“All roads led to this job,” says Jon Rouse. “Everything that I’ve done previously feels relevant: it brings together all the experiences I’ve had working at different levels of geography, and across different social and economic policy areas.”

Rouse is Chief Officer at the Greater Manchester Health and Social Care Partnership (HSCP): the body charged with strategic management of health and care across the city-region, where £6bn is spent annually providing services for a population of 2.8m in 10 council areas. So it’s a wide-ranging role covering strategy, service reform and frontline delivery within a complex public sector landscape – and right up his street.

Rouse even helped kick off the process which led, nearly two decades later, to Greater Manchester’s (GM’s) health devolution settlement. A former head of the Housing Corporation and architecture watchdog CABE, he was also Secretary to Richard Rogers’ Urban Task Force – whose 1999 report Towards an Urban Renaissance helped catalyse the revival of northern cities. In the 2000s Manchester became the poster boy of regeneration; and its continued economic resurgence and ever-strengthening city-regional governance eventually made possible the deal that, in 2016, drew Rouse back to the city.

From property to people

Meanwhile, Rouse had moved on from the built environment sector: the turning point came when, whilst working as chief executive of Croydon Council, he and his wife adopted two girls. “That changed my life,” he says. “I saw how fundamental it is that people have a good start in life. By the age of three, there can be a load of stuff that’s really difficult to put right; many of the issues society struggles to deal with have their origins in those first thousand days.”

His family’s experiences sparked a keen interest in human-centred services, and he moved to the Department of Health as Director General for Social Care, Local Government and Care Partnership. There, he began putting into practice the lessons of the ‘Total Place’ pilot he’d run in Croydon: mapping all the public spending within a geographical area, the scheme represented an attempt to create a more coherent, collaborative public sector. Total Place “was probably the most compelling thing I’d done during my career,” he says. “Ever since, I’ve tried to stay true to those principles and the localism that underpins them.”

Those principles, of course, lie at the heart of GM’s health and care plans – which aim to strengthen public health, build services around users, provide care in the home, and improve mental health and children’s services by strengthening collaboration across professional and organisational boundaries. And because HSCP’s plans are integrated with GM Combined Authority’s other work strands, its influence extends well beyond health and care services.

Health, social care – and beyond

“We are passionate about influencing the broader social determinants of health,” Rouse explains. “We have a supported housing strategy, with a full audit of what housing we need over the next 15 years. Our executive lead for population health sits on the Greater Manchester Transport Board, working on walking and cycling infrastructure. I co-chair our work on health and justice, in terms of reducing violence. The richness of Greater Manchester is that it’s a whole public service model: it’s about trying to influence all the factors that are stopping people from being healthy.”

At the heart of HSCP lies a Joint Commissioning Board, bringing together local authorities and clinical commissioning groups (CCGs). Here, commissioners work together to reshape services across GM – though Rouse emphasises that “wherever possible, we’d want to work on decisions collaboratively with the providers. If you can do that, then you get ownership; and if you get ownership, you’re much more likely to get successful implementation and delivery.”

Similarly, though Rouse holds “a statutory assurance role” for the CCGs, giving him some firm leverage among commissioners, here too he seeks to work “through influence, collaboration, resourcing, encouragement and problem-solving”. The hard powers available to him bring “pros and cons”, he adds: they “can bring a degree of discipline, but on the other hand, knowing that one of the parties in the relationship has ultimately got a stick behind their back can be a negative as well – so I see it as a mixed blessing.”

Indeed, consensus and collaboration is probably the only way to make progress in GM, whose people combine fierce local allegiances with a healthy disrespect for authority. “One of the things we dislike in Greater Manchester is any concept of heroic leadership,” comments Rouse. “If anybody tries to be a hero leader, they just get the piss taken out of them!”

Councils & commissioners, collaborating

Happily, the Chief Officer has found that “when presented with a compelling case for change, most organisations will see the benefits of collaborating”. The merger of two large university hospital trusts was completed in a year; two mental health trusts merged even more quickly. “Anybody who knows anything about the NHS will know that is quite extraordinary,” he comments.

Below this city-regional level, GM’s 10 boroughs and 10 CCGs – whose boundaries line up almost perfectly – are creating ‘local care organisations’ (LCOs), with integrated management, combined commissioning functions, and pooled budgets for health and care. Progress is variable, Rouse concedes, and shaped by the attitudes of local GPs and councillors: “If they agree, it’s game on,” he says. “We wouldn’t try to force it, because it wouldn’t work. Politicians and clinicians have to want to go on this journey together.”

But some areas are moving fast. In four LCOs, the council chief executive has become the CCG’s accountable officer; most have joint commissioning directors, and several share finance directors. So community health, mental health, primary care and social care are, for the first time, sharing management structures and beginning to operate as a single system: “We’ve got local authorities loaning CCGs money; CCGs supporting social care,” says Rouse. “When you get people into dialogue, it sparks very quickly: the binding force is their desire to meet the needs of their populations.”

Bottom-up solutions

Taking another step down, below the 10 LCOs lie 67 defined neighbourhoods: “In each of these, you’ll find a network of GPs working with multi-disciplinary teams from the public and voluntary sectors to provide support for people who’ve been identified as having additional needs,” Rouse explains. The goal is to provide personalised, multi-agency care for vulnerable people, breaking the pattern in which they cycle between inadequately-supported home living and admission to A&E. And it is at the neighbourhood level, he believes, that changing working cultures and staff attitudes are laying the groundwork for organisational transformation.

“The models that are proving most sustainable and embedded are those built bottom-up: the ones that started with the frontline workforce learning to collaborate; to operate co-located, integrated teams; to design services together,” he says. “They appear to be doing better than those pursued in big, top-down, procurement-led models. And if we do it bottom-up, there will come a point where people will say: ‘Actually, this structure is getting in the way; can we change it?’”

The meaning for managers

There are obvious implications for GM’s health and care managers. “System leadership is going to be the order of the day; it’s going to feel much more organic and networked and messy. And that requires a new mindset from managers,” says Rouse. “They’ll have to work much more flexibly across the health and care spectrum: more proactively and creatively, and with an emphasis on agility and problem-solving.”

To succeed in this new world, he adds, managers must stop defining themselves by grade, employer, budget or team size, and ask themselves: “Am I a great adaptive leader? Am I comfortable working with ambiguity? Am I okay in a space where I have to rely as much on influence and comradeship and solidarity as an instruction or a line report? That’s the world we’re heading into.”

To help drive this cultural change, he continues, “we’re trying to create one workforce and one leadership model” – making it easier for managers to move between employers and sectors. Diversity is a priority – targets are being set for BME representation in senior roles – and a Leaders in GM programme helps people adopt new ways of working. “These courses are fascinating,” he says. “You’ve got waste disposal experts, police officers, NHS leaders, IT gurus – and you see their mindsets changing, their landscapes expanding. They begin to think about their roles in a different way.”

Top-down problems

And what are the biggest obstacles to progress? The greatest, it seems, is the competitive structure and regulatory framework created by the Lansley NHS reforms: HSCP’s work “could be made easier if the legislative framework caught up with the new reality,” Rouse comments, adding that he welcomes NHS England’s consultation on system change (see news).

Resources present another challenge: “We desperately need a long-term funding settlement for social care,” he says. “But in the meantime, there’s no point whinging: you just get on with it. And in our first two years, we delivered back to the NHS a surplus”. That money will come back to GM, he adds: “The principle should be that if the risk lies with us, the upside lies with us as well.” Meanwhile, “we’ve proven that we can steward a system in hard times, sustainably.”

Asked whether GM’s integrated care model will prove more efficient than traditional service delivery, Rouse replies that “the jury’s out”: three years in, the evidence isn’t yet clear. But there are interesting findings around care quality: those LCOs with the most integrated management are, for example, proving most successful in reducing demand for emergency hospital treatment.

“One of the things we dislike in Greater Manchester is any concept of heroic leadership. If anybody tries to be a hero leader, they just get the piss taken out of them!”

Bending the curve

So in Salford, the first LCO to unify management of health and care, demographic changes would – all else being equal – be pushing up non-elective hospital admissions by 3-4% annually. “But in the year to date, they’ve seen a 2.5% reduction, so that’s bending the curve pretty well,” he comments. “And two of the other more mature systems – Tameside and Rochdale – are also seeing positive results. The key now is to make sure that those localities which aren’t doing so well get on with implementing the model at pace, and begin to see the same results.”

Across GM, the number of A&E admissions via ambulance crews has stabilised – HSCP “seems to be making an impact” here, says Rouse. But A&E self-referrals continue to rise; GM missed its 85% target for four-hour waiting times during the winter, prompting an intervention by NHS England. “There’s always a danger of optimism bias: of going too fast in terms of reducing acute capacity and moving services into the community,” he comments. “But our goal remains the same: if now and then you have to recalibrate because you overstretch – well, that’s life.”

The big picture

Meanwhile, out in the community, staff from across GM’s public services are collaborating to tackle the wider problems that drive ill health and hospital admissions – particularly in the field that Rouse calls both “the favourite part of my job”, and “the most important work that we do”: children’s services. A Children’s Health and Wellbeing Board is working to transform services such as maternity care, mental health, looked-after and adopted children, and care leavers. “If we get it right for that cohort, the benefits will be massive for Greater Manchester,” he says.

And that’s just one facet of HSCP’s work, within a remit that is “mind-blowing in its breadth and its complexity.” Jon Rouse has spent his career trying to improve the way that cities work, and the last decade experiencing how public services operate around some of our most vulnerable children. Now, in “the most complex and the most satisfying and the most enjoyable” job of his life, he’s bringing together his professional expertise and his personal passion – breaking down the barriers between organisations and letting public servants focus on their true goal: serving the public.

“It’s all public money. We’re all working for this place, for this population, and at the end of the day the organisational construct is completely artificial,” he concludes. “What an amazing privilege to serve this great city region, and to wake up every morning thinking about how I can improve the health of 2.8 million people.”

For more of Jon Rouse’s views on England’s “broken” system of health care regulation, please read our accompanying news article.