On 1st July we saw the introduction of legislation for Integrated Care Systems (ICSs) in the NHS. In the weeks since, what has changed for healthcare leaders, practitioners and patients?
What are the key priorities for NHS decision-makers and what is getting in the way of change? How can Pharma and Medtech support their NHS customers as they implement this change?
In this episode Tom Clarke (Director, Mtech Access) explored all this and more with Steve Reed (Head of Community Services, York Teaching Hospital NHS FT) and Dr Viren Mehta (Vice Chair, Viaduct Care and Clinical Director, Cheadle Primary Care Network).
Together, they explore:
This podcast was originally broadcast live as a webinar on Friday 22nd July 2022. Please see further details at https://mtechaccess.co.uk/ics-go-live-nhs-first-3-weeks/
Subscribe to our newsletter to hear more news, insights and events from Mtech Access.
On 1st July we saw the introduction of legislation for Integrated Care Systems (ICSs) in the NHS. In the weeks since, what has changed for healthcare leaders, practitioners and patients?
What are the key priorities for NHS decision-makers and what is getting in the way of change? How can Pharma and Medtech support their NHS customers as they implement this change?
In this episode Tom Clarke (Director, Mtech Access) explored all this and more with Steve Reed (Head of Community Services, York Teaching Hospital NHS FT) and Dr Viren Mehta (Vice Chair, Viaduct Care and Clinical Director, Cheadle Primary Care Network).
Together, they explore:
This podcast was originally broadcast live as a webinar on Friday 22nd July 2022. Please see further details at https://mtechaccess.co.uk/ics-go-live-nhs-first-3-weeks/
Subscribe to our newsletter to hear more news, insights and events from Mtech Access.
- Good afternoon and welcome back to the Mtech Access Words of Wisdom webinar. I'm Tom Clarke, and it's great to be back with another two guests from the NHS to talk about their current challenges and the environment as it evolves around them. Just before we start, a quick reminder in case you don't know that we are running a full day symposium in London on the 29th September looking at payments, people and planning, all the things that you need to know about the NHS and your strategy for 2023. You can download a flyer from the handout section in the webinar or visit our website for more details. Back to the business at hand. On July 1st, Integrated Care Systems were formalised, becoming statutory bodies responsible for the provision of care, health outcomes, and equality across their populations. This long heralded change promises to change how we all experience care within our professional lives, how we interact with the NHS, and approach challenges around the introduction and implementation of health technologies. The reality, however, might be quite different as constraints around capacity, budgets and workforce continue to have a profound impact on frontline care and patient experience. To lift the lid with me on how the ICS era has started, I'm joined today by Steve Reed, Head of Community Services at York and Scarborough Teaching Hospitals, NHS Foundation Trust, and Dr. Viren Mehta, he's the Vice Chair of the Viaduct Care GP Federation and Clinical Director of Cheadle PCN. So Steve, Viren, welcome, thank you for joining me today. Steve, I'll come to you first. Can you just briefly introduce yourself, the role you're in and a little bit about the system that you're working in.
- Yeah, afternoon, Tom. So, as you said, I'm Head of Community Services for an acute and community foundation trust based up in Yorkshire. So we serve as a trust about half a million, but for our community services about 350,000 people, and that covers the traditional range of community nursing services, therapies, lots of intermediate care and specialist teams. Our ICS was not one of the early adopters and had some challenges over the years in terms of the geography that it covers and some changes to that, and then how that aligned with local authorities and provider trusts, feels like it's in a much more stable place now, but as a system overall, we've lived with quite a lot of financial challenges over the years, and some performance issues as well as trying to balance kind of pockets of quite high deprivation with a lot of rurality versus urban challenge. So it's an interesting system that's got quite a bit there.
- Yeah, brilliant, thanks Steven. We'll come back to lots of those bits, I'm sure, as we go. Viren, to you, same question I suppose.
- Yeah hi everyone, nice to be here. So I'm a GP partner in Stockport, Greater Manchester. I'm also a PCN Clinical Director, and as we started to move into ICSs, because I hold a role across the practice, the PCN, the LMC, and our GP Federation, I was asked to sort of become the primary care representative on our shadow locality board, so I've been doing that now for just over six months. Where Stockport has a population of about 315,000 and we're part of Greater Manchester ICS, so, following on from Steve, I suppose in some ways we've had a bit more time to mature in ICS because we were part of the GM Devo sort of experiment. So I think quite a lot of the system working across our ICS has been in place for some time. So in Greater Manchester, we have a Greater Manchester primary care board where LMC federations and PCN clinical directors come together to discuss primary care strategy across the piece. We've got 10 localities or places in Greater Manchester. One of the challenges that we have is in terms of demographics, those places are quite different, and I think for us in Stockport, there's a sort of double issue in that we have, again, a very polarised borough. So managing health inequalities is one of the focus for us as a place.
- Yeah, brilliant, thanks Viren, and we'll come back to localities and places at some point, I'm sure. Just in terms of where you come, obviously you said your system Manchester was kind of one of the early ICSs long heralded, thinking about, you know, July the first and that very important date, what's changed since then?
- I think the sort of transition to ICS has been really interesting. We were told, you know, there's a big fanfare originally, everything's going to change on 1st of July, and actually as we've approached that date, I think increasingly the message has been, nothing's going to change immediately, this first year is going to be a year of transition, so, I think, as far as kind of things changing immediately, there hasn't been, I think, a huge change that people have noticed. I think for staff that used to work in CCGs, there's been quite a lot of upheaval, as people have tried to work out, you know, where, they're fitting in the new system, have they got a role, have they not? And, you know, my reflection has been, every time we go through a big change in the NHS, it seems to get worse at doing it rather than better, and I think that certainly managing our people, I think on reflection could have been handled better from sort of a commissioning, system point of view. So it feels like people are now just trying to settle back into role, in some ways carrying on doing what they were doing before, and I think that in most areas we are finding ICSs are coming together. I think that relationship between councils and the NHS, you know, feels like it's featuring quite highly in all ICSs in Greater Manchester, actually, all of the place leads for our boroughs are chief executives of our councils, and so therefore we now have a deputy place lead who comes from that NHS background to try and sort of align those two areas together. I think locality boards feel like a really interesting space to be where people are trying to collaborate and do things differently, but I think one of the things that has come very clearly from ICSs is, or from nationally, I suppose, is that challenge around elective recovery, that challenge around post COVID recovery, and quite frankly, that financial challenge, which seems quite significant that all areas are kind of going to be focused on over the next 12 months.
- Yeah, fantastic, thank you, Steve, from your perspective, what's changed since July 1st?
- I think probably from a provider perspective, not that much, I think for us this has been a process that's been building over a number of months towards that kind of formal handing over of power. I think for, as Viren says, as for those individuals who were working in former CCGs or in ICSs, that was a really significant day in terms of their kind of organisation identity and that clarity over what their roles are, but I think in terms of from a provider organisation, we've carried on as we were, probably slightly harder to find exactly, where decision making is happening now, as that balance is, again, is very describing between what you're doing at place level and what decisions are are being taken at ICS or ICB level needs to work through. So I think for us, we'd already seen that the ICS had taken a much greater role in the planning process last year, and sort of the ongoing revisions of those plans as we try to live within the financial envelope that was available, whether it's kind of action to tackle urgent emergency care challenges, or a number of other things that there are up now ICS kind of wide interventions, and so I think for us, the 1st of July didn't make a big difference to that. It was already happening, and probably now we just kind of, I think, probably going to have another two or three months just while everyone kind of lets the dust settle on that, some holidays out of the way and come September, and I think there'll be much more clarity about structures and process.
- Yeah, brilliant, thank you, you've both talked a little about the journey and it's been a period of time to get to this point, so it hasn't been a sort of an over-night switch. Do you feel that your colleagues in your organisation around your system are ready to work in a system, a joined up system way rather than still being organizationally focused, Steve?
- Yeah, I think COVID probably more than the move to ICS has helped people on that journey for certainly in the kind of the part of the system that I work in, it was incredible to see that the shift almost overnight from people feeling, you know, territorial around their organisational priorities, and wanting to work together, but as long as it helped to achieve the things that they were looking to do to really kind of focusing on what is the biggest problem for our communities now and how do we all work together as best we can, kind of not being precious about who's kind of staff or resources. It was really about that common goal, and I think, that's helped us as we we're trying to move to that way of working longer term. It does feel that that's got more challenging as the financial situation has got worse. I think it's always more difficult when people haven't got enough to start with, to think about how they work differently, or to think about how you can work with someone in a way that perhaps doesn't benefit the service that you are responsible for, or the team that you work as part of, but I think the strengthening and deepening of relationships that happened, that was in a good place to collectively deal with those challenges, and it does feel like there is more of a sense of shared challenge, whether it's workforce or finance or recovering the elective position or dealing with the demand for a acute services that no one can really respond to as quickly as they want. So it does feel that that is more of a system rather than just being an individual organisation problem.
- Brilliant, thanks, Steve. Viren, does that resonate with you?
- Yeah, absolutely, I think, what the timing I suppose of ICS is coming in, as Steve alluded to, actually we've seen, if ICSs weren't happening, we've seen so much other change, I think that has driven new ways of working, and I think COVID being the sort of prime driver, I think for forcing people to come together in ways that they perhaps wouldn't have done before. I think as we move into ICS's one reflection, I suppose, is the important of OD, organisational development, and people development, and, you know, I think, when there is that burning platform of COVID, it allowed people to come together because some of the shackles, I suppose, that exist in the public sector were almost removed. Now that we're moving into this new period where we know there's going to be scrutiny on finances, we've got a huge challenge of elective recovery, and I think we've also got a fundamental shift in society, I think we're going to see, I suspect, some real changes in demographics and the way that people work, the way that people move and therefore the impact on people's health over the past two or three years, that we're only really starting to understand and the way in which they consume public services as well, and want to engage with them. We're all going to have to work differently and it's finding a way to do that and taking our staff with us, I think at leadership level, it does feel like there is a real will to work differently, and I suppose it takes time for that to cascade through all of our organisations. As far as frontline staff are concerned, nothing's really changed from the 1st of July. They're still doing the job that they were doing. The challenges are greater than they were before, and how you kind of cascade that willingness to work in a new way down to staff who are just got their nose to the ground, thinking about almost day to day in some cases where we need them to look up and start to look ahead and look at what may be coming is a challenge, I think, for all of us as providers.
- Yeah, brilliant, thank you, and I mean, there's the old adage of form following function and that's been a lot made of the appointments to various sort of borders across ICSs. Do you feel there's kind of a common sense, you both talked about, you know, that coherence, do you feel there's that common sense of understanding what the priorities are within your system?
- So I think, I suppose it's for us, as leaders to drive that conversation, so certainly, in my place, in my ICS where we wanted to start the conversation, it's very much looking at population health, really understanding your population, and what those challenges are, and then you can start to shape a narrative and a strategy around that. I think all too easily in the public sector, we can start with the finance, we can start with the huge issues we have around workforce, and try and build a plan from there, and that always takes you into a slightly different place. So I think that idea of starting with the population, but also really starting with a strength based approach, and looking at your assets that you've got, I think it's on us to drive that, I think, sometimes it feels to people that the ICS is some ethereal thing over there for us that are working in a place, whereas actually we're all part of the ICS, as much as we are in places, we should be driving that ICS strategy, which is difficult. There's enough of a job to do locally, as well as trying to do that system working, but I think we need to think about how we free up the right people from our place to be able to do that work, shaping that ICS strategy overall.
- Yeah, and you talk about population health there, and it's something we've talked about several times over the last couple of years. Do you think, are your colleagues locally ready to, or have already made that mental shift around we're not now looking at specific cohorts or not specific pathways, not specific episodes of care. We're looking at a different type of picture. We're looking at a broader piece. Do you think people have made that mental leap so far?
- So I think, that really, I suppose in most areas, it's moving that conversation to, rather than focus on kind of disease cohorts, and specific kind of populations, it's really thinking about neighbourhoods and PCNs, and I think that that working between primary community care, as well as social care, those integrated neighbourhood teams really understanding your local population is the key driver, I think, to work in a different way, because once you start to look at some of those population challenges, you recognise that actually the ability to really to turn that dial, doesn't sit with us in health necessarily, is those wider determinants that are really important. So in our place based board, as well as our neighbourhood boards, we're starting to bring in housing, we're starting to bring in the voluntary sector, we're bringing in health watch and patient representation, but we're also bringing in say a fire service and our local police and crime commissioner, because actually the ability to influence that health in its wider sense, it's far out with the traditional services that perhaps were commissioned with the NHS.
- Yeah, thank you, Steve, I'll come to you with the same question about, have you got clarity over what priorities are for your system?
- I think we've got a long list of things that we want to do, and the challenge is going to be how to prioritise within them and where that prioritisation will take place so that, you know, that's absolutely right, that this is our opportunity to think differently about the communities that we're here to serve, what will make the biggest difference for them, and whether you are doing that at ICS level or place level or neighbourhood level and where those things are perhaps in conflict, because the priorities are different in different neighbourhoods or in different places, how you then square that back at ICS level where the board and the partnership will be setting the overall strategy and direction and access to analytics. So getting the really good data, as well as it properly engaging with communities about those things, that are important, are going to be really key to doing that, and I sort of see for organisations and for the ICS more generally, how you balance the pressures of the things that must be done now, which are the traditional things that as a service we've always been trying to do, you know, waiting times for elective procedures, the kind of pressure on access targets in other ways, meeting the financial challenge, how you stop some of that in the moment to be able to do the other bit to reprioritise, and then to commit to doing the preventative work that stops people going on to be in crisis or to need other interventions and doing that work collaboratively with others, recognising the limits of where we do is probably going to be the litmus test in some ways for the ICSs in terms of whether this is really a new world, or whether it is just a reorganisation of the world we were in before, and I think it's probably a little early to tell, I think that the language is different. I think the objectives that people describe and the lens on inequalities and prevention are important, I think, it's kind of beholden on all of us who work within those systems to make sure that we do keep those as being at the forefronts, and I think as well, not losing sight of how you do engage with communities so that we are not prioritising for them, but actually with them and kind of using those lived experiences and people's insight.
- Yeah, thank you, and yours is a really interesting role 'cause you're employed by an acute trust running community services, engaging heavily with primary care, so I guess you've got a really good view on all those sort of traditional parts of the healthcare system, if you will, you talked a bit about language evolving, have you known the kind of cultural evolution or the way in which conversations are being held is changing?
- I think it is, and you know, how much of that is directly related to the changes of ICS, and how much this is a continuation of a journey that probably started decades ago, but really that five year forward view shift in terms of a community level, how you bring different health teams and care teams together to work differently, and I do on a daily basis now see shifts in terms of people talking to other organisations where historically you would've done the work internally, and then once it was ready, you might have shared it, but only to tell people what you were doing differently, whereas now it does feel like there's more of a recognition that from the start you're going to do that work together, you're going to think about whole pathways, not just the small part of it you might be responsible for, and with that starting to unlock opportunities, and I think the more that the kind of frontline clinical teams see how their daily lives could be made better, and make it easier to support their patients in the way that they want to, the more momentum we will get to taking that forward. I think there's still lots of work to do, Viren was right about the kind of work and the cultural bit. We've worked in these organisational silos, and with team identity for a long, long time, and so shifting that into this completely different way is going to take time to bring everyone, but I think that the more people who do it and the more success that you see and the more colleagues that they then bring into that approach, you can see it starting to spread.
- Yeah, brilliant, thanks, Steve. So, Viren just sticking with priorities for a little bit longer, so in primary care, you are subject to lots of competing priorities anyway, and now for you your a GP partner, you also sit on a Federation and a PCN as well as being on the locality board, so you are kind of privy to possibly lots of the different drivers. So you've got your core contract, as well as primary care DES, and kind of locality things that be going on, as well as national initiatives that are going to be thrown at you every once in a while. How do you, or how are you kind of managing those competing priorities at the moment?
- Now there's a question. So I think, what certainly, I mean, so at the moment I've a role at practice level, PCN level, Federation place level, but also ICS level in Greater Manchester, and I think that what you've got to try and do is, my approach to it is actually, I don't say anything different at those levels, because actually the right thing to do generally is the right thing to do. Your lens might be slightly different in terms of what you're trying to achieve, but I think the key is, what we sort of said earlier is actually making sure you set your right priorities and set that throughout that organisational structure, so everyone feels they own those priorities, everyone feels they own that strategy and direction of travel, and everyone can see that everything that you're doing both at practice level or at ICS level is taking you on that journey to that place that you want to get to. I think all too often, we create strategy in a room somewhere and just expect people to follow and go along with it, and I think the trick that we've got and how you do that across sort of the new structures and the ICS is really important, and I think therein, I suppose, one of the challenges that you've got is the brand of the ICS and the brand of the place, because we're used to having, you know, either an NHS logo or a council logo, or, you know, people have gravitated around those things historically, I think what each place has to do is find out what that identity is, how do you? So we've created the brand of One Stockport, which is, you know, all of us in that place coming together, regardless of which organisation we work for, but all working towards that same strategy, and we have a One Stockport strategy that isn't owned by any one organisation, but hopefully contributed to by all, including the people that live and work in Stockport themselves, that's really difficult to do, and I think that that shift in culture, you know, the whole purpose of ICSs is to break that traditional split between commissioner and provider, is really difficult for people who've worked in either setting to do that overnight. We've had 20 years of increasing competition between providers in the NHS, and we're now talking about, well, forget that, and now you collaborate in a provider collaborative and deliver, you know, on a set of kind of high level outcomes. That's really big change, I think for our staff, and for us as leaders of the system, and I think the more effort we put into supporting that change, managing change, which traditionally we often don't do as well as we could do, I think the more successful we'll be as we start to have conversations in a different way.
- Yeah, yeah, okay, and do you feel emboldened, I suppose, to be in control of those priorities, whereas, you know, traditionally having worked in primary care myself, you know, it's been a case where we've got a contract, we need to stick to that, and there's certain things, rules we need to follow to kind of play the game, if you will, kind of that idea of coalescing behind the One Stockport, do you and your local partners feel actually, you know, we're in control of this game now, it's our place to decide what we're doing and then the bits that we are contracted to do and what have you will make sure fit with what we're trying to do.
- I think that lots of us that became PCN Clinical Directors really hoped that PCNs would be given the freedom to really understand their population, start to plan services with our community services, colleagues and our social care colleagues and our local sort of assets that we have in the community, and start to do things a little bit differently. I think that was the ambition that many of us had. As the PCN has developed, it has turned into a bit of a nationally set list of directives that you have to deliver them, be that enhanced access, and, you know, when we have such different populations across the country, actually specifying that everyone needs to get an appointment up to 8:00 PM and all day on a Saturday, is the kind of priority for what most PCNs are focusing on at the moment, how do we do that from October? As opposed to actually, we've got a real challenge around health inequalities, that's different in every PCN across the country, how do we understand that and tailor our service to meet that demand? So for me, I think it's been a bit of a shame that the PCN seems to have lost that direction into a list of very specific nationally set indicators when actually the opportunity is much greater, and as Steve alluded to, there's challenge, certainly for me, is how do you create enough head space for people to still do that stuff when there's so much day to day happening that they have to hit in order to hit target so that you get the finances to do the other stuff? That's the challenge I think, is a lot of the time is just creating that head space for people to come together and giving them permission, I think, to work differently, and I think we are yet to see as a place and as a PCN, how much autonomy do we have in decision making as we go forward in what's going to be a very challenging 12-18 months for the public sector. How much is going to be set at ICS level? How much are ICSs going to have mandated to them in terms of delivery and therefore how much freedom do we really have to do the things that think all of us want to do, have the ambition to do.
- Yeah, brilliant, thank you, Steve, I'll come to you just on that piece. You work a lot with locality partners all over the system. Are you seeing them feeling empowered yet or seeing people finding that head space to do things differently?
- Yeah, I kind of would agree with Viren in terms of people can see the potential and whether that is, as you say, through PCNs federated practices, working together, the opportunity for the people at neighbourhood or place level to come together and do things differently, and I get a sense from talk to colleagues around different parts of the country that quite a lot of CCGs and providers had evolved relationships around their localities and had managed to move away from that really traditional commissioner contract provider delivers sort of way of working, and I think there's a risk with the ICS that because of the size that it covers, and that it is harder therefore to have those kind of interpersonal relationships rather than doing what it intends to, which is that kind of collaborative ownership of the problem. In some ways, it goes back to a more traditional sort of command and control way of working because it's dealing with such a disparate kind of range of different providers across the places that it serves and as well a danger we've added another layer of governance in, because you'd still got all of those things happening at place that were before, you've still got your regional NHS England structure, and something else has come in in the middle as part of that decision making, and so perhaps that relationship between the NHS England region and the ICS, and how much NHS England allows the ICS the freedom that the legislation sets out, that it should have to do its work, rather than they just become a conduit for the latest top down kind of must do, and just challenging down to places. So I think we've probably got 6 to 18 months where it'll go one way or the other, that will go through this forming stage that all ICSs will be doing, and some that have been as part of this front runner sites, that have been doing this and have got their kind of governance between place and ICS working really effectively already, and first it was just kind of putting in legislation what they were already doing, others that are kind of still evolving a little bit in terms of that, but coming out of it and having real clarity of where the freedom to act lies, so your place, these are all the things that are within your scope. This is where we want to do the work at a bigger level, because it makes sense to do it once and we can learn from each other and we can get those efficiencies and economies to scale versus that it's, as I say, it just becomes kind of a repeat of what we were doing before, but just with a different group of people wearing kind of organisational lanyards, and describing it being different when the day to day reality for frontline staff is unchanged.
- Yeah, brilliant, thank you. I wonder if you both can help out with something I've been trying to figure out, so I'm trying to think, what's the new word for commissioners? So, we use commissioners, will we still be talking about commissioners in terms of those people at the top of systems sort of paying for and designing service, or are we going to have a new lexicon there? Wasn't on my original list of questions, but it's been bugging me.
- I think we should, and 'cause I think in defining what that word is, might help the clarifying the role. It should be more of a coordinating function, something that brings together all of those people, not just traditional health, but as very much described in kind of local authorities, wider services, really community and voluntary organisations to achieve the sort of a shared kind of agreed priorities. So I think something around a sort of coordinating function would be a better description.
- What do you reckon, Viren?
- Well, I think that's a very interesting question. I mean, I've been smiling quite wryly, kind of watching people from CCGs introduce themselves now with the past couple of weeks and trying to work out exactly what they call themselves and what their new role is, but I think the core function of commissioning must still exist, mustn't it? You know, so you hear that split of kind of strategic versus tactical and yes, but what commissioning, the ethos of commissioning, what it aims to do is still something that's needed across a place, but also across a system. I mean, before commissioning, the word that was used for what commissioners do was planning, and I suppose, that that's kind of what the, and it may be that we start to go back to that sort of language again. It's interesting, working more closely with local authority colleagues where their view of commissioners and commissioner providers split et cetera, is very different to what we've traditionally had in the NHS, and I think as we start to work with our council colleagues more closely, I think that will evolve, but I think that, as Steve said, that function of planning, of coordinating of that strategic work being done slightly separately to the kind of tactical work that needs to happen on a day to day basis remains really important, and it's important as a focus on both.
- Yeah, brilliant, thank you, yeah, go on, Steve.
- Tom, I know you're the question master, but I was just going to ask Viren, do you think there's something that we can learn from the local authority model?
- So I think there's lots that, you know, local authorities have worked in a different way to the NHS for a number of years, and as I said, I think they have a much more, you know, that I suppose the way in which they manage conflicts of interest, the way in which they manage that split between commissioning and provision, the way in which they're able to, I think, flip much better than we do between the strategic and the tactical, but still recognise that they are different, and there's a different space for both, I think the way in which they engage with the private sector actually, or the, you know, the not the public sector, I think is definitely something where we have a lot to learn, I think we have to tread carefully, but I think we can mature our relationship in the NHS with colleagues that actually have a huge amount to bring, and the way in which we have that dialogue, I think, has the potential to shift quite significantly.
- Do you have any thoughts on that, Steve, at all?
- Yeah, no, I think there's probably something we can learn from a lot of different sectors around how these things are done, but I think the other thing for me is that democratic accountability and the way that the local authorities, centrals of national direction is often secondary barring what's in legislation, and instead take much more of their lead from that local democratic process and priority sitting that there is really centred on a place much more than I think the NHS, which is driven through up their central mandate and targets, and I think some of the challenges we've seen when we've been working together with local authority colleagues often does boil down to that as a difference in terms of where organisational focus and approach comes from. So I think for ICS is being able to function in a way that local authorities have done with that real roots in the place that they serve would be a good opportunity.
- Yeah, brilliant, and earlier on, Steve, you were talking about the sort of 6 to 18 months, which might be a kind of defining period of time, so, which way things go, just picking up on that kind of local authority conversation, Steve, we've talked before about converting autonomy for systems, do you think that's going to be part of this, that systems that really show that they can do good stuff and are engaging well locally and actually driving change, implementing change, developing strong partnerships are going to be empowered to do more of it, and others will be given more direction, or do you think it'll be a more consistent either those direction, others autonomy?
- I think that that's one way of managing that relationship challenge with NHS England, and NHS England focusing its energy and resources on the, as you say, the places with the greatest challenges, or that not necessarily achieving everything that they set out to do, it requires some bravery, because allowing individual organisations freedom with foundation trusts or PCNs was a challenge for the NHS, but suddenly you'd be talking about, you know, million plus population regions being able to do, and Viren probably got more experience of that from the Greater Manchester and evolution work, I think given the challenges that the NHS has across the board, how many places will be in that end autonomy space is probably going to be lower than it perhaps would've been at different times, and some of that may come from sort of ministerial level as well in depending what changes we see in government, and how much kind of ministerial direction comes with whoever long term is the secretary state for health, 'cause that's one of the other things in the legislation is that the secretary's got more power to direct the NHS than they had previously, and so I think how NHS England responds perhaps will be kind of influenced by that, and then that will follow down through the system.
- Yeah, brilliant, thanks, Steve, so, Viren, I want to comment kind of the structure and decision making piece that we've kind of touched on throughout the conversation. I suppose, as a starting point as the system developed, the Manchester ICS and component parts of it, what is it you want to see from the structure and the governance and that side of things to allow you to do more locally?
- Well, I think for most of us, I think clarity is what most of us are asking for as think the just starts to settle off of the kind of reorganisation, and I think one of my fears is that we end up having the same conversation at, you know, certainly for me, at practice level, PCN level, you have the same conversation again at place, and then you have the same conversation at ICS because all of those people are trying to skin the same cat and tackle the same problems. So I think clarity around what's the focus of the ICS, and you know, for me, it should be doing the things that are best done at that scale, and sort of solving those system problems around sort of tertiary level sort of provision, around some of those really fragile services where bringing those things together is helpful, and I think once places know that that work is happening at the system level, they can then be much more clear about what they are doing at place level, and what their key priority is, and as I said, really speaking every place should have a different type of priority because we're all very different, and our challenges should be different, even though there are some key crosscutting things going on in between. I think that the working at system level, but also working collaborative at place level has some opportunities around, I suppose, what I'd call the enablers. So, you know, actually how do we address our workforce challenges collectively at system ICS level, you've got much more ability to, for example, to influence your higher education institutes around training and development. You've got much more ability to think about actually kind of aligned roles across health and social care and so currently, one of my current challenges is, I'll go and visit a patient at home, they will have district nurses, and then also have a care package and have people coming in during the day, how do we reorganise ourselves, so that we can try and align some of those contacts and make every contact count and try and use some of those generic skill sets across the piece? That requires quite a shift, again, a shift for our staff in terms of their focus and how they work, but also requires some flexibility across organisations for people to be able to work in that slightly different way. So I think, it's about clarity of what's happening where, I think decision making currently does feel very difficult, I mean, you know, it's quite, in terms of what freedom does a place have to make some decisions to go off in a slightly different direction, if it wants to, finances, I'm hoping things will become clearer, but financial flows is still something I don't think we've certainly figured out, especially as we approach winter where there's often a need to make some tactical decisions around finances to address kind of key challenges. So I think clarity, I think more than anything else is, is what people are asking for, and I think recognising that locality boards really should be staying quite strategic, so I suppose, where those more tactical decisions that perhaps would've been made between CCGs and individual providers before at a place level, how does that happen? And I think one thing that we've not talked about is the provider collaboratives or provider partnerships that are evolving, and in some places they've been in existence for many years, in some places they're a new entity, I think increasingly the importance of those provider collaboratives, I think in terms of being able to work cross provider in new ways, recognising that there isn't more money, we're going to all have to use our resources more efficiently than we currently do.
- Yeah, brilliant, thanks, Viren, there's definitely a couple of things I think we'll come back to in there, Steve, in terms of your systems kind of structure and governance, what do you want to see from things across yours?
- Yeah, I mean, completely agree with Viren, that clarity over where decisions are made is going to be crucial 'cause you can't make every decision at ICS level. You need well local insight to make some of them anyway, but also there's just too much that needs deciding for it all to sit centrally. So, knowing what is delegated to local level, and the resources that are there within that locality's kind of gift to use as they see fit and with freedom to move those around, it's going to be really important for people to know who's doing what, and where they're doing it, and also not to be left in a, the risk is inertia whilst it's not clear where decision making is, that in the end decisions don't get made. So, I think for me that that's a real priority. I think that the collaboratives is a good one to think about because I see it happening sort of both horizontally and vertically. So you've got, and perhaps, you know, Viren and I both work around community organisations. We feel it probably more than perhaps our acute colleagues, because there's a desire to collaborate as community health providers across the ICS and some real rich learning that you can get from understanding what others are doing in different places, 'cause sometimes it can be a bit insular in my world around community, 'cause your relationships are all within the place. So knowing what other community organisations are doing, and the same is happening with primary care working in increasingly sort of larger collaborations of primary care to sort of an ICS level collaborative. So you've got all of those vertical collaboratives happening and an acute one whilst at the same time trying to have horizontal collaboratives happening at place level where all of those different types of organisation are coming together, and it's not a bad thing that you've got both of those, but the risk is you are not quite clear, who's doing what and where, and you end up having, as Viren said, the same conversations, 2, 3, 4, 5 times, each coming to slightly different conclusions or with slightly different people in them, and there's not enough time in the day already to do all of the things that needed, and we talked earlier about priorities and how would you make the head space and time for people to work on the population health challenge, which is, when we come back to, is the real kind of goal of working in this way. So, I think, the cleaning up of the governance, which is why I think you've got that 6 to 18 month period, is 'cause it will take a bit of time for that to work out and people to know what their roles are, particularly for people who were working in commissioning roles before, and I think are still getting that clarity, and as that comes, there'll then be some transition as people move and do different things, and therefore systems come back together with the people who'll be working in them. It will be making sure that we do things at the right level once. So we should delegate everything down as low as we can, other than the things we're doing it 50, 60 times across an ICS is a duplication of effort because it's the same conversation and the same work there, the things we should be doing once at ICS level or doing their place, but really getting as much down to that neighbourhood team level as we possibly can, and definitely trying not to do it each of the three levels.
- Yeah, thanks, Steve, just listening to you there without wanting to do you out of job, do you think community services, as they have been commissioned sort of historically will continue to be a thing or do you see that just kind of being absorbed one way or another into either place or neighbour type working?
- Yeah, I mean, functionally, they will, you know, there will always be a need for the work that they do. I think you've already got a real mixed bag of organisational models for delivering that from standalone community organisations as community organisations, through to NHS standalone community providers being part of mental health trust, being part of acute trust. So being kind of properly paired up with local authorities in some places and in the country. So I think you will probably see that same kind of variable approach across the country in terms of places doing what makes sense for them, and for some that will be still being hosted within foundation trusts within the area. I think you may also get some places where actually the majority of PCNs or federations of PCNs is such that they could take on the delivery of community services. There's a risk for me around some fragmenting, some of that down too far in terms of kind of governance and shared ways of working, but I think it's probably going to be horses for courses, it's going to be based on the organisational structures and their maturity, their kind of relationships trust, and I see an evolution of that sort of local provider organisation, that's going to be doing a mix of local authority, some of the work that's traditionally done by local authorities around social care, the work around community health, probably some elements of mental health, some elements of primary care provision, and some more things that will add in with shared management structures, but what organisational form sits behind that I think will probably be different in different places, 'cause you know, we can't just do things once across the NHS, it'd be far too simple.
- Yeah, thanks, Steve. Viren, you let the finance's elephant into the room. So what, in terms of that, obviously there's lots of conversation around doing things differently, innovation, everything that goes with that, but the money's not necessarily there to attach to that. How do you see that kind of playing out? Do you think that the lack of funding is going to stop innovation or do you think there'll just be different ways to approach it?
- So I think it comes down to the maturity, I suppose, of the system, I mean, it's not that the funding isn't there, there is, so, I think there is always an opportunity for us to look, now we're looking wider than just the NHS at maximising efficiency and driving out duplication, I think the amount that goes in duplication and wastage, I think there's a huge opportunity to look at that differently with different partners around the table. I think that the flow of funding and where decision making around funding sits is probably in some ways the bigger issue, where I think all of us ideally want to have that focus on population health, we want to move from a more, you know, from a reactive system to a more proactive system that focuses on prevention, but we all know that those sorts of interventions around prevention are not something where you see benefits within 3, 4, 5 months, they're 2, 3 years, and I think how we allow systems and places to hold their nerve, I suppose, as they make these decisions is going to be the key, how we give them the breathing space to give them the time for these things to evolve and develop, I think is the key. So I think that we can always complain about there not being enough funding, there not being enough money, but actually when you look at every ICS in the country and the potential funding at therapists' disposal, we are talking colossal sums of funding, and within that, there are always opportunities for us to do things differently, but I think that real focus on duplication and wastage, I think that real focus, which I think, so one of the issues that we have in the way that traditionally this NHS was set up, is that every organisation actually often struggle to make the change because it relies on things that happens outside their organisation, and I think if ICSs and places are to be successful, it requires us to focus on the things that require all of us to come together around the table and completely redefine a pathway in terms of how it currently works, and then I think you do have the opportunity to unlock some results, when we've had big changes like this in the past, we've always had the opportunity to somewhat pump prime, I suppose, and have a little bit of double running, and I think that's one thing we don't have this time around. So that's something I suppose we just need to consider that it takes time for changes to bed in before you start to see the benefits, be they're financial or sort of patient outcomes, and it's whether the new structures will allow that time, I suppose, is the biggest question for me.
- Yeah, brilliant, thank you, Steve, same question to you really about how's your system going to innovate, where's the money going to come from? You've got any clarity around that?
- I think probably limited clarity today. I kind of reflect on some of that real strong innovation we saw in COVID undoubtedly, some of it was the kind of pressure in the moment and the need to do something, but the other part of it, which we'd always talk about as much was the access to money became not a challenge at all. So anything you wanted to do, money wasn't a barrier, and I think what we saw with that is an unlocking of the creativity within public services generally, that is often constrained by how are we going to fund this, or how are we going to resource it? And so how as an ICS and how as a system, we start to bring together all of those little pools and pots of money and funding, that are always there into a more kind of like almost like an innovation fund that you can tap into to do the double running and to do the kind of proving that that way works, and the opportunity we start to have by working together across sort of organisations and services is that traditionally, we might have done something different in community health where the benefit largely sat in primary care. So, then your challenge becomes well, who pays for that? I think as you work as a system, it becomes less of an issue where the benefit falls and where the investment comes from, because it's all part of the same. I think there's still an issue there about kind of lost flows across teams and services within that bigger structure, but it really is not an opportunity to think, and particularly where those economic benefits fall broader than the NHS, so certainly into social care, but also kind of into the wider public sector, thinking about how we use the billions of pounds, if we are honest, that we've got our disposal to do more good.
- Brilliant, thank you, well, I've just got a couple of minutes left, I suppose, the last question, well, penultimate question hopefully, Steve, if 56:13in terms of that bit around innovating, if you could do one thing differently, or you and your colleagues in kind of getting towards a more joined up way of working, what would the innovation or the area be for you that you'd want to look at?
- I think the thing that comes up in almost any conversation around integrated working or more collaborative working is around access to shared records and the ability for people to all have access to the same information about the people that they're working with. So I think for me, if we're only allowed one thing and it would be a single easily accessible digital record, that worked, I think it, one thing on its own is never enough, but that for us would be a really big thing.
- Yeah, Viren, you're not allowed the same thing. So what would your one thing be?
- It's just, 'cause I've seen the benefits, I suppose, when you get, for example community services and general practice onto one record, it's a game changer, and in terms of reducing duplication, it makes a huge difference, I think for me, actually the bit of the system where I think there's the most variety in kind of the model of provision is in community services where as Steve alluded to before we have things that have grown up over a number of years and within community services, I think the bit of the system that feels particularly fragile for me, where I think we can do a lot and innovate, is that intermediate tier, it's that step up and step down between primary community care and secondary care where, you know, traditionally people have often ended up in the hospital bed and then staying in that bed for longer than they need to, and that process of getting them back home and getting them to hopefully as full function as possible is often that lots of different providers in that space, lots of different, sometimes perverse incentives to people to do one thing or the other, I think we could put some real focus into that bit of the system and make some real improvements to how we do things, and I think that's where technology, I think, has a particular role to play around. You know, it doesn't require five different people necessarily to go into somebody's house to deliver an intervention. There are potential ways that we can monitor people. We can intervene with people, we can support people, but it requires quite a shift in how we might do that. The other area of innovation I suppose, is thinking about that relationship with the outside, the public sector and the private sector, and, you know, recognising the huge expertise that exists there, but actually one of the things we struggle with is often around workforce, and actually there's a way of supporting some of that innovation with manpower for want of a better word, to create some of that space that you need for your own staff to be able to do things differently, and one of the things that I sort of, my reflections of colleagues across the public sector is that we've built up strong relationships often with CCGs at place level, and I think it's really difficult now for people who are trying to engage in a particular change, they might want to make as to quite know where to go. Is it the ICS, is it the PCN, is it the place? And I think that's probably something that we all need to think about in terms of where that fits in in how we work.
- Fantastic, thank you very much, Viren, thank you, Steve as well, both for joining me today we're just about out of time. So that's been another fantastic conversation, great insight from you both on the journey today. So thank you very much. I'll be back on August the 19th, speaking with Dr. Alex Degan, who's the Primary Care Lead for the Devon Integrated Care System. We'll be talking about what system planning looks like, the priority setting down there, and how they're looking to bring innovations in as well. So continuing some of the same themes and then building on it, hopefully with another month under our belt of integration. Final reminder for anyone that hasn't signed up to have a look at the handout for our symposium, we're nearly full on that, so again, while you can, thanks again to my two guests today. Thank you everyone for watching, and we will see you next time, bye bye.