are being encouraged to build partnerships with other organisations. Photograph: Graeme Robertson/Getty Images

Many NHS staff have already been looking beyond business-as-usual, to really get to grips with the challenge of major clinical service change.

There is no silver bullet. Health services will continue to experience increasing demands, both demographically and societally driven. Against this backdrop, the challenges of maintaining and improving quality standards and improving things for patients, at the same time as reducing spend, have been brought into sharp relief by recent events in Staffordshire and elsewhere.

But how does the NHS affect the cultural and practical changes to patient behaviours? How do they achieve the investment in technology and other resources? How, without surrendering control of the clinical decision-making agenda, do they seek the funding and additional, commercial and other skills that they require?

To meet this challenge, commissioning support units (CSUs) are being encouraged to start building partnerships with other NHS, commercial and third-sector organisations, who can bring fresh thinking and wider expertise to the NHS.

For clinical commissioning groups (CCGs) as customers, dealing with a CSU-led commissioning support partnership may also help to simplify contractual arrangements. CCGs will also be looking for ways to better align the incentives of commissioning support organisations with their own successful delivery of the quality, innovation, productivity and prevention (QIPP) agenda. A broader CSU partnership, where there is greater ability to invest, manage risk and explore outcomes-based risk and reward contracts may be the way to move towards this.

Between 2008 and 2011, my team partnered with NHS Ashton Leigh and Wigan to deliver Transforming Commissioning Saving Lives, one of the first large-scale commissioning transformation programmes under the national framework. Ashton Leigh and Wigan undertook the programme in response to a number of challenges; mounting financial pressure to reduce acute activity, poor health outcomes (compared with national benchmarks), and commissioners struggling to gain control in a health economy dominated by the local hospital trust.

Working together, we devised and implemented a number of strategies to improve commissioning of clinical care services, to both enhance performance and achieve savings. We undertook organisational development and leadership coaching – working with the chief executive and his team and in joint programmes with the local authority.

We worked closely with commissioning managers, clinical commissioners, patients, doctors, nurses and health systems partners to redesign local stroke services, commissioning a pathway to diagnose and manage patients following a transient ischemic attack (TIA) or mini stroke, and to provide holistic and person-centered health and social rehabilitation for people who have had a full stroke.

This resulted in a reduced average length of time a patient spends in hospital – from 56 days to 12 days. It achieved £14.39m worth of savings. But it also achieved more long-term, fundamental changes through the skills and knowledge transferred.

My experience leads me to believe successful partnerships can offer significant benefits to both the public sector service delivery organisation (for example, a local authority or, in this case, a CSU) and the private or third sector partner. They offer greater resilience in terms of both capacity and capability.

Partnerships also mean that risks can be shared and that investment can be attracted from partners who are more able to fund new technology and other resources. And lessons can be learnt from the experience of other parts of the private and public sector about innovative ways to get service users and their families engaged, and providers of healthcare services doing things differently.

Matthew Harker is director of healthcare consulting at Capita.

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