Why are we waiting? - Pressures facing the NHS and how to deliver change

With so many patients left waiting for NHS care, what will the long-term impact be? How can Pharma and Medtech support the NHS with systematic challenges, like waiting? Where can industry work with the NHS to improve patient flow to get people appropriate treatment sooner and limit the harm caused by waiting?  Prof Phil Richardson (new Chief Innovation Officer, Mtech Access and until recently, Executive Director at NHS Dorset ICS) joins Tom Clarke (Director, Mtech Access) explored all this and more.

In this NHS Whispers webinar, we explore:

 - The pressures facing NHS systems and how this results in patients waiting
 - The long-term impact of this waiting; what it means for patients, their  - outcomes and treatment
 - What informs how NHS system leaders identify and approach these challenges
 - How health and care systems can make effective decisions in this climate
 - How Pharma and Medtech can support system leaders with these challenges

This webinar was first broadcast as a live webinar in November 2022. Learn more.

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Transcript

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- [Announcer] Welcome to this Mtech Access webinar. At Mtech Access, we provide health economics and outcomes research and market access services from strategy through to implementation. Our unique NHS relationships guide and validate everything we do in the UK. We work with over 80 NHS associates to bring our pharmaceutical and medtech clients authentic insights into the NHS. We can help you answer key questions related to the NHS from how to communicate with integrated care systems, places, and primary care networks, to how to capture pathways of care. Get in touch today to discuss your market access goals. First though, I hope you enjoy the webinar.- Good afternoon and welcome to the Mtech Access Words of Wisdom webinar. I'm Tom Clarke. I'm here for the last time to interview and to hand the baton over to Professor Phil Richardson. I've been running these webinars for two and a half years now, and it's time for a fresh perspective to help you continue to develop your understanding of the evolving health and care landscape. As we were preparing for today's session, there were so many topics that we could address, but one that jumped out was waiting. Over 7 million people are waiting for elective treatment, 69,000, waiting more than 62 days to start cancer treatment. But in October, over 43,000 patients had to wait for an admission from an emergency department following decision to admit. With strikes looming, winter starting and a rapidly advancing vacancy rate, what can be done to improve access to care. So, Phil is perfectly placed to be able to walk us through this complex landscape. Until recently, the Executive Officer of the Dorset ICS, Phil has a passion for system thinking and innovation through data. Phil developed the ICS model and is well equipped to talk to the complex issue of waiting. Having chaired clinical strategy and transformation groups in Dorset, as well as having been gold command for Dorset's COVID response, now, Mtech Access' Chair and Chief Innovation Officer, Phil looks forward to leading new conversations with you, our clients and NHS colleagues, about how we can collectively overcome some of the significant challenges facing health and care in the UK. So Phil, it's great to be here having this conversation with you. Welcome. I've given a bit of an introduction for you there, but could you, for the audience, just give a a bit of a broader introduction about yourself and how you've come to be here?- Great. Thanks Tom. And thank you very much for inviting me to join you on this webinar. Hello everyone. I'm Phil Richardson. As Tom said, I just recently joined Mtech Access in October. Prior to that I worked in the NHS system in Dorset. I started there in 2014 with a responsibility of doing what was the NHS's first whole system reconfiguration. So this was right across primary care, secondary care, mental health, the link through to tertiary care, and how we connected through wider partners in the local authorities with a specific focus on social care and developing relationships with the university sector as a whole. I started out with that particular programme, then moved on to take responsibility for digital, so it was the SRO for digital across the patch, looking at how we created the integrated care, shared care record, how we looked at population health management, how we identified the flow of data and the use of data, and how we started to look at data solutions at home. So our broad focus was delivering care closer to home, and that became the digital. I then, have responsibility overall for commissioning, for urgent care and elective care specifically. So, this was looking at the urgent care pathway for people who had a need at home, where they believed they had an emergency and how did they connect right through to being in the right place for the right service. So responsible for all of that, including the emergency response through COVID, which Tom has just covered, and elective care, which leads into the waiting list and the broader conversation. So that was my broad portfolio and underpinning that was a responsibility for innovation and research. And that became more and more critical as we went through, including the need to set up a COVID vaccine response service and the delivery of research around one of the early vaccines that we used in COVID. So, it's broad scope of responsibility across the patch. As Tom says, as part the executive team, I sat in the CCG, but worked on an integrated care system point of view. And that working with colleagues in that system, we developed one of the first STPs and went on to be one of the first three ICSs in the country setting the template that's subsequently been used to set out what an integrated care board and an integrated care system looks like.- Fantastic. Thank you very much. So, from this point, we're all aware of kind the integrated agenda. Could you just comment a little bit on how you see integrated care systems progressing and maybe a couple of examples of the kinds of things that you were involved in Dorset?- Yeah, of course. I think the important bit first of all, is to get to get an orientation around some of the language. So integrated care system is often used to mean what the NHS is doing and what the broader partners in a geography are doing. The new legislation's really helpful for that. So as a progress in terms of just language, it's been really useful to get some clarity around an integrated care board, which is the combined NHS effort managed through an executive structure with the chief exec and an integrated care partnership, which is led by an independent chair and partners around the table, one of which is the NHS. And those two structures together create the integrated care system. So there is a good interplay now between the wider determinants of care, which we all understand are critical to developing health and care strategies for geography, and then the NHS's specific role in how it delivers clinically led care in different settings. So I think, just progress generally in getting some structure on the language has been really important. I think focus on patients, whilst that's always been part of the conversation, does get overtaken from time to time by focus on activities, so counts, number of people at certain places, and I'll touch on that later when we start to look at why are we waiting and start to look at that question. Well, I think the key thing by focusing on patients and patients in a community, their language used again is local neighbourhood, which is part of a place, and then a place is part of what is now a boundary around one of the 42 integrated care systems in England. I think that really does set out a framework for the focus of effort, whether that be workforce effort, funding effort, research effort, change effort, I think that's really helpful. So I think I see that structure being the way forward. I fully support that. And having been part of its genesis really see that being an important way of going forward. And as a result of that, people are working differently. The, the COVID pandemic whilst horrendous in lots of different ways, did accelerate some of that for systems around the country. And I've seen much closer working where people less define themselves on the organisation they work for and more define themselves around the purpose they're there to help solve. So that's been really positive, particularly in the digital space, particularly in local authorities across multiple disciplines, not only social care, working together, but also bringing police and fire around the table, bringing the other public sector organisations, but also importantly the other public service organisations. So, organisations that have a common need, they're addressing a common public need, whether they be charities, third sector voluntary organisations, other commercial organisations for other, as I say, public sector organisations, all of those people are now around the table trying to solve things. And I think ICSs will start to emerge, they're all at different levels of maturity. Some having worked on this for either much longer or they've had a much more logical geographic boundary where the local authority, like Dorset, really quite nicely self-contained, where the NHS boundary, the local authority boundary, the police boundary and much of the fire boundary was all pretty co-terminous. So, that just makes it a lot easier to be organised rather than organisation. Others have had split flows. So, somewhere like Frimley where they flowed in three directions with a hospital at the centre of all of that, is harder to manage. Although Frimley has been particularly focused on making that work. Surrey done the same thing, Manchester's had the same type challenge. Gloucester has had the same challenge. So, everybody's at a slightly different stage of maturity. So I think thinking about ICSs as a whole probably is a bit misdirecting when you are thinking about what is the ICS and its strategy. So, I think you need to really drop down a level to each one, find each is working differently. So, if I look at things like innovation, the health foundations have funded for innovation hubs, one of which is in Dorset, which says that's good for a centre of innovation when they're looking at digital. Hampshire had focus on in investment in digital. So, the ICSs themselves have got centres where they're becoming role models or at least centres of best practice, which are being shared out through others. So, there's a strategic play which is broadly what the ICS working. As I say, with the integrated care board and integrated care system. Then on top of that is, there are specialist areas emerging in each of the ICSs, but the overall aim is for everybody to take the experience and the best practice that comes from that, but then tailor it to its local place. And I think population health management's a really good example where the concept is the same for everybody, but the application is different. So I think, Tom, coming back to your question, I think there will be thematically lots of things which are very similar. Though we looked at things that look the same, but once you drill down, there'll be local differences and there may well be some things which are very different in ICSs. But the plan is a good plan. And what's being achieved so far in quite a short period of time is really phenomenal due to the effort of the teams who are now leading this.- Yeah, brilliant. Thanks Phil. And obviously they're all planning and developing at different rates as you say. In terms of the challenges they're facing again, there'll be some variation. But from your perspective, what do you see as the key challenges that will impede patient care over the next 6 to 12 months or so?- I think if we focus on a patient, and I think that's right, and I'd like to use the word patient to mean any person because there are people who are not particularly patients right now, but they may need services going forward. So, I'm just using patient as a generic term. I think that the challenge is around patient care is how, how do we collectively become organised to make sure we get the right care in the right place at the right time with the right professional team or service or products sitting around it. And then coupled with that, we need to be clear on how that's all being achieved. I think lots of the challenges at the moment is, how do we access services? People knowing where to go. There are definitely some very big things which are obvious. Either a hospital is an obvious place to go to or a GP it might be an obvious place to go to. But as I look at the development of services and tools and different interventions, for some people, the first place to go to may be a self-service solution. So, I think it's really being clear, making clear to people how that might work. And if you talk to [] who work in the primary care space or in the emergency department or in social care or out in the community, there's a proportion of the people who engage with them who would be better off somewhere else doing something else to help provide the optimum support. There are clearly mechanisms to, you know, people who end up in the wrong place. They can get moved somewhere else. But the sort of shuffling around element, that's an overhead or a burden on the system that if there was some clearer ways of all being organised and people really understood how that works, then I think that would help. But it does mean though is that, we end up with congestion in our system. And so, we end up with waiting because there's such a lot of moving parts, some of which are obvious. We've all seen the headlines; the queues outside, the ambulance queues outside a hospital, patients in a bed who don't have a clinical reason to be there but may have other reasons such as the need for some level of support in the community or a complex need, so they need to move on to another setting of care or they're waiting for family or support networks to be available at home to support them. Then all of those things lead us to challenges in giving patients the care, the ideal version, which is where I started. And there were lots of things that are just a consequence, a bit like traffic congestion and often the frustration that I'm sure we will all experience at some point, is getting to the front of the queue finally to see that there isn't anything there, which has been the cause for the reason why we've all been waiting or stuck. And sometimes that congestion is caused by a volume issue, or two things happening at the same time. Sometimes it's happening due to capability not being available. Sometimes it's due to a timing. Sometimes it's location. Sometimes it's a quality issue, misunderstanding gaps in comms, gaps in data, contradictions between policies and procedures, between different parts of the system. All of those things play into providing the challenges that we've got. So, I'm trying to really avoid a tokenism answer, Tom. I'm trying to avoid, if we just fixed it, it would all be fine because I think if we would all be fixed with the top three things, we would've pretty much cracked it already. And I think the bit really, I would like to share with the audience is that, the whole of the health and care space is extremely complicated because of all of the moving parts. If I think about my role in the CCG, we were probably managing about 1,000 services, commissioning 1,000 services, give or take. All of them....changing groups and changing locations and changing settings of care. So, there isn't an easy fix. But I will touch on later if we could, if when we talk about the waiting specifically, some of the areas I think collectively, the audience and the NHS and industry and academia can collectively get involved to make a difference. But the real bit is that I think, the threads that we have as part of this session is about waiting. The waiting in quite a lot of cases is not really waiting for somebody to do something. It's a consequence of lots of the moving parts in the collective processes.- Yeah. Brilliant. Thank you, Phil. Really nicely summarised. I mean, in terms of that particular waiting bit then, obviously you've got that view as a system leader of all the different component parts of an ICS. And thinking about, I suppose the ICP and that broader partnership, we've all seen ambulances outside A and E and all of the kind of the media implications of waiting. But thinking from that broader system perspective, what are the impacts of increased wait for whatever services they might be? How does that play out at a system level?- I think there's a few things that are at play here. One is the immediate piece for the patient where something's being identified as a need for them and expectations being set that something will be done for suddenly that, that whatever it is, not to then happen or not to happen as quickly as expected or in some cases something different happens, which wasn't what was set out as expectation. So, I think that one of the real issues waiting presents is that it's as a consequence for the person and their expectations can be massively worrying. And some of the work that we've looked at in Dorset, if I take queues, is one aspect of waiting is, well, how long have I been in the queue? That question, whether you are waiting for a GP appointment or you're waiting for an ambulance or you're waiting for a procedure or you're in a bed waiting to go from an acute hospital or a tertiary centre down to another bed more locally, or whether you're waiting to go into a care home or a nursing home or a specialist dementia home, or you are going directly to home. You are waiting for something to happen. You're waiting for an event or a series of events. One of the issues of things not happening in a smooth way, systems talk about flow, the flow of people to whatever they need next, whatever intervention or support or activity they need next, the energy and the flow really matters. So, keeping the flow going is, it gives us the least impact. It's the least worst position. So somebody's waiting, but they are moving forward in the queue. I don't want to, you know, devalue the conversation by talking about Disney, but the sense of, you are waiting for a procedural experience and you can get a sense of you are moving towards it. You're not stuck with any information or without anything. So, there's re there's something around that. But there's the visible bits we talk about. As I mentioned already, the ambulance, the queue, the bed or something. But there are other things that are waiting in the background. GPs are waiting for results. Hospitals are waiting to get a letter approved to send out, patients are waiting for a piece of equipment or they're waiting for a bed or they're waiting for somebody at home to agree that they're available to the health support or they're waiting for a private nursing home to have a bed available or something. There's a whole lot of other things which play into it. And it could be about the service hasn't been commissioned fully or it hasn't, it has never been commissioned. It's just become practice and now something new happens. So, something needs to be commissioned. So, waiting for a process to run or waiting for a product to be approved or waiting for research results to be available or a business case to be finalised or some evaluation to come back or in some, you know, if they've take an extreme case, waiting for somebody to come in in the morning and unlock the door so they can go in and sit down and register to do something. So, we have all of those different things. But the key thing about it, from a system leadership point of view is, you need flow, you need people's expectations managed, you need really good communications around that. You need to understand what the precursor was to the patient that you're seeing and what happens post you where they go next and then understand how to connect that. You need to have sign posting sitting internally. And once you start broadening out as I mentioned earlier, into the wider determinants of care where in fact what you might want the person to do is to do swimming or do cycling or be part of a gardening club or to be a part reading group or to be a part of a local community, you need a really effective way of engaging people in that process too.- Yeah, brilliant. And kind of thinking from that system perspective, what's the impact? So if you took out all of that waiting and you've got the flow there, you've got patients moving through to the services they need, maybe not going elsewhere in the system because they're not getting to where they need, what's the overall impact of taking that waiting out? It's not just that patient gets treated a bit bit quicker, but how much of an impact does that have on all the other bits?- I'll give you a couple of examples. There are a number of people who booked in for an appointment who don't show. They don't phone to explain, they don't get in touch afterwards, they just don't appear. And some of it that might be is, they don't think they needed it anymore. Some might be they've got the date mixed up. Some maybe they've got stuck somewhere in traffic, but there's lots of different reasons. But there's a direct result. There's a measurable bunch of people who don't appear for an appointment. The consequence from the system though is, you've had to plan for that. So, you've had to put resources into that place, which means you've had to make decisions about how you resource other places. So, you're constantly working in constraints, you have building constraints, you have material constraints, you have access to intervention constraints, you have a workforce constraint, you've got a planning constraint, planning consumption. So the operations leads in the various settings of care, are constantly replanning based on what the dynamics of what is happening and what their anticipation of what the flows are. The impact of that though, from a overall system point of view is that, you've got to be thinking about how you can build flexibility in, but you are trying to do this at quite a large scale. And we've had historically challenges in the past where we've had services, we've got two hospitals historically in Dorset where services were delivered, but quite often people would need to be moved between the two services. So you've got a huge amount of ambulance transfer, moving patients from one setting to another. But if you had a new design, a design which said actually let's centralise the services for this particular time here. And that's what the structure is for, also major emergency centre on the Bournemouth site in a major plant centre on the Poole site, then you do less inter-hospital transfer. And there's quite a bit of that grown up over time because systems structures have developed and particular areas that are primary care and secondary care and tertiary care and community care will develop their own approaches to things. But some of it just doesn't add up anymore. So, I think that bit around, I think from a system point of view, the real challenge is, who's looking at the box of the jigsaw lead.- Yeah, yeah.- Lots of people will need to be down in the pieces looking at right, well, who's got the corners and where's the sky in, you know? Is it the sky or is it the sea in the pictures? So, lots of people very competent in that space. But you just keep to keep lifting up and say, well, hang on a minute, what is the design? What's our intent? How are we going to make some of this joined up? And that links through to a piece I think about data, which you might want to touch on later. But there's a huge piece which is well, who knows what,- Yeah, yeah.- in that system?- Yeah, absolutely. And I was going to come onto that as you say, Phil, in terms of, so for you as a system leader, and actually your people in running hospital services that know what their own waiting list is and how many people they need to see this week, this month, this year, that fraction of what you as a system need to look at. So what would you be looking at? What data do you have access to give you that full picture? What what is it that you'd want to understand about that?- So, I think data's really important in this and I'm sure you've had previous guests and some in the future and many of the national teams and people working in the digital space will talk about the really important part of the data place. And that's absolutely essential. I think the root of it is really about decision making. What decisions do we need to take? And then what data do we need to help us do that? And if I just give you a a brief example, if we look at waiting times, the systems are very clear on who's in the waiting list, what are they waiting for, how long have they waited for, anything that might have happened to them in the meantime, they have all of that data. So it's very clear right down to the individual and they can identify the individual and they can contact the individual. And that's the process they would use to bring them in or change their time or do something else. What data they don't have is what's happening to them in terms of their overall care in the meantime. So, unless that person has presented somewhere else, so if somebody's been to a GP being referred to a specialist in a hospital setting. The specialist said, I need you to come in for me to do something, assuming diagnostics have happened. So, a decision about what the procedure is going to be, they're then put on the list waiting for the procedure. What isn't tracked because the data isn't set up that way is what's happening to them to the meantime? So the work that's being done, Dorset's definitely doing it, other systems are doing it, is saying, well, the length of time somebody's been on the list may not be as important to the potential harm that's happening to them while they're waiting for something. So, there are some clear things that we can all work out logically. If somebody's sort of being referred to for an eye condition where the risk of the eye condition is, eventually people will go blind. You can kind of figure out that, if you leave them on a waiting list for a very long time, you're increasing the risk of them going blind. And that really makes no sense whatsoever from a quality point of view, from a harm point of view, from a patient point of view, from a professional point of view, and certainly, not from a system point of view. You can kind of work that out. But the work that was done in the Dorset system identified, for the people on the waiting list for Dorset is, there was a real risk of hypertension that was undetected. It was an increasing risk of hypertension. So, at that point you can start to say, right, that's really useful. That helps us make a decision. What are we now going to do? Okay, so we'll now do remote monitoring of hypertension lab. Okay, so how do we build that service in? How do we get that implemented? How do we support it? And when we get the data back, we can use that to help us re-look at the timing to say, we need to move some people around or we need to do some intermediate help with hypertension, whether it be a lifestyle change or a lifestyle or a medication change or whether it's something that actually now is a real issue, we need to bring people in for some very specialised care. So, that's an example where data, it's too easy I think to talk about we need data, data's really important, we need to do lots of data. and then everybody rushes off building databases and apps and analytics and dashboards and you think, no, hang on a second, what is the problem we're trying to solve here? The problem we're trying to solve is, we've got a bunch of people who are somewhere around our system who might need something. How would we know what it was? And then once we know, how do you prioritise our effort to another decision point. And then once we've got them in here, how do we check that things are working the way we expected? So you've got a verification and a validation. So, that's a data piece which is just as an example becomes really important. And I think of just sticking with the waiting lists, you know, hospitals have done re-validation of waiting lists and found that quite a lot of people, because they've been on it for a while, need either something else or don't need what they were set up to do. And I've seen that with orthopaedics where somebody's on their list for an orthopaedic operation, a surgical operation for a knee or a joint or something, a knee or hip or something else, and actually in time their situation has changed or their circumstances change or, or what they'd like to do is changed. And they may not then go through for surgery. But currently, from a planning point of view, you're planning for a, for a surgical workforce, they can deal with a volume going through for surgical. Whereas in fact you might actually, have an intervention workforce, which is a therapy workforce. This is doing much more about therapy development and therapeutic improvement, which is not surgical. So that becomes really important from a system point of view from data planning. You've also got meta level data such as the increased number, I'm sorry I keep using Dorset, but that's just my familiarity. But Dorset has a net import of over 65s. And in the main has a healthy older population. So, you need a different type of services as your population is getting older and it's getting older faster at the top end. So, you end up with a skew in the information you need. But lots of the data that exists already is activity based data. So, how many plans? How many people? How many procedures? How many doctors do we have? How many nurses? How many AHPs? And whilst lots of that is relevant for some of the data, some of the questions that we need to ask are qualitative. Some of it is propensity, some of it is layers of data. So, great great example again locally which is, here's our clinical data, here's our social care data, here's our societal economic data. Now, they're not directly relational, you know, they're one equals one equals one equals one. There's not that tabulation. But if you look at them as layers, you look down through the top, you think, oh, hang on a second here. So we've got a frail population, we know that clinically, we know they're in an area of deprivation, we know that through the local authority data, we know that there's some level of social care, so we have that through social care groups and we know there's issue around housing or unemployment or something else. So you can start to build a pattern. Say, actually from a health inequalities point of view, we need to do something about this particular cohort of people. But if you've broken it down to the individual data sets, you may never have spotted that. So I think that's another really key thing.- Yeah. Brilliant. Thanks, Phil. And so, obviously we've explored a little bit, kind of what the challenges are and kind of how to understand them. Thinking forward then, in terms of coming to solutions or fixing some of these problems,- Sure.- How would you classify some of the ways in which systems and their partners can approach some of these challenges caused by waiting?- I think this is really hard to do. It's really hard to do because everybody is head down working flat out to just try to keep the head above water with what's happening right now. And it's really hard because the flow of need or demand in the system is increasing. So, it's a really hard place to be. And everybody's drawing on in the main, how they've responded to these type of pressure historically. But I think we're absolutely the end of coming in earlier, staying later and working harder. And frankly I'm amazed just how people have managed to keep going when they're running on fumes. And we see this day in, day out with people just doing extraordinary things and you just think, well how on earth did they manage to do that? I think it's unfair to continue that. I think it's unreasonable to expect that, and I think we need to do things differently. But the challenge in an environment where safety and quality and consistency are important, it's very hard to then say, let's do some radical transformation. Let's do some really big change. So, I think the way I would frame it is, there are probably four major levers that we can move to help. There is definitely something around transformation and definitely something in certain areas which say, we should really be asking this question, do we need this service designed in this way at all? So, we should be doing that. We should be looking at digital and saying, how are things going to work as opposed to what IT system should I have or what app should I do or website should I do or what dashboard should I do? We should stop having those conversations until we're really clear of what is the model that we're trying to run. What is the business model? What is the end to end process? Then what data do we need to run that business model? We should be in that space. And then, how do we do all the clever tech stuff that sits underneath it? So, I think there's a digital space, I think there's a research space which is, let's have a look at what research we're doing right now? What we're doing with universities? What's happening with NIHR? What we're doing nationally? What's happening in the global stage? And we need to think about how we do that? And I'd like to spend a bit more time on that later if I may. And then finally we need to look at the innovation space. And innovation is for me, about getting an idea implemented that makes a difference for people. Innovation is not about just generating a whole load of really interesting cool things. And I see a huge amount of effort being put behind a broad investment in products and services where it's presented as, here is my really cool product. How could we implement it? And you think, well, hang on a minute. We've just started at the wrong end of the question. I have a problem here or what my problem is. So, I can't tell you what the solution might be. And there are people already working in this, which was really helping this conversation. So the HFMA, the Health Financial Managers Association, really nailed it when they talked about value makers and the focus of value and trying to move away from just driving out efficiencies really comes to the effectiveness question. What is the problem I'm trying to solve? Does this solve the problem? Can I solve the problem? Do I know how to solve the problem? Those questions are much better than, we need to save 10% on this or we need to make this 10% more effective. And and the extreme, you know, the question for a hospital shouldn't be, how do we get slightly faster flow at the front door? The question should be, is the hospital the right answer for this thing we're trying to solve? So there's something about that. So I think, we need to bring it back to, how to answer the challenges presented by waiting to see, well what is the problem we're really trying to solve? And the queue of ambulance is isn't the problem, it's the symptom of the problem. So, we need to understand that complexity. And it's complicated rather than complex.'Cause I think if we call it complex, I think that's really just a lack of understanding of how things work. So, there is something about understanding the complexity. But it is a bit about dropping down and those four levers are the ones I think we can, we can work out. The answer's unlikely, to be putting more money into something that's not going to have the same dramatic effect as thinking about what it is we're trying to solve and then investing appropriately in that.- Yeah. Absolutely. Yeah. Thanks Phil. So I mean, probably lots of people within the audience are looking to work with the NHS or working within the NHS to try and implement some of these situations. With those kind of four domains you've talked about, and I was going to say the complexity, but the complicatedness of some of the challenges, how are those decisions made about what to focus on and which approach to take to try and solve some of those problems?- I think the key to this is the Integrated Care Board. So this is the NHS board who are responsible for the NHS in a local system. However, I would counsel against thinking about the different approaches or thinking about what the priorities might be. And I'll come back to why I've said that in in a second. I think the approach that is being followed nationally about mandating local systems to drive the model of care which is fit for their local population is the right thing to do. And I think decisions will become clearer as that becomes more embedded. I think it needs to take a focus away from counting activity. Whilst that is important operationally for managing performance changes, it doesn't actually drive outcomes. And I think you need to have systems which focus on making a difference. Am I making a difference for this community, for this group of people, for these patients at this point in time? So, I think that's really important. I think working in partnership is also important with other stakeholders. This is not going to be done by one organisation being the hero of the day. And I think it really comes back to industry too. I think industry, if we take about individual organisations, whether it be Pharma, Biotech, Medtech, service provision, I think they're going to really struggle if they want to come into an integrated care board and say, right, I'm here to help. What do you need? Because two things, if me in that role, I'd be thinking about, I have no idea what help I need. So, I can't answer that question. And when you start getting into the conversation, you say, well actually you can only offer a limited part of that because of the expertise you've got. So, I'm now not sure what to do with it because I've got a piece of a solution, but I'm holding the jigsaw box lid and I have no idea which group to put you in to help sort, you know, in the corners group or the sky group or whatever it is, So, those things are really tricky. So, we need to lift it back and think about how we do as a team collectively rather than how we do as individuals. And if I think about where do you start and how decisions are made. I think decisions will definitely be taken at the Integrated Care Board, but it's not in the interest of the Integrated Care Board to take all the decisions. It's most effective if you can delegate the decisions down to where the problem is. So, that is where place becomes really important. And then, that would be low place becomes the neighbourhoods and what happens in a local neighbourhood. And that will be driven by population health management and how that fits to the broader health economics agenda. So, where the integrated care partnership comes in,'cause it will say, this is what I'm on as a strategy. And the NHS will say, well this is how I deliver my part of the strategy, and then this is what local place would say. And then neighbourhoods underneath it would say, right, well this is how we make it work. So decisions, right, really at the point of need, which makes more sense. You want the decision makers next to the customers. You don't want the decision makers three or four layers away from it, getting three or four layers away type summarised data, which isn't really focused on what's happening in the local place. But if you think about what I was dealing with before, you know, regular part of a conversation, what the priorities are. And we'd had about 500. We had about 500 priorities, which were a consequence of national policy, regional programmes, local need, individual organisations, professional focus, day-to-day programmes, initiatives that have been run over, funding that come in from somewhere that we'll have to do something by a certain date. So, there was a real complicated decision making as well. And I think trying to summarise it down into an executive summary for a board, if you are a say a pharmaceutical company, will be nigh on impossible because you're going to have to try and distil that down. But if you look at the big handfuls of things where you could work collectively as part of a common solution, I think that will be much more relevant. So, much better focus on the ways of working, common approaches, common language, what we mean by outcomes? What a person wants? Change in leadership approach to leader, leader rather than leader, follower or kind of control, co-production with the local community. They all become really important in decision making. And at the end of the day, really, we want the wisdom of the crowd involved in the decision making because individual expertise really only gives us suboptimal answer.- So, am I taking from that, if I can play it back to you that, there's nothing in particular that you think, if Company X or organisation Y could bring me this information, this data, this solution that's going to accelerate things. Actually what you want to do, as a system leader, is start from that point of, okay, well, everyone that's got an interest, let's sit down, understand the challenge and then start to create the solutions.- Yeah, I think that would be the ideal, Tom. But I think in practice it's going to be impossible to do it that way because in my previous role, I just don't have time to talk to everybody. I couldn't just get, get people in play to make it sensible. And I think that's one of the things that attracts me about joining the Mtech Access team is that, I think an organisation like Mtech Access does have that skill set. So, it has has that ability to understand what the ICS need is? Who the key players are? What challenges they've got locally? And understands how Pharma, Biotech, Medtech industries work and what the strengths and weaknesses of individual organisations are. And I think there's that, that brokering type solution, which you and I talked about in the past, which just helps get the join up and takes away the rush through the eye of the needle, which is the big risk here with integrated care boards. There are only 42 Chief Execs. They're probably 5,000 people who want to talk to them. They've still got to deliver their treatment rates, their delivery rates, their GP access rates. So, they have all of that to deal with. They're just really not going to give their time to thousands of people wanting to come through. But I think if we could do it in a managed way that was open as a combination, I think that feels to me like a good way of trying to make that work. But I've certainly had approaches in my previous role from senior people in Pharmaceutical companies particularly, who said, what can we do to help? And I really haven't been able to be useful to them in that question 'cause I don't know, apart from some immediate knee jerk type things, what I could really do with some data scientists or a business analyst or a project manager or somebody who's got some sort of clue about ophthalmology. I get that. But that really undermines what a Pharma company can really offer. And the bit for me would be that interface between the two different worlds who are coming at it with a slightly different language and different focus and different points of view. I think that would be really helpful. I think the other challenge in that space is that, I touched on it earlier, is finding a way to back from a product centred view of the world. So I've definitely had people talk to me about a particular product or make it easy for patients or do something. All of it is valid from a product argument point of view. But in my context of trying to manage a big thing, it's a marginal benefit. But if there was a cluster of organisations focused on the setting of care, the pathways, the how I might be able to move people from a hospital to a care home setting if that's appropriate for them or to a home setting or how I support it from a data analytics point of view or how might be able to do better decision making, then that's very attractive. But my experience was, individual organisations could only solve a piece of that. So, I think it's the team. How do we get the right team together for a part of the ICS that's trying to struggle with a certain area? It may well end up being a therapeutic space and then we just will collectively have to figure out how to make that work. But I think in the main, if we can get the horsepower collectively focused on the root cause problems, not the, almost the rhetoric around the symptoms. Then I think some real magic could happen.- Yeah. Fantastic. So, in a world where you've kind of, landed on an area a decision, this is something as a system that we need to fix or whatever the language is you'll use, what's needed as a system leader or as a set of system leaders to actually gain traction to drive that change and engage everyone in it and see the outcomes at the end of that piece?- Yeah, well I think there's a few parts of that. I think having the right stakeholders in the room are important. Having the right people who are sitting behind, championing this is the right thing to do. I think having a focus on purpose, if you can get alignment on purpose, So everybody's in the room to achieve the same purpose, although they may not necessarily agree how, I think that is really, really positive. But I think the big things that we need to collectively look at is, you know, how do we get people home safely? How can we keep them at home? How can we reduce the number of people who need help in the first place? How can we make it easier for staff to do their jobs? How do we take a step out of a process? How do we remove a pathway? How do we remove the service? You know, the ultimate, how do we invert the setting? The 'Do we still need cottage hospitals?' question when actually community based hubs doing services that 90% of the population get their service through a hub in the community and don't need to go to an acute setting? You know, those type of things. How do we get that? Because there are constraints that do exist. I've touched on some of them. There are some specialty constraints such as data science, project management, business analysts, health economics, business creation. There's kind a whole load of functional expertise that I think could really help with system wide change. And I sort of, you know, jealously look back at what I've now got access through with Mtech Access. I think blimey, if I had this level of, you know, analysis and deep research and health economics and I had then the horsepower that industry can offer and then particularly bring in academia, which I think got a really, really key role to play in this, and then I could just shuffle it all around a little bit and then put it into an ICS programme of work, I think, you know, as I said, magic could happen.- Yeah. Brilliant. Thanks Phil. You mentioned academia though, and you were talking about research earlier. Can you just expand on kind of how you see academia and research playing in a bit more'cause that's probably an area that our audience might think of less, I suppose when I thinking about some of these challenges?- I've sort of concluded with, I think academia is really important, but I think it's good to ask Tom because I need to I think explain why? The whole of the academia, and I'm thinking broadly, I'm thinking universities, I'm thinking further education colleges, thinking the upstream back into schools and then think of coming out further into think tanks and opinion places such as the Kings Fund and Nuffield and Gartner and others, I think if you start to look at that academia across that broad range of things, I think it's got a massive role to play. But if I go back to what I've done previously, so I was previously on the Academic Health Science Network Board for Wessex and I chaired the Applied Research Collaborative for the NIHR, National Institute for Health Research. So, I had those two roles. I sat those two roles. and I was sitting substantially in my system role. And it took some time to orientate the academic input into the need of the system because academia is typically starting with attracting students, which is obviously key as income is aligned to that. But also driving research, which is of interest to the academics and as a funding source through [ ] or somewhere else who's prepared to invest funding, grant funding into it. So the incentives are clearly not aligned to an NHS incentive, which is providing care for a person. But actually the purpose is the same. How can we do things better for patients, whether it's through social care research or economic research or clinical research or socioeconomic or psychosocial or some other broad area of research. So, having alignment really mattered there. So academia who can shift the viewpoint to look specifically at what challenges exist in the system? What challenges will exist for the system in the future? What the direction of travel is? And what people are going to do, both through the macro levels such as sociology, technology, through the changes in legal systems, all of those things, if academia engaged in that, that it makes a massive difference. I certainly found with the AHSN, that was really well placed to do that, but also the ARC moving to have a system alignment really helped change what was coming through and that made a difference. So, there's a direct application through to innovation around services, innovation around management and management practices and innovation around practice, whether it be clinical practice or social practice or wellbeing practice in its broader sense. So, academia is a really key role to play in that. But it's also academia is by its very nature focused on education and training and development. So I think we need a way for the workforce, for academia to create a fit for purpose workforce. So, we need to work with them really close, close coupled so that as people are working, they're learning and we've got that cycle of continual learning. And I'm sure a lots of people sign up to that, but it's very hard to make it work when you tend to have those two things separate as solutions. So how do we bring that more closely together? So I think getting that clear alignment where we're all facing, walking, and working in the same direction and I think academia's got a role to play.- Yeah. Fantastic. So, you just see academia as another partner in that system collaboration to be another piece of the pie so that actually there aren't any gaps and when it comes to those capabilities, that's all plugged?- Absolutely. Yeah, absolutely. It's all part of the team to solve the problem. It's a different set of expertise and capability and capacity, but absolutely all part of the team, and an essential part of the team. And if we get the relationship with academia wrong, then we won't have a fit for purpose workforce. We'll be churning out what we needed in the past, not what we need in the future. We need clinicians coming out who are digitally enabled, who are research skilled, we need people doing continual learning. So there's that continual mentoring piece. So that I think, you know, really, really key. And it's not just in the NHS itself, but it's in, you know, everybody on this call I would imagine, would need to be part of that. And then, for academia need to be closer coupled with, well what are the needs then? What's the pressure? What is the problem you're trying to solve'cause I'm able to help you do that.- Yeah. Brilliant. Thanks Phil. So, from everything we've talked about and probably other things as well, what, what would you say are key takeaways for our audience in terms of how they can support the NHS, sustain and reduce the amount of waiting going on?- I think the first thing is everybody has a role to play. So it's not can we help? It is you can help. But we just need to figure out what their help is. I think each business needs to be clear, whether it's an industry partner or an NHS organisation or an academic institution, it needs to be really clear on what it offers. And offering help isn't an offer because you're expecting then the people you're talking to, to figure out what help you need. So, you really be clear on your offer. In how it would work with others, there needs to be alignment between systems and what was offered. So, that clearly needs to happen. And if I think about, you know, the new world I mean, it's a market access question. And so, you need to understand your research, you understand the capabilities, you need to understand who you could work with in partnership. You need to understand what your value proposition is. You need to be clear who the stakeholders are. So, it's all the world that everybody is familiar with. if you are currently listening from a Pharma or a Medtech type organisation. If you're working from academia, it's a similar thing. It is, you know, how do you attract funding? How do you do the pitch? What's a bid? What's that? So, you kind of need to get your head around those things. And I think, it's get getting some help around it, you know, getting some of the people, Tom, and your team know how to do this. Getting those type of people around the table and saying, right, we can help you figure some of this out, and then we can help you connect others together who've got similar ambitions, and then we can get the right people in the room. And then you are into the co-production, collaboration, co-development, and you're no longer asking the question about how you can help. You're really churning through what your core capabilities and skills are in this space, whether it's a functional one, digital or data science or BA or something like that. Or whether it's just intellectual horsepower, which is, well, hang on. Like, I'm really good at problem solving. Let me part with the team which is problem solving or whatever this facilitation is, whatever it is. So, I think, you need to do that. You need to do a better self-analysis on, you know, what's your offer? And I think coming back to where I started with, you know, why are we waiting, which is the broad theme of this. And whilst I can see there are policy, political, practical changes needed, people changing behaviours and all sorts of things that need to happen, I come back to the four levers. Yeah. Can you get broadly behind the research idea, broadly behind an innovation idea, broadly behind a digital idea, broadly behind the transformation idea? Think about those levers. And then start the conversation around that. I think, that for me would be the takeaways, Tom.- Yeah. Fantastic. Thank you very much, Phil. Really enjoyed our conversation today. So, thank you very much for that. And a good thank from me to the audience as well for following over the last couple of years. As I mentioned at the outset, I'm handing over to Phil now, who's going to pick up running the webinars from this point forward. So, again, thank you from me. I'm just going to hand over to Phil now just to say a few words about what to expect in the future.- Great, Tom. And the first thing I'd like to do is, first of all to you, thank you for today. That was great. Some great questions in there. So, I really enjoyed being part of that discussion. And then, to thank you as well for hosting this session. As you said, at the start, for two and a half years, that's quite a long time to be front and centre on something like this. So, you know, absolutely fantastic. You've done a brilliant job. And if people listening haven't listened to some of the previous sessions of Tom's, you should listen back. It's a catalogue of really useful insight. So, really commend. But thanks Tom, that you've been absolutely brilliant. So, I want to continue Tom's legacy, really take it forward. In the first few months of next year, we're lining up the Chief Executive of an AHSN to help us understand a bit better how we might look at the adoption and spread and innovation in a broader sense. And also looking for a senior leader who's key in affecting NHS policy, particularly around the economic space and how we drive the four objective of the ICS, which is about the NHS's role in economic growth. So, we'll be bringing those two in the next year, probably February / March, I think, by the time we get that drawn together. I'm very happy, of course to get ideas from others who think might be useful to listen to. But that's our plan for the next year. I just want to wrap up by thanking everybody today who joined the call. Everybody who's been a lifelong member of the NHS Whispers podcast, which is fantastic to see your continual support, which is brilliant. Thank you new members who joined today. Hopefully you will join us again next time. And just want to say thanks very much for today and hope you have a good rest of the day and a good weekend when you get to it. Thank you.- [Announcer] Thank you for watching. If you'd like to find out more about our work with the NHS or how we could support your market access goals, please email info@mtechaccess.co.uk or visit our website at mtechaccess.co.uk.