How does funding flow in NHSE Regions?

Which decisions are made at Region level in the NHS in England? How do finances and funding work at this level? And how can industry best support and engage with Region leaders?

We sit down with guest speaker Richard Smale (Interim Director of System Co-ordination, NHS England [NHSE] – South West) for an all-encompassing discussion that explored finance, funding flows, system priorities, and the decision-making process in NHS Regions.

Richard heads up system co-ordination work across the NHS South West Region. The Region has seven Integrated Care Boards (ICBs), 22 Trusts, nine counties and a resident population of over 5.5 million patients stretching from Gloucestershire and Wiltshire to the Isles of Scilly.

The interview was led by David Thorne (Principal Consultant, Mtech Access and Transformation Director at Well Up North Primary Care Network [PCN]) who put both the NHS and industry perspectives to Richard to explore the real state of the NHS.

In this episode, David and Richard discuss:
- Where the NHS is heading and what this means for your strategy and business planning
- Decision making, finances, and funding flows across the NHS
- The role of NHS Regions, particularly with key funding decisions like Specialised Commissioning
- Delivering service change across integrated systems
- Policy priorities in practice and what to expect in an election year
- How Pharma, Medtech, and Diagnostics companies can best engage NHS leaders at Region level

This episode was first broadcast as a live webinar in February 2024.
Learn more about the webinar and Richard at: https://mtechaccess.co.uk/how-does-funding-flow-in-nhse-regions/

Discover more about our NHS Insights services at: https://mtechaccess.co.uk/uk-nhs-insights/

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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. Welcome to the highly anticipated Mtech Access Webinar. I'm Rob Hull, and I'm a senior consultant in the NHS Insight and Interaction Team here at Mtech Access. And it's my pleasure to extend a warm welcome to our speakers for today's session and our attendees who have joined us from around the globe. For those of us who don't know us very well, Mtech Access is a specialist market access consultancy, and we provide strategy and solutions to help Pharma and Medtech companies bring interventions to market, both in the UK and globally. We also work as a collaborative partner to the NHS and in these webinars we speak to our NHS Associates and connections across the NHS to share their insights on sort of key topics. Today, we are joined by David Thorne and Richard Smale, who are two experts in their fields. And they're going to share with us a wealth of their knowledge around their experience on funding flows in NHS regions and their insights, so I'm sure it'll be thought-provoking and give some valuable perspectives that will be really interesting to hear from. So I'm thrilled that so many of you could join us today, for what will be a really insightful discussion. So I'm going to hand over to David Thorne, our facilitator for this section to give a bit more of a formal introduction. So over to you David.- Thank you, Rob. Thanks very much and good afternoon everyone. Thanks for joining us. My name's David Thorne. If you haven't met me before, my career is equally split between the NHS and market access roles. So part of what my aim is to be a kind of translator today, but mostly we're going to hear from Richard Smale, and I'm going to allow Richard to introduce himself in a minute. I've had sight of your previously submitted questions, and if questions do come through while we're live today, I may also be able to see those as well. Richard hasn't had sight of them. He's a really capable guy. I've spoken to him before, but it's some months ago since I did. And I know that he likes to be prompted and stimulated, so don't hold back from your questions. If I do my job properly today, there are basically three questions that we're going to try and resolve today. Where are we? Where are we headed? What does any of that mean for those of you out there in our audience today? And I'm going to be really intrigued. I'm speaking to you from the far north of England, right up on the Scottish border, which is why it seems to be quite dark on my screen. Richard's in a horizontally different position in the South West of England. So Richard, who are you and what you do? Please introduce yourself.- Yeah, thanks David and good afternoon everybody. So, as David said, my name's Richard Smale. I've worked in the health service for most of my career, starting as a graduate trainee in finance many years ago. My current role is as an Interim Director of System Coordination within the NHSE South West region. But prior to that, I spent four years in the BANES, Swindon and Wiltshire Integrated Care System, working as a Director of Strategy and Transformation. And my role really at the moment is about that interface that exists between the region and the seven systems in the South West, and how we get real value through that interface and support the systems to be as successful as they can be really.- And that's great. So you can see there, one of the things that, one of the reasons I so enjoy doing these sessions with Mtech Access is the themes are based on things that you guys out there in the audience have submitted. So one of the things that people really want to talk about was the role of NHS regions, how the funding flows between them, what is the relationship between them? So Richard's excellent succinct introduction there is he's just spot on. So there are seven NHS regions, 42 Integrated Care Systems. And as you said, he represents, at the moment, he's working in the South West region with seven systems. So Richard, let's go straight away to that, and our focus today on funding flows and how all this works. Tell us about the South West region, your role, and as you said there, there that interface between the region and seven Integrated Care Systems.- Yeah, and David, there's that great quote, isn't there?"Once you've seen an Integrated Care System, you've seen an Integrated Care System." They're all different. And the South West ones are relatively small compared to some of the others in the country. But in the South West, as I say, we've got seven going down from Gloucestershire to Cornwall. It's quite a long area that we cover really and geographically quite challenging. But they are all different organisations, they've all got different dynamics of some very urban populations in the areas like Bristol and some very rural counties as you'd expect with some of Devon and Cornwall. The role really around regions, and I think that is emerging now. It will continue to be the arm of NHSE that has an oversight and an assurance role. And it will continue to have legal responsibilities for making sure services are run correctly through the ICBs and things. But I think increasingly the emphasis is on supporting systems and supporting the integrated care boards and the Integrated Care Systems that have been created to be successful, to be self-governing, to manage things themselves as much as possible, to put the money at their disposal and allow them to make decisions and guide things. There will always be national policy. We're a National Health Service, we're sort of paid for by taxpayers and governed by ministers. So there'll always be that push around sort of national priorities. And we know at the moment, don't we? Things like elective care and urgent care services are priorities, but also, I think part of the regional role will be to develop and support systems to really understand their local populations and to really champion tackling their local population needs alongside those national priorities. Is that enough sort of context, David, around that?- Yeah, and there's some really helpful prompts into there, because supporting an oversight. Yeah, how does that balance get achieved? Because who manages an ICS? If I'm a Chief Executive on ICS, am I accountable to region? How does that work in practice?- So there is, as you'd expect, wouldn't you, there is a bit of an oversight and assurance framework that has four levels, and basically at level one, the ICS is running itself full steam ahead, everything's okay. And then as you progress up to level 4, you've got real challenges in that level of system. So that support to assurance gradates, if you like, as you transfer across those four. So with systems in level one, it would be very light touch, it would be leaning in to support them where they ask for help and things like that. But as you get into levels three and four, you would have much more planned interventions. You would have sometimes it would be absolutely under direction. You would be in there taking more direct control as you imply in your question, David. So it does vary and it does depend where the systems are. I think the thing that really we're passionate about is how can we help all the systems get to level one. That's the aim, it's not seeking out an assurance role. It's about supporting systems to develop and evolve. I think we need to remember these organisations are still very new. They're only formed in July, 2022. They're still finding their feet and the job they've got to do is difficult. They're doing it in challenging circumstances, financially, workforce, all those challenges. And they're doing it without perfect governance arrangements. So they're working through how do you build effective partnerships with local authorities, things like that. And I think the job of the region is to be there to be a good ally alongside them, but also, if things do start going awry, it's to have those powers of intervention where needed to step in and support systems and yeah.- And on a practical level, you've got seven systems. How many of those are level one? How many of them are level four?- So you've got me right on the spot there, haven't you? We've got some areas of our system that have level four and have an intensive support programme. We have one I think, but generally they're in the twos and threes space. To achieve level one at this stage for most systems is a huge challenge, because they are so new.- If my memory's right, sorry, Richard, putting you on the spot, I think Frimley is the only one that's level one.- That's right, in the country, I think.- You say, most are level two and three.- Yeah, and Frimley, was operating in a certain way that is, if you like, a role model for some of the other systems earlier than the ICSs and the Integrated Care Boards were formed. So it had a bit of a headstart. It's a bit more mature in that sense and got a bit more practice. Some would say it's also a bit simpler, it is a system built around one hospital. So there are very different challenges if you go to somewhere like a Devon in comparison to a Frimley, but the aim is how can we get everyone towards that level one status? But I think most will be in two and three for a while.- Okay, and then also what you saying before about the funding flows and as I said in my introduction, that's a key thing people want us to talk about. How does money, money sits there in London, obviously, through taxation, Amanda Pritchard, NHS England has got 150 billion or whatever it will be. Does that then come down to region, go down to ICSs and go to trusts? How does it actually flow around the system?- You're right, most of it comes through and goes into the ICBs and gets allocated into the provider organisations. And the vast majority does that. There are bits like specialised commissioning where the money is held at a regional level, because the services operate at that sort of scale where it makes sense to do that. And there's various other services where some public health services, things like that, where there is money held at a regional level, but the vast majority does go into the systems. I think we'll see changes at that system level. So in the previous era, if you like, we had Clinical Commissioning Groups, they commissioned the services. I think increasingly what we're seeing within the systems is the emergence of provider collaboratives and potentially those providers taking on more of a sort of commissioning-type role, holding some of the money perhaps being lead providers. So I think we'll see change at that level. We've seen change where we've moved money that was held at region into the system, so around the dental, community, pharmacy, optometry-type services, and there is an aspiration to do that with specialised services as well. So the aim is to put as much money into that level and then allow local decision-making based on local needs. That's the sort of the phrase and the approach we would like to see come. It's building the infrastructure to make that possible that we're probably in that stage at the moment.- So you've given me great prompts there, because there's at least three or four sort of pathways that I want to go down to for the rest of our conversation, okay? So let's start with the first one of, usually at this stage we're what, depending on how you measure it, five, six weeks from the end of the financial year, the start of a new financial year. We'd be talking about the content of the NHS operating framework or the operating plan that would've come out two, three months ago that hasn't happened this year. What's the effect of that? Are your ICBs, are they clear on where they're going? Are your Trusts clear on where they're going from the 1st of April? Do we know what the priorities are? What's the implications of that framework not being available?- So there are implications, David, because that provides clarity, a purpose, it provides clarity of direction for everybody. So clearly it would be wrong to say there's no implications, but I think as we increasingly evolve the conversation to be about local focus, local services, local needs, actually I think that dependency on some of that is less, and the opportunity is there for people to shape and design services. And if we're honest, we don't change the health service every year when the operating framework comes out, we tweak it. And so there's a lot of stuff that continues on, gets evolved, gets refined, but it's not as if somebody suddenly taken away all of the rules and nobody knows what to do. A lot of it is understood. We know that the priorities are going to be there around elective care and urgent care. We know the priorities are going to be there around mental health. We know the priorities are going to be there around tackling inequalities for example. So a lot of the themes are there. The other link I'd make is that over the last March-time, all of the systems created an integrated care strategy. And that was meant to be the forward-looking document, the thing that really set the scene for what are we trying to do and particularly what are we trying to do as partners working with local authorities, the voluntary sector, all the agencies in the area, housing, etc. And I think actually that's the roadmap that still stands the test of time. Now those integrated care strategies will get refined and improved over time. But actually a lot of the thinking that was done at local level, the joint strategic needs assessments that the local authorities produce, things like that, have all informed those strategies. So for me, I think there's a real importance that yes, the operating framework is helpful, it provides some clarity, but we've got so much direction set. We've had so much local thinking into what services need to be for local populations, that actually, this should be a year of continuity rather than a year of significant change in my mind.- So that leads us to, hopefully quite neatly to something that's a slight concern and is a regular feature in the questions that were pre-submitted, and a phrase that was used several times in those is postcode lottery, okay?- Yeah.- How do we bridge this gap? I mean, you and I have spoken before. Bristol always fascinates me. I don't think there's many big cities in England where areas of such extremes in affluence and deprivation are so near to each other. You mentioned Devon. I mean, I'm sure all of us who are listening have got an image of Devon. Well, is that inner city Plymouth or is it a fading seaside town or is it a thriving market town? What is the balance between that local variation, national priorities? And I'm quite happy for you to talk at length here, because I'll also add in how do our friends who are listening, how do they adjust to that, that there might be a different set of policies applied in one part of Bristol from another part of Bristol, let alone between Bristol and Weston-super-Mare?- Yeah, and can I sort of talk about the two things in that, David, the sort of postcode lottery description of that and also the variation bit, because there's connections and there's separate features. One of the things that happened when we created some of the Integrated Care Boards is that they brought together former CCGs. And those former CCGs were at a smaller scale. So I think we had 209 CCGs and we've got 42 Integrated Care Boards. So clearly you can see there's a scale that's happened across a lot of the country where things have changed. Now for some of our systems in the South West, it hasn't changed. Gloucestershire was always Gloucestershire as it were. But for many you've seen a consolidation. And what you've found when you've got that consolidation is that the different CCGs may have taken different commissioning approaches. Some of those commissioning approaches may be entirely valid, they may be entirely informed by the needs of the population, but some will just be about one system prioritised, one type of care and another system prioritised something else. And it wasn't that they looked at everything rationally, it was just their energy went into falls prevention or their energy went into mental health services or whatever. So part of what the changes have done is bring that up a scale, and I think it has exposed us a number of ICBs are commissioning things for different parts of their population that there isn't a sound logic as to why some of that's done. So I think there's an opportunity in the new arrangements to really begin to unpick those. Now as much as you might like to, you can't under-pick all of that overnight, you can't solve it all straight away and you can't simply invest everywhere to bring everyone up. There's some real challenges in that conundrum. So that postcode bit is certainly there. And then the second bit that you spoke about is the variation bit. And I think this is potentially one of the most exciting opportunities that we've got. We've spoken about tackling inequalities, we've spoken about variation for years, and we do it sometimes really well, there's some places that really do it, but actually I'm not sure that we're doing it with enough of a proportion of our funding to make that difference. So how are we really putting a level of investment into more deprived communities and communities with greater needs and really prioritising and sometimes those are the communities we are not very good at reaching out to or we don't hear from. And yet other communities are very vocal and we hear a lot from. So I think we've got a real opportunity to be upfront and honest about that and have a more honest conversation about if you are going to tackle inequalities, it does mean that you begin to look at your overall spend pattern and you begin to absolutely invest in those communities, those areas that need that investment. And if you can do that and all of the evidence is there that tells us this, if we tackle those type of challenges head on, it will make the health service more sustainable, it will reduce demand, the evidence is there. So I think we need to have a very honest discussion with the public and with the local MPs and things like that, local counsellors and say, we are going to work hand-in-hand with the councils and with other colleagues who work in this space, the voluntary sector in particular, and really look to say, what does a good wraparound support into more deprived communities look like? And how do we offset that with other areas and other choices we have to make financially?- Because what's underpinning that, at the end of the day, you have a certain limited fixed budget, yeah. And so there's a resource pie or pizza. If one slice becomes bigger, then by definition one has to become smaller. Well, what's your advice to our audience about that then? And I know we won't mention individual products. I always think of something like IVF, does that mean yep, we're going to prioritise heart disease or diabetes in certain communities, so you have socioeconomic pressure, and therefore the money's going to come out of IVF or it's going to come out of something else? I mean, how do these decisions get made and what's your advice to, to our colleagues?- I think you've just described the most wicked issue we face as health services, haven't we? Whatever amount of money we put in, there'll always be a sense of rationing. You've got to choose, and we don't use that word, but you've got to choose where you spend your money. And that's the reality of healthcare. And it's the reality of healthcare in every system. It's not about this one or any, you have to choose how money gets spent in the best needs. And that's difficult. And I think the two areas where I see lots of work and effort going on, and again, I think we talk a lot these days, don't we, about being, having a learning culture, having a willingness to learn and accept that we don't know everything and evolving and improving over time. And I think that is really important. But the two areas where I see that potential is around work where people are really beginning to say, well, what outcomes matter? So we've been counting stuff for years, we've been counting how many things go through the door, we've been counting how many appointments took place or didn't take place. But what if we really understood outcomes and what if we really understood outcomes through the perspective of the people we serve? What if they were telling us that their life has got a bit better or whatever metric is important to them. So I think we need to pay a lot more attention to those outcomes and how we develop those and think about those with the populations we serve. And then the other bit, and I think this is a bit that's particularly pertinent to the people on the call is well, the outcomes is pertinent, because a lot of the people on the call will be experts in saying, look, we can show how we improve outcomes, and are probably also very good at engaging with the people with those outcomes. So that bit, but the second bit links back to your question about money. We have not had a mature system for really understanding return on investment. We've had a cash-based system in a way, if you like. Are we balancing the budget rather than are we driving the best value out of the budget? And I see again, over the last few years I've seen the voice of Public Health get louder. And I think that's really exciting. I think there's a real prospect of saying, if we really understand the return on investment, if we really understand what a exercise programme or a smoking cessation programme or whatever can contribute, and if we can try and encourage a longer term perspective and not just a sort of short-term, somewhat politically-driven timescale, we've got a real opportunity there to say, let's do the interventions that matter. Now, we can't turn off huge chunks of the system today and just switch the money. We've got to phase out over time, we've got to work out. But I think some of your colleagues on the call today will be, they'll be screaming, I'm sure saying we can show the return on investment, how do we get in the rooms to have that conversation? And I think it's on the onus of each and every ICB to say, how is it developing its understanding of return on investment, best use of money? Even if they got really mature at that, you would still have people competing to say, look, our return on investment competing with your return, it's still going to be a difficult decision, but at least you are basing it on good evidence, good analysis, and good perception of this is where money spent in health and care would yield the most value. And I think for the taxpayers, that would be a huge asset. And for people who are passionate about improving health and outcomes, that would be a good thing as well.- But as I listened to you as a citizen, I'm really encouraged by that, yeah. But then I would look at my ICB's finance performance at the moment and probably yours as well, if I looked it up on the internet, and what I would probably see on there is money being taken away from public health, prevention, primary care, and going into, you know what I'm going to say, and be going into ambulance response times, elective waiting times. We keep talking the talk of moving upstream of prevention. How do we break the cycle that you've just said? Because what you said to me makes absolute sense, but how?- And David, I'm not going to disagree with you. I've seen those things as well. And that is the reality of people having to make difficult choices and they're having to make difficult choices at this moment, and under the pressure sort of there. I think this is where, going back to that strategy that I mentioned earlier, the integrated care strategy was written by all the partners. It's owned by much more than the NHS or it should be. It very clearly, if you read most of them, they would talk about inequalities, they would talk about prevention and wellbeing. They would say all these things. As systems, I think part of the maturing journey will be how well do we pay attention to tackling those things? How genuine are we being about whether our money is going into, as you say, dental prevention versus treatment? And there's not a magic switch for this, there just isn't. But there is an evolving maturity I think that will come with it. And I think you asked earlier about the role of regions. I think region can play a really helpful role here. It can be partners alongside the ICBs and ICSs and be saying, you said this in the strategy, how are you getting on with evidencing it? How can we help you evidence it? How can we draw on the best evidence from elsewhere? So, I've sat on calls in the last week where colleagues are really getting under the skin of some of that return on investment opportunities and things. So I think the green shoots are there, the pressure to do what you've described in that question is there as well. And we need honest discussions about how we prioritise. And I think giving the voice to Public Health, giving the voice to the senior doctors as chief medical officers, chief nurses and things like that at the ICBs and the Integrated Care Systems is absolutely key.- And yeah, so there and a particular strand, again, our colleagues listening would be interested in is, so where does NICE sit in this? Because one of the things I'm sure they're screaming about at the moment, or many of them listening now are saying, well, yeah, but I work for a company, we've got a NICE recommendation that the pull through on that in, I don't know, Liverpool is very different from what it is in Norwich, why is that? And some of it could possibly be explained by the kind of local variation you are talking about, about epidemiology and demography, but a lot of it isn't, it's much more finance or something else. I mean, how does NICE actually get managed in practice? If NICE makes a decision this week, what happens next?- And this is the dilemma, isn't it? Because as you said earlier, if one piece of the pizza gets bigger, another piece gets smaller. And that's the harsh reality here is we recommend these things, because the evidence base says they work, but it doesn't take away the other challenges that the system is facing. I do very genuinely think, David, this is probably a five to ten year journey of maturing and understanding return on investment. It is about understanding how the choices get made and NICE guidance is one factor coming into the mix here. But sometimes that NICE guidance will be at the far end when somebody's already ill and what have you. Well, what if we'd spent the money originally on prevention? And these are all the tensions we've got to explore. And how do we balance the need to spend money on those people already in ill health with the need to keep particularly children and young people who are fit and healthy and give them the best start in life. And there are no silver bullets to this. I think what we would hope to see over time, and I think at the scale of 42, you stand a chance. If you're trying to do everything at the scale of 209 systems, that's quite difficult. But at the scale of 42, you can create some critical mass, you can begin to share the evidence and the data more efficiently. We've got better ability to do that now than we've ever had. I think nationally there's a lot of good work going on at looking, how do we pull together the evidence spaces, make them available, make it accessible? So I hope ultimately what you have is Integrated Care Systems where the leaders are able to look at a really good set of evidence, they're able to look at the numbers and understand them in terms of what they're returning for them, and they're able to begin to prioritise and shape. But that isn't going to happen overnight. Some of the more advanced systems will be better at that. But we know, we're a really complex set of different things. Providing specialist care is really different to providing prevention and wellbeing. And so we've got to work that through as partners where we invest. And over time we can get better at it. It won't happen overnight.- So let's move on to that specialised commission. But before we do, particularly for a couple of the people who submitted questions, if you want to go back, we can't really go into the detail of this today, but two of the questions in particular were based on the assumption, which I've heard before, that if NICE makes a decision today, specific ring-fenced money would then come down from London to Richard's region that would then go down to ICSs and then would go down to individual hospitals or whatever. And just that is not the case. If you're wondering about that and you want more detailed things, approach the people from Mtech Access, because I know they've, they've got some really good simple training programmes that can explain it. And an area that is even more cloudy, we'll get into now, that Richard's mentioned a couple of times is specialised commissioning. So specialised commissioning in what five, six weeks time is being devolved at a local level. What does that actually mean in practice to the region and the ICSs? Spec comm, as we call it, is coming down. The budgets for it initially are going to be kind of managed on a shared basis. How will that work, particularly in the examples that you've just used about local decisions around how money is used and moving the slices of the pizza?- And I think that's the key to this, David, it's about making the decision and looking at the whole pot of spend. I don't think it's about trying to manage those services or oversee those services at a local level. I think it's more about getting oversight of the money at that local level and saying, are we aware that we spend this chunk on specialised services as opposed to could we have spent it somewhere else? And I think that's where the conversation, the richness of the conversation and the richness. So when I think about the devolution of dental and optometry and pharmacy into systems, that gives them a massive opportunity to say, hold on, we've got all this primary care spend, are we spending it in the right way? Do we want to top it up? So we've seen, haven't we, those questions about if we could get more dentists, if we spent more money there, that would have a huge impact. And the impact on, again, small children coming through school with tooth decay is dramatic. So I think the oversight of the money for me is the key bit, not necessarily that instantly they start making changes to the way specialised services work, because you could very easily destabilise some of those services if you're not careful. There could be real unintended consequences. So I think that keeping an oversight at a scale that is appropriate for each specialised service feels really important to me. But allowing each of the local systems to see how they spend the total. The money they spend on their population, how is it spent as a total offers a real insight that we just haven't had-- And if you don't mind me coming in now, it was just last week, I saw they're still described as draft budgets for ICBs, primary care, mainstream services, in other words secondary care mainly, and then spec comm. And you can see the variation by population and things like that. I think you've given a great answer. Again, if I was a citizen in the South West, I'd be really reassured by that. So just for our audience, let's say it was MS or haematology or whatever, don't expect anything dramatic at the start, but people like yourself and your colleagues and the clinicians, they're going to get a much better picture now of the spend on MS or haematology across the South West. And they can connect that with the spend in primary care, community care, possibly even social care and start to make some plans based on that, but not to expect sudden changes at the start.- And the thing that really struck me over the last four years when I've worked in a system is it is so big, there's so many moving parts, there's so many things and it's really difficult to see the rationale of, making an individual decision in the context of that bigger thing. So you're right David, this will take time. When we're most effective sometimes is when we focus in on a particular service area and say, right, let's have a proper look at this. And I think that's the dilemma we've got. You can't fix everything. You can't change funding flows for everything perfectly overnight, but if we really go after things. So colleagues tell me, coronary heart disease and things like that, these are the areas where we could really pay attention and get something. Children's mental health, another example, what are we going to prioritise to really look at? And that does unfortunately mean not everything can be looked at at the same time. But I think again, keep gathering the evidence, keep talking about it, keep making it available, because there's so much data. The better the way you can tell your story, the more concise a story can be told about a particular service or whatever, the more it will help those who are making decisions understand it. And the other thing I would say is, nobody's trying to make bad decisions. Work with them, lean in, support them, help them come on that journey of learning, understanding all those things and support that process. Even if it feels like you've been doing that for years and it hasn't quite worked, I would say now's the time that we can really learn together and move forward.- So if I summarise some of that and then you can come back and say, I'll summarise, it's a bit hard for the audience. You can come back and just say that I've done it incorrectly. Firstly, I can't resist throwing a little fact in here was I was part of some meeting the other day, in my eyes it'd be 1/3 of calls to NHS 111 are for dental pain. There's a classic area that if we sorted out the cause of that we wouldn't be spending money on calls to NHS 111 and presumably dreadful consequences for some of the people who are ringing up. But going back to your point, there'll be people on the call listening today who are concerned that they sell a product or a medicine or a device that's covered in spec comm that's now going to go to local decisions and they see threats to the continued use of it. What you're saying, if I've got it right, is embrace that opportunity, because if they can show the value of that and the holistic benefit of that, but in order to do so, instead of just looking at what happens in a tertiary hospital in the middle of Bristol, for example, they need to follow the whole chain through. The diagnostics, the primary care, the prevention, and to see it as a holistic thing and therefore the benefits on a longitudinal basis. Yeah, is that?- Absolutely, and that is a challenge, isn't it? Because if we've made a lot of money, because people get sick and we start doing a lot of prevention, that stops them getting sick, that's going to change the business model. And I think, let's be honest about those conversations. Let's talk about how services can work, let's talk about how things can keep people healthy and well. But let's also recognise need appropriate spend for when people are ill on the right products and the things that work and the things that treat them well. So it's a conundrum how you balance it all. But being open, sharing the information and thinking about it and working with decision-makers, I think is key. And I know that's easy for me to sit here and say, and it's not always easy to do.- The other thing which if anybody follows me on LinkedIn, I follow you Richard, for example, now they will have seen me comment about is the variation, it's often not appreciated the budgets I was talking about before. And if you're not familiar with these, Mtech Access, can again explain them and show you the actual figures. But where I live and work, we're funded at something like 25% per capita higher than most of the ICBs in your region. So, all the ICBs start from different places as you are saying, and now I was talking to somebody last week from the East of England where the hospitals have got this RAAC issue and so that's going to be devil in the next few years. How do you cope with that for start? Because the South West has got particular issues about influxes of holiday makers. You alluded to before about the road transports through your patch is dreadful to be blunt. The communication issues, half of Plymouth is closed down today, because of the Luftwaffe and so on, but anyway, to be serious, you've got all these regional variations, nobody starts in the same place. But again, how do our colleagues cope with that?- And this is one of the eternal questions, isn't it? And every few years the formula will get revised and there'll be a sort of different emphasis upon it and it will never please everybody and it will never be exactly right. When I was a trainee accountant, I used to have a saying,"Please stop talking to me about the 10 pounds you haven't got. Tell me what you're doing with the 100 pounds you have." And I think the first thing we have to focus on is these health and care systems, the one I worked in was 1.5 to 2 billion, depending whose money you included in the pot. That is a lot of money to be paying attention to. And I think if we start by paying attention to that, the value we get from what we have got, we've got to have a bit of faith then that if the formula needs to be tweaked, because of as you say, RAAC is a classic example, isn't it? Of where did that come from? Suddenly we've got a huge bill that nobody saw coming. That's what happens to an organisation as big and complex as health and care services really. So, but the emphasis on are we doing the best with what we've got and energy going into that I think would be the priority for me in any system, rather than what would we do if we had 10 pounds more? And that's a difficult thing to say, but in all of these systems, they are spending a lot of money and justifying the use of that money. It is really critical.- Great. I can see why you're working at region now. That's really nuts. Moving on, when we do get the operating framework and you've said before that we perhaps, unless I've got it wrong, we shouldn't expect too many surprises. We're probably going to have an election this year. If we were having this meeting again in year's time, hopefully Mtech Access will bring you back and we'll look back a year from now, what might we be saying in year's time? Are we expecting any differences? Are we still going to have the same drivers? And if they are the same drivers, what are they? We've kind of alluded to them, but I want to give you the chance to be specific. I've thrown in things like ambulance, you talked about mental health. What do you think are going to be the big hooks this year?- So access times are really important, whether you can access a GP, whether you can access an ambulance, whether you can get into A&E, these things are important, how quickly you can access your surgery. So we can't ignore those things. They have absolutely direct impact on the people we serve. So they're important. They sit as part of the stuff we need to manage and we need to do better. The COVID pandemic caused some challenges to that. Industrial action has caused some challenges to that, and workforce shortages are adding to some of those challenges. So we need to keep paying attention to those things. But I think for me, the hope in the future is that alongside those, we are giving equal or more weight to those conversations about prevention, about tackling inequalities, that we are sitting down at Integrated Care Boards and beginning to say, look, we're beginning to see not necessarily the outcomes of our interventions, but we can at least identify and be really clear about the interventions. We can see how we are using population health management data in particular, use the insight that we've got about the populations we serve better and be really beginning to sort of measure some of the outcomes that are coming through. And I'd love to see more reporting of this is what the people who use our services are saying, not this-- I was going to say, because you've mentioned outcomes several times. What is that? Is that a good death? Is that curing me in inverted commas? Is it keeping me out of the hospital? Because sometimes I'm part of those conversations every day and I'm guilty of it. So I say, we'll stop people going in hospital, stop it. And you think, what does that actually mean? Does that mean someone's going to be stuck at home now in pain and discomfort, incontinent? So what are the outcomes that you would advocate.- And somebody who's just had a repaired broken wrist when we need emergency and specialist services, we want them. So this isn't about decrying any bit of the system. We need the whole system, but I think you are right, it's not a singular outcome, but it is about different things. So you used a good death example. I happened to spend the day a couple of weeks ago with three of our local hospices doing a bit of design work for them, collaborating, working together in new ways and really exciting change of culture and change of behaviour coming forward. And you're right, for that particular cohort there's a really significant, what does a good death look like? And what looks right for you, David could be completely different for me. And one of them I was speaking to a few months ago and they said, the chap absolutely wanted to die in the hospice, because he didn't want the home to be the place where his wife remembered him dying. And that's a different dynamic to what lots of people say. So we have to be really subtle with these things, don't we? We really have to get under the skin of understanding individuals. For children and young people, there's loads of evidence about, the school attainment at school being a major factor in the rest of their lives. So what if we really put all of our energy into that? So if children are not attending school due to dental health or mental health or whatever, we are setting them up with poor outcomes for the rest of their lives really. So what effort and energy could we put into that? For people a working age, there's lots of evidence isn't there, that if people can hold down a good job and be successful in employment and things like that, then that adds huge value. It keeps them healthy, it keeps them well, it gives them purpose. So I think we have to have that ability and I believe we've got that ability now, we've got the technologies, we've got the capability to really say, let's have personalised care. That's the word, the phrase that we use is, personalised care, let's really think about what each and every individual is saying is important to them. And if for one person it's attending their daughter's wedding before they have surgery or whatever, then that's where if we're a really healthy system, that's what we can accommodate. It's not easy when our frontline teams are working out under absolute pressure at the moment. But again, the evidence tells us if we personalise care, actually there's less demand for it. People aren't going to just say, "I need more and more." On average, they will generally say, "I don't need that. I just need support for this bit. Help me get a job, help me, achieve the school results for my child. Help me have that good death in a supported way."- Well, it can be as small as, yeah. And forgive me audience now, I was talking to somebody just recently from a major Pharma company and one of the things I said there was,"How important it is to have a downstairs toilet in your house." And they said, "Well, everybody's got a downstairs toilet in their house, haven't they?" And I thought, "Well, do you want to come and live in the United Kingdom? Because that's not what I observe." But anyway, what I'm sure our audience will be screaming at is,"Right, we get it, Richard, we're with you, we hear it. Who would we need to engage with?" Particularly as you've several times mentioned local authorities, you've brought employment into it, then you've brought schools in, which is local authority. And a lot of our audience are constrained by compliance systems, but also, because they don't know these people. Who do they talk to in the NHS and around the Archipelago with the NHS? Do they find people like you? Who on earth do they talk to?- So I would really recognise that. I used to be head of IT at the IUH many years ago in Bath and I always used to say to suppliers,"We must be a hard customer to deal with," just because it is hard and it's not the National Health Service, you don't sell it once and sell it everywhere, do you? In terms of what you do. So I would really recognise that dilemma that you've presented there, David and I don't yet know how many systems are ready and mature for that. I think what we've had things like the Academic Health Sciences networks over recent years, which have tried to support working with innovation and companies and trying to create that link between the commercial sector and research and development and delivery of frontline services. Those are positive routes in, but I'm increasingly of the view that we could do a bit more on the NHS end to say, how could we create, organisations like your own in a way do some of this work, don't you? You work on that access interface between the systems and the organisations. But I wonder if there there could be more open collaboration, sharing, events type things. And I know I've referenced this before and I haven't yet managed to land the thing that's in my head, but I'm hoping, over time we might work with some of those systems and say, okay, how do you know you've got the best pharmaceutical products, being prescribed in your system? How do you know that you are making the best use of technology or AI or whatever element it is? And I think that's the bit where when people are extremely busy, this feels like a nice to have conversation. I think we have to try and prioritise it in a way that says, no, no, no, this is an essential bit of the conversation about sustainable health and care services and perhaps look at ways for how we facilitate that. And I think regions do some of that really well. I think the AHSNs do some of that really well, but I think we could do more and particularly where you've got smaller suppliers, they can't afford the time to be working their way around everywhere, can they? So what are the opportunities of regions, AHSNs, others working with systems to say let's understand what the market can bring to us.- Well, let's spend a couple of minutes with that. I wasn't planning to ask you this, but I think I ought to. So there's seven regions. Give us an idea just so we get... You are the South West region, you cover seven ICBs, right? Huge patch, millions of people. How many of you work at region approximately? Let's give an idea. For our colleagues listening, they're probably wondering is it a massive tower block in Bristol? What is region?- So it is people dispersed across the area really. So it was, I believe don't quote me entirely on the numbers, but I think these are pretty accurate. I think it was around 900. We are the size of regions is changing. Some of that's because people are being moved into systems directly. So some of that's a really positive, get the resource to the front line. Some of it is because we're being asked to save some money. So I think it will be about 600 in the South West is about the right number. And so those people are dispersed across, a strong medical, clinical nursing-type grouping where they lean into programmes associated absolutely with the medical, clinical. You have got people who are there for performance and oversight-type roles, but you've also got people who've traditionally supported programmes of work. So be that mental health, be it children and young peoples and things like that. And I think those people leaning in and working with systems and really helping them deliver the transformation work is one of the key parts of the changes we're trying to make.- And I wasn't expecting, so for our friends out there, I've carried the bag, okay, it was as we call it in our side. If I were going to do that again, I'd be really interested in mapping out. The regions have good websites and you can see the people, the main people. The risk of making Richard blush, regions tend to be full of very experienced, highly qualified people, senior people, well-paid, influential. He's hit on something a couple of minutes ago that I thought, "Yeah, that's right." In my experience, generally, people at region have a more open attitude to dealing with commercial organisations than people a bit further down the line, okay? And I'm thinking of people in my own region at the other end of the country from Richard's. And if you think of my region, it's got a population that is bigger than Wales and Scotland combined. Huge organisations, but there are many people, not just several, and I know you said several, there's many people at my region who I would go to if I was in a promotional role and I thought I had a value proposition that made sense and I was being frustrated. There are people there that can unblock things that can prompt, invite you to things, open doors for you. Yeah, I think regions are really powerful. I'm keeping an eye on the time just to show I've been carefully listening to you. I'm going to go right back to something said at the start, because it's something that is a hobby horse of mine that is rarely covered. My ICB has a provider collaborative for all the foundation trusts, has one for the mental health trusts, it also has one for primary care and I'm on the board of that, okay? You mentioned provider collaboratives before. Briefly, you're very good at being succinct, much more effective than me. What's a provider collaborative? And would you advise our friends who are listening to have interaction with the provider collaborative?- Yeah, so certainly the second part to that is a definite yes, but I'll come back to why in a minute. We've spent 20 years haven't we in health services designing competition between units of organisations. So be that between hospitals to some degree, you chase the money, so you're creating competition between primary and secondary care, community services, all those sorts of things. So we've had quite a small scale, I know they're still large organisations, they employ tens of thousands of people, they run at a billion pounds a year. They're big organisations in one sense, but actually they've been designed to be in competition with each other and that has driven certain benefits. You would look at certain times and say, well, that had a benefit in terms of some of the elective treatment times and what have you. But we're now in an era of encouraging collaboration and I think the provider collaboratives are where we're encouraging providers to work together. So some are absolutely provider collaboratives of the same sector. So they're three hospitals joining together, working together. And what they might do is they might look at some of their support functions, procurement, finance, HR, and say, well we don't all need one of these, we could share that. They might look at their clinical front teams and say, actually we're delivering three bits of service, perhaps not as good as we could, but if we collaborated, maybe we could get a really good service and structure it slightly differently. In all of this, you've got the public voice in that. So I'm aware of local initiatives around stroke services at the moment, where two organisations not that far apart, are trying to reconfigure, but of course that's contentious. The public have a view about what they want at their local hospital. So part of it is about single-sector organisations working together, but increasingly I think what we'll see is cross-sector. We will see hospitals, mental health trust, community services and elements of primary care coming together and saying, if we're genuinely going to offer integrated care, it's not helpful for us to be all operating in a slice of this space really. So there's a real opportunity here, but what we mustn't do is obsess about the structural change and have another load of structural changes without saying, but why, what difference is this going to make? So if the difference it's going to make is that a specialist is going to work more closely with a local team to look after people with long-term conditions, and they're going to spend more of their time supporting, educating, contributing to that and keeping people out there in the community, keeping them well, keeping them working, then you can see real benefit in that. So the vision has to be, I think about what difference is it going to make, not just about the organisations being bolted together and scale being better than small-scale, because we've all seen that cycle.- And there's a particular opportunity there. But I think, I have to go back. These sessions are being recorded and I want to listen to the start again now, but I'm sure you kind of mentioned provider collaboratives and the contractual opportunities that are around now, through the provider selection regime and things. So going back to my ICB, what we're expecting is the ICB would give contracts and the provider collaborative, they might subcontract them, for example, to primary care networks or individual practices, and create some real, I don't know, a bit of vim in the system to go away from competition to bring people together and cut the bureaucracy out and meaning we can accept innovation faster. I mean, you were nodding there. Is that correct from your-- Yeah, let's not deny the fact that commissioning is difficult. Understanding how you prioritise how resources are spent on a population is really difficult. So we've got to be careful here. We can't just take a commissioning conundrum that hasn't quite worked to the best of its ability and move it somewhere else and think suddenly it will be better. But there are certainly opportunities, I think, for providers to say, this isn't a win-lose, we're not taking some money off you and giving it to you, because we think that's a better way. What we're saying is, here's the whole pot, you work out whether you could run a system more sustainably by moving that resource. And if you say, right, we're going to move some of our specialists out the hospital, they're going to work more in the community, then that's a really positive change of direction. But it's an organisation owning that decision, making it happen, as opposed to a commissioner saying, right, we're taking some money from A and giving it to B. And I think, again, I've got to be honest, these things will take time to mature. The behaviours that have been associated with competition are very different to those with collaboration. People are going to have to let go. And a lot of our leaders today have succeeded in the world of competition. So either, they've got to relearn the skills of collaboration and the behaviours that come with it and teams have to as well. So it's not a quick fix, but that's the direction of travel, we're being encouraged to go in. And I think what we need to do is make sure that whatever emerges in those collaboratives does commissioning really well, that it takes on those responsibilities of understanding the needs of the population and working out how the resources that are spent across the whole pathway could be better utilised. So back to that conversation we had earlier, really, David.- And if I'm going to be didactic for our audience here, and which I really shouldn't be, but I can't resist doing it. Basically, if you've got a marketing plan or a territory plan or if you're looking at your KOLs and it's not taken into account provider collaboratives, if you're sitting there thinking,"I don't know what Richard's talking about," you need to think about it. It is a real opportunity for you and it's a way your traditional links will be in with the providers, with the clinical KOLs, for example, and they can push upwards and access funding and access change. So, that's why I wanted to come back. I thought it was a great spot from Richard at the start.- And David, that's such an important part. Can I just emphasise what you've said there?- Yeah.- It's such a key opportunity. They will be making a lot of the buying decisions and so getting in and talking with them, working with them and demonstrating how your solution could help them solve the problem they now own entirely. Whereas in the past they only owned a bit of the problem. They now will own more of that problem. So there is a real opportunity there to have a different relationship, but it will take time, it won't happen just because you pick up the phone. It will take time to mature.- Yeah, and we're kind of making the rules as you go along. We've got a couple of minutes left and I'm going to leave it to Robert at Mtech Access to summarise. But Richard, I always ask this question. I'm never likely to interview you, but I always ask this question at interviews and things. What should we have asked you? What were you expecting to talk about today that we haven't covered? Is there anything that we've missed off?- I'm glad we didn't entirely talk about money or flows, I'll be honest with you, David, I would've struggled to do that justice. I think we've covered the big themes. I think it is a changing landscape and it's an evolving landscape and I think I would often say, we need to be kind to each other and we need to have empathy with the fact that it is a changing landscape and people are doing their best. And I think on all sides, let's start with that mindset in a way. And for me, a lot of the problems we have are behavioural, and if we start with changing our own behaviour, then I think we can influence others. The operating framework will guide us and be helpful, but actually, it's the behavioural stuff that will be the biggest gain in my mind.- I totally agree with you. Let me just check this out in 20 seconds. When the operating framework comes out, if you do a word count of it, I think productivity will be one of the words that is mentioned frequently in there. What that actually means in practice is change the behavioural stuff, isn't it?- Yeah.- I can remember working in a hospital where the nurses in theatre started at half past seven and the doctors came in at eight o'clock and everyone couldn't understand why the theatre has always overran by half an hour. It's that kind of thing. And being kind to each other and flexibility. One of the big takeaway messages I'll hear today is your point about, it's not just saying, can we have another 10 quid? It's what we are doing with the billion quid that we've currently got and how do we spend it? That makes a lot of sense to me as a citizen, as a taxpayer as well. Richard, thank you so much for all your insights today, absolutely cracking and your candour and also how skillfully you've negotiated some of the policy things given your place at region. So thank you very much for that.- Thank you for the opportunity.- Thank you Richard.- Sorry I cut you off there.- Rob, over to you.- Oh, thank you David. Yeah, just basically echoing David, thanks. That was a really insightful session today and as we bring the webinar to a close, I just want to offer all the participants the opportunity to work with Mtech Access, those of you who have attended today, if you want to delve deeper into those pathways about funding flows and how they impact your business and looking at products and assets, organisational levels, then that's certainly something that we can help support you with. We can also look at some real world examples and identify case studies and stakeholders able to help you. So if you'd like to talk us regarding one of these services, please do reach out info@mtechaccess.co.uk. Thank you very much both of you, and bye for now.- Bye.- Cheers. Bye Rob, bye Richard, bye-bye everyone.- [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.