Pharma Market Access Insights - from Mtech Access

Primary Care and ICBs – what is the next step in the integration journey?

• Mtech Access • Season 4 • Episode 4

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How will changes to the structure of primary care impact decision making?
How is the relationship between Integrated Care Boards (ICBs) and primary care stakeholders evolving? How will funding flows be impacted?

Prof. Phil Richardson (Chair and Chief Innovation Officer, Mtech Access) is joined by Tim Goodson (Executive Officer, Dorset General Practice Alliance) to explore how primary care is evolving and what this means for decision making, funding, and relationships with industry.

Phil and Tim explore:

  • The integration journey across primary care
  • Evolving relationships and structures in primary care in the NHS
  • Where decisions are made and who makes them
  • How understanding commissioning priorities and funding flows can help Pharma and Medtech to identify decision makers and understand their needs


This episode was first broadcast as a live webinar on Friday 28th April 2023.
For more information please see: https://mtechaccess.co.uk/primary-care-integration-journey/

Learn more about how Mtech Access UK NHS Insight services at: https://mtechaccess.co.uk/uk-nhs-insights/

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- [Voiceover] 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 HNS 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.- Hello everyone and welcome to this NHS Whispers session. I'm Phil Richardson, and today our webinar is about integrating primary care. It's good to say that we've today got a great mix of audience between industry and NHS, and I'd like to particularly welcome our associates who play a key role in the work we do. For those who don't know about Mtech Access, we're a specialist health economics company, focused on outcomes and market access. We've got a substantial track record in delivery of expert technical services. What I'd like to do today is welcome you specifically to, our guest Tim Goodson, who is the Executive Director of Dorset Primary Care Alliance. And we're going to focus today on integrating primary care and and the future facing view of how some of the things that might be involved in that. So welcome, Tim. Great to have you here.- Afternoon Phil, good to be here.- Yeah, good. And maybe we could start with you just giving us a bit of an introduction about you, your role, and your responsibilities, and maybe a bit of your background, to just help everybody get orientated.- Okay. Perhaps I'll start with a bit of a background. And, how we came to know each other. So previously I was the Chief Executive Officer for Dorset Clinical Commissioning Group. So I did that for the whole sort of nine and a little bit years of Dorset CCG, including being the Integrated Care System lead for the last four, 'cause we were one of the first wave one pilots, actually. So started all the integrated care systems sort of stuff off and going, and was part of that right from the infancy. My actual sort of background by trade is accountant, so I was Director of Finance for nine years. Prior to that I was in the primary care trust of various forms and shapes across Dorset. So I've been in the NHS quite a long time and sort of board level for a good 18 years of that career. I'm now doing the sort of Chief Exec role for the Dorset General Practice Alliance. And I really started that when I left the NHS in October, and just sort of getting to know all the team there. I mean, obviously I knew some of 'em from the CCG days as well, so still part of that sort of Dorset system.- Brilliant. Thanks Tim. So, for those who don't really understand what the Alliance is, I wonder if you could explain a bit more about that, and maybe if you can explain, I'm not sure if you can at all whether it fits into the, what's the relationship with the ICB or the ICS and then, bring it to life a little bit about what happens on a day-to-day basis.- So the General Practice Alliance came about really, just towards the end of the Clinical Commissioning Group. So the practices I think were a bit nervous really and a bit concerned in terms of, you know, going from a CCG, which was a general practice membership organisation, with the GP chair, lots of GPS on the board, you know, it was their organisation. They were the commissioners, to effectively the integrated care boards where all of a sudden you got the local authorities got seats on the boards, the providers trust got seats on the boards and the GP's, or a representative from primary care only had one. So, you know, there's quite a big sort of shift there. So they sort of felt it would be good to come together as a collective across Dorset, so they they can maintain a sort of strong voice in the system. So all 73 practices endorse it, have signed, really just a memorandum agreement to form the Dorset General Practice Alliance, so that they're all members of that. And effectively, we've put together a mini board to do that. So there's, Forbes Watson who was the CCG Chair, Chairs it, I'm the Chief Exec. We've got an AHP representative there. We've got a patient representative there, and then various GP's that represent the sort of east of Dorset, west of Dorset, sit on it. And we spend a lot of time also at the board with the Primary Care Network, leads come along. And it allows us really to be that sort of continued voice of general practice to sort of unite it and act as one. And since doing that, the ICB actually has sort of recognized that as well. So that the place on the ICB board for primary care, effectively the General Practice Alliance Chair takes that and the other two GPS we've got, which, effectively as deputies, which one represents east, one represents west. They also effectively attend the board as as well. And then they sit and represent general practice on our, on the ICBs Primary Care Commissioning Committee, health and wellbeing boards, some of the groups that have come together. So we're being that sort of voice now for general practice in Dorset, and I think people are using this as well. You mentioned sort of day-to-day stuff, there's somewhere to go. It's very difficult to get a view from general practice without going to 73 different organisations in our case, which clearly doesn't really work. Whereas now, people appointing them to the alliance and saying, "Well actually if you want to engage with general practice in Dorset, there's somewhere to go." Clearly all our GP's are still being GP's in their sort of day job. And myself and some of the other people that run it, we're effectively part-time as well. So it's, yeah, it's not a big sort of organization but it, it is quite effective in terms of having sort of touchpoints with GP's. We have a monthly board meeting where again the primary care clinical directors come, our members come, and effectively now the ICB now likes to attend, and other people like to attend, 'cause it's just a good place to engage with sort of general practice. So, we've had to ration attendance actually,'cause everyone wants to suddenly come and engage with it, so, it is gone well, and we work hand in hand with the Local Medical Committee, the LMC, which for us is Wessex. So that represents a bigger sort of patch, and we let them deal with sort of contractual stuff, what's in the contract and negotiations, and things like that. We don't want to really be duplicating what they're doing, and we try and focus more on, what's the actual general practice provider and provision side that's going on in Dorset. And if some of the various sort of pathway groups are looking for a representative or think it'd be good to have a GP on there, then we see if we can sort of find somebody to fit that, to keep really, sort of strong voice from general practice in the decision makings, and some of the thought processes and innovation stuff that's still going on in Dorset. So it's not a trust, in that sort of context, but in many ways I think people see the alliance kind of as, well, there's the equivalent, if there was a general practice trust, that's what it is. So, let's sort of use them as we can.- So that really touches on a number of things that, some of it would've come from the earlier ICS work that you touched on earlier about, integration was, was quite a strong theme. And I think it is reasonable to say that Dorset was seen as one of the leading integrators of practice, as a system. What do you see as the role going forward?'Cause I hear you talk about the, you didn't use one-stop shop, but it feels a little bit more about a one-stop shop to have the primary, the general practice conversation. There's clearly a wider conversation around primary care. Is it working both ways? So more than just representation on the board, is it, is something from the work that was in historically, or perhaps the work you're doing now, helping integration of expertise in a much more holistic way?- I mean, Dorset's had a, you know, quite a long history really, I think, sort of working together. So it's not saying it's been new really, the integrated care system and even, you know, when we were approached to be, you know, sort of that wave one pilot, that came off the back of the work that we'd already been doing. So I don't think the switch at Dorset has been such as a big bang or forcing people together. I mean, we certainly started in Dorset with, same as everyone else actually, you know, long, sort of battle scars, really around PPR and long contract negotiations and disputes, and things like that. And, you know, it really just wears people down, and you know, after a while, you sort of think,"Well, is this really helping the delivery of any of the patient services, or improving things, or is it just a bit of a battle?" So, you know, we've been there done that, kind of got the T-shirts, the same as a lot of other people, and I think really at, sort of the start of the, it was really the start of the CCG. We wanted to try and do that in a sort of different way, and effectively we sort of, we knew that the issues really were going to be around workforce, finance and quality. They were kind of our three cornerstones. And up until that point there'd been so much focus on the finance, 'cause everyone was just, you know, going after everything they can get. So, you know, if the CCG gave out, 99% of its funding, everyone's fighting for that final 1%, and it's probably not that different now, but you know, that's kind of how it sort of felt at the time. So we came together and endorsed it to agree to sort of a finance collaboration agreement, that was the first thing we did, was really, that really set some of the rules, how we wanted to engage in the finance, move the money around. We didn't want to start something if it created another cost pressure somewhere else, and we didn't want to do, you know, a new initiative unless there was cash releasing savings as opposed to theoretical, the patients have moved there, so that saves X,'cause this is cheaper than Y. We said, "Yeah but can you actually take staff out of the one or have we still got to run it, because it's still a service." So, you know, when we got that agreed, that really allowed us then to focus on,"Well what do you want to do on top of that then?" As a system, and you know, people then really did want to look at some of the difficult things that we hadn't done in Dorset, because we hadn't had the joined up approach. We refer to it as integration, but for me it's really, is everyone actually joined up on what they're doing? And, you know, as soon as we sort of got a stable basis, I think, on the financial side of things, people were happy then, to actually, let's look at some of the big ticket areas and you know, as yourself knows, we started the clinical service review then, which was a long journey, which ended up in implementing and you know, getting capital funding for a new sort of A and E, maternity unit, children unit, community investment, mental health, acute care, all sorts of things. But I think what it really did, which, you know, you don't really see, 'cause effectively the buildings and the stuff around that are easy to see, but it did get everyone really on the same side. And it got people, I used to describe as walking in the same direction. And that really was the legacy, I think, of that piece of work. And we started to put people, they started to come together themselves really, in terms of just in the same room. So I remember down at, it was Westhaven Hospital, down in Weymouth and it was no more complicated than actually teams coming together in the room. And if the phone went in that room, anyone from the team would answer it, whether they were from the NHS, or social care or you know, some of the voluntary sector. And they started to take ownership and work at it together, and that sounds really simple, but it doesn't really happen, you know, everyone I think, prior to that had got very much stuck in the sort of isolation of different organisation, sort of boundaries around them. And I think some of the work we did early at Dorset was say,"No, that's not the way we want to do it. Is it really best for the patient, medical system?" If it is, let's start to go through and do that. And it started a trigger, almost a series of events that then followed. So, as we were going through the journey, naturally, the Vanguards came up, and we had three acute trusts then. We had Bournemouth, Poole and Dorset County, and they decided themselves to become a Vanguard to start sharing some of the pathways and doing things together, so that they then jumped ahead of where we were, some of the stuff that we were doing, and it was good to see that. We saw the general practices starting to merge and come together, again to get a bit more resilience there. So when we started the CCG, we had 100 GP practices, and when we finished we had 73. So that's, and if you think those that went, went with another practice, you know, almost half of the practices, in one way or another, had sort of come together and gone up at scale to do that. And I think some of that sort of collective, you know, acting as one and starting to come together as one, that probably was the main sort of legacy or the platform that was created, just through some of the on-ground work that was going together. Similarly, the clinicians when we were doing, saying, what's stopping you do this. And then there's very much a view of,"Well if you can't see each other's record with patient, it's very difficult to do some of the integration stuff." And that led to the Dorset Care Record being created, where we started,"Well okay, let's join up so we can see each of the, what was then the three different acute trusts, the community trust, let's get it so both sides can see the general practice care record as well, and social care could then link into that and see it." And I think last month there was, you know, there's just over a hundred thousand record views, in the last month alone. So it's got a massive hit rate, and you sort of think,"Well, how can you go from not having that system, to a hundred thousand records being accessed a month now?" So that shows the difference in actually, let's see the whole picture for this patient, not just what we do in terms of, you know, our department or our services. And I think that really was the journey we sort of went on in Dorset, just trying to get that together. And others have been on similar sort of journeys as that, but we were probably slightly ahead of where some other places were in that. And that's why we were invited to be one of the, one of the pilots for it. And I think some of that, you know, so that journey is still going on now, and we sort of described it really, that we reached base camp. We're at the infancy of that, the rest of the mountain is still there to climb in front of you. But it really did bring together all the different sort of clinicians and services, and sort of park the organisational alliances, so that if it's the right thing to do, let's just do it, 'cause we're, as I said, we're walking in the same direction. And that's really how it sort of started.- So that's really great, and as you say, there was a lot of good work done to, to almost make the move through into an integrated care board just the next logical step. But have you, have you noticed, having gone from where the whole thing started at the, let's start at the CCG through to the end of the CCG, and now the ICB. Have you noticed, has there been a change in the role for primary care or have you, did you, was there an inflection point at the ICB, or have you felt it's pretty much just continued on the trajectory and just in a continued improvement?- Well, I guess the structure has changed, hasn't it? So I said, you know, the CCG was very much a membership organisation, and the GP's were there with commissioner hats on. And we were quite, quite insistent on sort of saying that to them,"You know, you've got to park your provision hats again as a GP, you are here to commission on behalf of the whole system and the whole pathway." So I think the big change with the ICB, is now they sit there really as a general practice with a provider hat on. So they're very much more vocal on,"This is what general practice can do, or primary care can do within this sort of pathway, or this system, and these are the things we can't do, or what our limitations are, what our challenges are." So they kind of sit there and, I don't really want to say they're a trust, but you know, together there are about 3000 people working Dorset's general practices. We've got 130 odd sites, and the vast majority, 90% or more of the patient contacts, happen in general practice. So really, they wanted that to come together as, you know, people need to recognize this, that actually, we've got all these staff, and we've got all these sites, and we see all this huge amount of patient activity, you know, we are as important, effectively as some of the NHS trusts, where it's easier to touch and see and, people are more familiar with that. So, I think that role has changed from the, you know, the commissioner to the provider. Probably a bit more bullish really, in terms of general practice and the position it's at. The essence of, I suppose some of the primary care, and what they do on a day-to-day hasn't changed, but I think they view it with a slightly different sort of hat on now. And of course, what we're going to see, well what's effectively just happened sort of this year as well, if I take the wider primary care, some of the stuff that NHS Dorset was doing, has now come back in to the ICB, round the sort of dentistry and the opticians, and community pharmacists. Which the CCG didn't do, became a bit, sort of out sight out of mind 'cause we, you know, we weren't involved in that pathway and, that always felt a bit odd really, 'cause, these are very local services that, you know, you need to effectively make the whole system work appropriately. So, I think for Dorset the change wasn't enormous. I think other places around the country perhaps, would've had a bigger change where they weren't so used to doing everything all together and taking collective decisions. But the ICB board in Dorset, and certainly the, the Integrated Care Partnership in Dorset looks similar to what it did with the CCG. We were keen to have lots of partners around the table, particularly at the partnership we already had, the local authorities were there, fire was there, police was there. So you know, it wasn't a massive difference there, but the fact it's now laid down in statute and right, okay. It gives that some authority to, you've got to write the strategy and you know, the ICB boards will implement that for the NHS part of it. It's probably put much more structure around it. And we were doing it through really a, a coalition of the willing, was sort of the term that was being used quite a lot. I think Rob Webster might've come up with that, actually. Part of the, you know, the ICS wave one group, and that's how it felt, you know, people were there'cause they wanted to be there, but equally, people could walk away at any point. Whereas now that has changed, obviously, you know, it's a statute requirement, so there's a lot more sort of, you know, power behind the ICB really. They've got much more control in that respect than the CCG had, I would say.- But I think what's interesting with what you just said is, it really shines a spotlight on general practice, particularly at scale, is now an organised, or becoming more organised, meaningful operation in its own right. And that's a shift in dynamics, in the conversation, because historically everything, both within the NHS, within NHS policy leadership, and within industry has all been hospitals. Everything's a hospital conversation. You know, the BBC, all of their pieces on NHS are outside A and E with ambulances buzzing,'cause that, buzzing around in the background, and that's where the NHS happens. But, you've touched on I think, a really important point that different, I've heard different quotes, but anywhere between 90 and 95% of everything happens outside the hospital. So why are we only talking a tiny bit about that, and everything else is focused on hospital. So, but I think you, I think that's really important message to come from this. The more organising around the provider capability, capacity, innovation, skills, ability, that general practice has, and now the integrating with wider primary care, that really is where the conversation needs to be, isn't it?- Well, as you said, you know, I hear different percentages as well, but they all seem to be in the 90% plus in terms of, you know, your total number of contacts are going to be in primary care. And you know, if I think about it, and most other people think about it, you know, I see the GP, the optician and the dentist far more often than I'm in an acute hospital for some outpatient appointment, although, we all have touchpoints of those in life. For the vast majority of people, it's going to be primary care, is going to be your most regular sort of contact. Yet, you know, we do seem a bit consumed in the NHS with the larger, sort of acute hospitals and that side of things. Whereas really, if you want to make, you know, the biggest changes, you need to make it where the most amount of care is provided, which is outside of the hospital. It's in the community, and it's in the primary care settings to take that forward, yeah. So no, I think you're right.- And I think it's interesting for industry, in its approach and thinking about what its strategy is, and the model of engagement that it works, to perhaps reflect on that change. So while it might look subtle, it is actually quite significant from a primary care in a disparate federated sense, and commission focused to some degree, with provision in the background to provision being at the headline really, and truly engaging with population. And I think if we look at, you know, the Hewitt Review is an example in this, the next logical step to integrated neighborhood teams. How would, how does that figure in your current thinking or, what you might be doing, or might already have done, in the Dorset system?- Yeah, so, I think the Patricia Hewitt review pretty much, you know, hit the nail on the head with most of the issues that she raised there. And you know, we've been asked to do a similar review in Dorset, looking at the sustainability of general practice in Dorset, and no surprise, we are finding the same things being fed back to which, you know, she's pulled out and the Fuller Report pulled out as well around some of the integration, but particularly the Hewitt Review. Calling out some of the complexities around, some of the QOF arrangements, ARRS arrangements the investment fund stuff, the bureaucracy around that, you know, the form filling in, the fact that general practices estates not had enough investment really, and keep creating new roles for people that are almost complimentary to GP's, but not GP's. So, you know, have a, let's move into practices, you know, sort of physios and pharmacists and paramedics, they all need to be housed somewhere and you know, there's not enough space to do this sort of service and there's not enough freedom around some of the funding that goes with it. So I think she really did pull that out and call, call it pretty well actually. There's not yet, I don't believe there's yet been a formal response to it, I think we're still awaiting that. So it'd be interesting to see yeah, what do they run with, or what don't they run with to do that. And yeah, wait for that space, and in terms of some of the integrated stuff and some of the neighborhood teams, which perhaps was a bit more where, her report was coming from in terms of, you know, can you really pull all these different providers together because you could really make a difference. I still think we are beginning to see some of that, but I think we are still very much at the early stages of that really, you know. The ICBs have come together, they're going through, effectively the norming and forming stage, in terms of their sort of journey at the moment. And that takes a lot, you know, it's a lot of organisational change and turbulence there for everyone involved in it. So, I think it's only now you'll start to see them settle down a bit and start to look more in the,"Okay, what can we now do the next stage in some of these neighborhoods." And getting in there, and different areas are going to have different views on that.'Cause some of the ICBs are much difference in their size, you know, the size differential is vast, really. So, some will talk about the neighborhoods that, you know, 50,000 populations or PCN sort of population. Whereas, you know, when I talk to some of our GP's, they're much smaller than that. They're sort of saying, "Well surely the neighborhood is, the local population just at this practice or almost a council ward size." So you can find your talking at totally different purposes, depending who you're actually engaging with. But, I think if you can engage with local public, volunteer groups, some of the associations there and get people really taking ownership of some of those issues, you can really achieve great things. And I think if ICBs and ICSs can tap into that, and can really pull that off, that really would be their legacy, I think. In terms of that, 'cause we've never quite done that in the past. The NHS will do things, you know, in the NHS and it'll progress stuff and go forward, kind of regardless of whether it's CCGs, PCTs, ICBs, but having all the system partners around the table, if you can then engage with much more smaller local communities and get stuff much, sort of co-designed and owned by them, that's a real, that'd be a real benefit, really. And there are some around the country, the Wigan was really good, the Wigan deal, people sort of looked that up, how they really did engage with local populations around some of the services the council was particularly sort of providing. You know, it's a different way of looking at it, and I think the ICBs and ICSs really could tap into that. And I think to do that, get that real ownership, it needs to mean something to the people that live there. And I think you only get that at the smaller neighborhood level. You know, I don't think you get it, for me, for Dorset I mean, okay, I live in Dorset but does it mean much? Not, not a great deal. Whereas if you talk about, you know, my local ward or the local town, and places you sort of know and go to, that you are much more interested in that. So I think there's hope for that, but it's in its infancy would be my take at the moment.- But it does feel like it's a logical step, doesn't it, from where everybody is currently? And I think if we just couple it with your comments earlier about, general practice as a provider, and being able to have an integrated view. I'd be interested to get your thoughts on industry. So here, share with the paradigm that I experienced in talking to different industry organisations, both the early startups in the Medtech space, through to more established Pharma companies. The old model of working was really down a product focus, down to an individual therapy or treatment, and then maybe as wide as a therapeutic area. And the launch of ICBs and ICSs has created what feels like really key points of focus, and lots of energy and discussion happening about how to access the ICB or the ICP to understand what's happening and to engage and influence and partner. But if I overlap that with what you've just talked about, it feels like it might be a bit of a risk everybody's heading in the wrong direction. If, in fact, the primary care in it's broader sense, as you touched on earlier and, really getting to where the patients are. That feels like maybe it's time for a bit of a rethink. So I'd just be interested in your take on, you know, if you were advising me as to what I should be talking to industry about, particularly heading in this way about integration of primary care, or the integrated systems. What would your top tips be?- I suppose at the moment the thing that everyone's struggling a bit with is workforce. So, you know, there's the figure seems enormous in terms of number of the vacancies in the NHS, general practice, Dorset's actually quite good actually. It's got a, I think it's one GP for every about 2000, in terms of population, whereas the average is about 2500, and some are nearly 3000, in terms of people to GP ratio. So, workforce is the biggest pressure I think in the whole system, even social security. So, anything that effectively helps that workforce, or saves time, or makes the workforce that we've got effectively more productive, that's what people will look at. So solutions around, you know, probably time is the, is the key, isn't it? I think. You know, this product or you know, this treatment, this saves time. So you know, you require fewer visits, they don't need to keep coming and seeing you, or it cuts the pathway down or, you know, removes this repetitive nature of it. I think that's where people will see it, 'cause you know, at the moment, particularly speak to the GP's, you know, there's various funding pots that they can see, But they almost don't, well they don't go after the funding, because they've not got a workforce to deliver it, and they know if they get it they can't recruit people. So yeah, things that focus around the time saving is where I point people towards, and particularly, I suppose the ultimate one of that is, around some of the self care, and I think people want to help this out. You don't really want to have to go to, you know, I think with some of these services if you don't need to. So, you know, we've seen huge increase, haven't we in some of the, sort of your self-help apps, and your websites and stuff like that. But equally, you know, I mean I've got a blood pressure monitor at home, in the drawer sort of thing. So you can take that if you want, and there's stuff you can do on your phones and things. So anything that helps around some of self care I think, is a way to go and people will be interested in that, and primary care will certainly be interested in that. You don't need to come to the practice if you can do it at home, and some of the technology around that. And equally some of the stuff that sits around, some of the prevention and the promotion of some of the preventions and stuff.'Cause you know, we are used to it, people do brush their teeth don't they, and take various supplements and watch their weight and stuff. But, I think that's an area that a lot of people are getting much, much more interested in, and I think that again is an area for you know, sort of industry and stuff. Primary care particularly will be interested in, this is a prevention to stop them coming to sort of see me or need so much, this allows them to actually self-care at home. This allows 'em to treat you at home. So we try and move stuff that perhaps previously you have to go to your acute hospital for, we'll move into the community, stuff you used to go to the community hospital. Potentially move into, just your general practice can do that now, and stuff the general practice used to do, perhaps you can do that yourself at home, and that constant sort of shift that way. I think that's always of interest, I think within the NHS.- Great, brilliant. Thanks Tim. That's, I think that's really helpful and some good points for people to perhaps ponder as they pull together their plans. If we look at the traditional groupings of acute primary care, general practice within it, the voluntary sector, community sector. Is the alliance looking at anything about culture? And how our culture might, might need to be nudged, or supported or something. I'm thinking about just digging under the, you know, the people behavior values piece, rather than the structuring bit. And have you considered anything in that space?- I won't say we've proactively done anything in it, but we, you know, we are still quite young, I mean, we only sort of formed in October, but I think people are quite well aware'cultural eats strategy for breakfast' doesn't it? was it Peter Drucker I think was accredited with that and the more you look at these things, the more I think that that is true. You know, you can have the best plans in the world, but if you've got different groups that just don't want to work together and they just don't want to get on and do that, you know, it doesn't happen. And I think one of the things that general practice has been good at, you know, the GP's are well respected and, you know, they've got a vast knowledge of the whole pathway and the whole system, and you know, I think that does put them in a good position to actually bring people together, to give a more sort of holistic or overview of the patient and the patient journey, which starts to actually, you know, tackle some of the cultural issues. And I know some of our GP's were just meeting with some of the consultants in one of our acute trusts the other week, and they were quite surprised in terms of just how specialized now, some of the consultants are. And I think one of them said, I only really do, just above the knee, just below the knee, you know, that's how specialist it is. So when they, if they see anything else wrong with the patient, you know, there's the fact of referring back to general practice again, and the GP's were well, but you are also a doctor, you really, you need to look at the whole patient and consider everything they present, not just the specialist area. And we've probably moved too far away from that. And I think that's where the GP's pretty much get the respect, really. And they can get through some of these cultural issues,'cause they do tend to see the patient more and you know, know much more what's going on with them or their family. You know, we talk about the the cradle to grave, don't we? Which is becoming increasingly difficult for a GP to have that relationship with individual patients. But they will have it with those I think that, perhaps the more complex patients, or have more multiple conditions and they tend to see them a lot more, and they tend to get to know them much, much more. So it does put them in a really good place to effectively do that. And I think that, you know, the GP's just have the respect I think really, of the people, you get a different response from the media to GP's. You get different response when counselors are talking to them. You get different response when people in the hospital talk to 'em. So, I think they can bridge some of those cultural sort of differences really. And I think the alliance can then do a similar thing within the GP community. So we are kind of a safe place to have a, you know, safe sort of zone for conversations with some for the practices may have with a fellow GP, or with the alliance, that they may not feel comfortable having effectively with, say the ICB or the primary care team that's sort of managing them. So that, I think that enables us to be, you know, quite useful in that respect. And the same, you know, because we are somewhere where we can speak for that general practice voice, you know, we can engage in there and work with the trust, voluntary sector, 'cause we're a body that can represent general practice. So, you know, it enables some of the relationships really to be built. But there's yeah, there's no magic bullet really to crack in some of the cultural things. I think they just all get built on relationships and up until now it's been difficult to see, well where is the general practice relationship. But I think with some of, with the alliance and other GP federations and the primary care networks that come in, you can effectively see, well actually, you can have an ongoing relationship with them and you know, there's a bit more stability there, and they represent a bit bigger area, and the relationships I think will build the culture.- And that's a very strong point, isn't it? I think the understanding how the rewiring of relationships has happened through this ICB change, and then the role the alliance plays around it, that feels like a force for good to help get an alignment, and one of the things I'd be interested in talking about related to that alignment is, about research and innovation. So, in my experience in the system has been, are lots of really good talent happening, talent in general practice, for both research and innovation and some good individual connections. But is there, is that something that also will benefit from this clearer line of relationships, and a way of working?- Well, I hope so. And I think particularly some of the GP's, I think they tend to like some of the innovation stuff, and new ideas and sort of technology, 'cause they can very quickly see is there a benefit to that? Can I see that benefit? Can I see how that's going to help me? I think they see those connections almost instantly, really. And when you get down to an individual GP practice, you know, they can be very quick to change 'cause they're, generally, there are relatively small businesses, so they are light foot so, you know, the ability to change what they can do and actually implement something, be an early adopter or try something is pretty, pretty good really at that sort of level. I think the thing that the new system, particularly the ICB or the wider ICS partners, sort of bring to the table now, everyone is around the table. You know, the NHS can be quite a difficult market to break or get some of those conversations going with,'cause it's massive isn't it? And you think, "Oh we'll talk to the NHS." And it's like well, crap, you know, there are hundreds of ships in this flotilla, you know, the NHS isn't, people talk about the oil tanker, you got to try and turn the oil tanker and it's like, no, the NHS is a flotilla of thousands of ships that are going along, and it's very difficult to actually get 'em all going in the same direction and, you can't just talk to one and it happens. I think the ICBs and the ICS's has probably helped that,'cause there's more people around the table and it's put the NHS into quite nice bite size chunks. So if you want to change something, if you can get a big national change, you know, that's great, isn't it? But they're fairly rare and less likely. But you could do some research or partnership up with effectively an ICB, or GP federation, or a primary care network and you know, you could do something much easier at that sort of scale. And when things work in the NHS, particularly in general practice, the second general practice is working really well, it actually, the the message on that goes around very quickly, and you remember in Dorset, you know, we had a number of GP sort of systems and then they, like one system and you know, they suddenly all went with the same one. We didn't really push that. It suddenly happened like, this works, and we can see your record, you see ours, off it goes. And yeah, it really gathered its momentum on its own, and a series of quick decisions in individual practices can happen actually quite quickly. Whereas trying to get everyone to do everything together can take a long time, which sounded the same. It's sort of the opposite thing, isn't it? But actually.- Yeah, of course.- They can be quick to change, and I think yeah, you're a certain innovation, yes. Smaller bite size chunks, you can suddenly get momentum and then it can suddenly spread very quickly.- There's certainly a lot of organisations interested in doing proof of value pilots. And I think from what you've described, the changing shape of general practice and wider primary care is starting to head that way, isn't it, to probably want to do similar things. And I just wonder, if we just scale it back to look at some of the big data bits, things like population health management, health inequalities, health economics, the value of change. It feels like that also could work quite well in bite size chunks in primary care networks, or integrated network teams or, if it was scalable, to an alliance level type of conversation. What's your sense about that?- Yeah, I mean, Dorset was a wave one of the population health management and yeah, some of the GP's that got involved in that absolutely loved it. I mean you know, they would talk incredibly passionately about the richness of the information that they're currently getting, it produces them. And I think the thing that we did, perhaps different than some of the other ones. So rather than taking all the existing data and sort of, this is what your population looks like and, this is how many of these you've got, and here's how you compare and benchmark.'Cause there is just loads of that in the NHS. We were quite clear in terms of, we need to be able to drill back down to the patient, so effectively for it to be of use to the GP, is no good knowing that we are an outlier in this area, unless you can see, well which of the patients that are causing us to be an outlier, so they can actually do something about it. And we spend a lot of time trying to get that right and say, okay, so everyone can see the big picture, everyone can get the variants, but effectively if you are the clinician, you've got the password, you can go down into your practice, and you can see which patient it is. So you can actually have the conversation with those patients. And I think the ability to manipulate data like that, but those that are now running with that, you know, they absolutely love that really and, it makes a big difference to them. And I know some of the stuff we looked at earlier on, was doing effectively, just a simple grid really, in terms of these patients have got, you know, hugely complex multiple healthcare needs, but actually, we don't spend much resource on them. You know, why is that? And then you add another group of patients that didn't really have much in terms of complex medical needs, very low medical needs really, yet we were spending a fortune on them in terms of, you know, the number of times they were coming back in, and the interventions and you know, the frequent cause. So why is that? And the fact that they could get back to those patients, they knew who they were, you could start to add real intelligence to it, in terms of the ones that don't really have the medical need, but we keep on seeing them, they've not got the social support around them, really. They've not got the family, or the partner's passed away, or I remember in one case, the dog had recently died and all of a sudden, you know, you you've got loneliness and the person's not getting out much, and they get more anxieties coming in, and all those things. So, you know, and I think in most cases it's not the clinical need, that really is the support need. It's much, it's much more around the, you know, the whole social and family support that sits around it, that actually provides it. And we were seeing this with some of the data stuff,'cause we could pinpoint the individual person. The area I think we struggle with on some of the, you know, big data and the business intelligence stuff is, it can just be overwhelming. So you can give these tools to GP's and they'll look at you in terms of,"Well when am I going to get time to go through that?" You know, we've got huge workforce challenges, we've got people, you know, trying to get better access all the time, you know, is finding the time to go through it. So I think any new technology that, you know, cuts that bit out, and it does the predictive algorithms where it does the AI, which actually then pinpoints, actually this patient is effectively a 10 out of 10 on the risk score for this, and they've not got to go through a whole sort of drill down and variation analysis. It just comes out. So it gives you the list, really you should call these in, and link these to these conditions, they're high risk for that. And we do that with some of our stuff, some of the, you know, high risk for certain cancers and stuff, we do it. But you could do that across loads of conditions, and I think some of the data now, it's there isn't it? Some of the care records are there and you know, some of the look into all those things and genomics and stuff, can pull that out. But you could make it real for GP's at that level, if you can do it. That takes out the churn of having to go through it and it literally tells you if this patient number high risk of this, and you could link possible things you should look at. And then I think GP's will pull them in, they'll pull in to look at those patients, and have a conversation.- And I think that, I mean that sounds like a really sensible way forward, doesn't it? Once everybody has confidence in what they, the list they're given as being a good a list as they would do, had they got time to work it through. That's often been the challenge. But if you were to sort of expand that out, you talked about prevention a bit earlier, but if we think about wider determinants of health, sort of the Michael Marmot's view and many, many people thinking and supporting. Could you extend your thought process then to look at some other things? So just give you an example again, should we close the, should the council close a swimming pool, when if you had a model which perhaps connected those things together, it might show you a downstream effect on somebody in later life not having had access to it. Obviously that's just a made up example, but is there some connection between wider determinants and what you've just said?- Yeah, I mean really, you know, the whole of health teams moved across into the local authorities was to have that influence, you know, at the heart of the councils on the wider determinants around some of the housing, employment, open spaces, you know, because public health used to sit within the NHS trying to, you know, promote some of the prevention stuff within NHS. It's like, well actually the NHS is more about, you know, some of the cures and treatments. If you want to make the biggest difference, it is going to be effectively on those wider assessments. I mean they're 80, 90% of what really affects someone's life expectancy. Yeah, so public health moved into the councils to do that, start those conversations with the counselors, the health and wellbeing boards to influence those budgets to do that, and effectively take that forward. You know, yes the NHS can increase life expectancy through some of the medical breakthroughs, some of the drug breakthroughs and stuff. But that's really incremental I think, compared to some of the non-medical stuff. You know, if you look at some of the most deprived areas, that's where we're getting the lower life expectancy. That's where we are getting, you know, some of the frequent people that just keep coming back and that is going to be the same area that's going to be of most interest really to some of the housing officers, some of the low income stuff, you're going to get, you know, police will be interested in some of the areas, in terms of some of the crime rates there. Same with the fire, everyone's looking at the same sort of grouping. So, you know, the integrated care system particularly, if you've got a new scheme to start, start it there. You know, look at, well where are some of the things that Marmot was sort of saying or even, you know, Maslow's hierarchy of needs, your shelter, your food, your security, stuff like that, you know, homeless people, their life expectancy is half that of the normal age. So, you know, you need to look at, well where are they? Where can we make the biggest difference? It's going to be there, and it's not going to be through NHS interventions, it's going to be through, you know, those other areas which are much more local authority influenced and linking in with some of the voluntary sector, charitable sector that work in those areas, you know, some of the, just the residents in those areas as well. That's where you make the big difference and the ICSs in particular bring together all, pretty much all, really, of the big anchor institutions of the public sector in that place. And if they all focus together at the same sort of area, with the same thing we're trying to achieve, yeah, they can make a difference there. Absolutely. You know, we can buy locally, start each new initiative in the same area, you know. Try and recruit and get the employment going there, try and invest there, and you can slowly turn the dial in some of those areas and yeah, I think, you know, the ICS's and the ICB's, very well placed to do that.- And I, and it's an interesting thought for industry, isn't it? Because there is the, if we truly have the patient at the heart, or really the person at the heart, where we're trying to help them not become a patient, would be one ideal scenario. There's something about how organizations might want to think about engaging in the ICS conversation, as well as more locally into a therapeutic area or similar, that sounds like that might be something worth considering.- Yeah, I think a lot of the, the whole person, sort of very, you know, just, we tend to talk about patients, don't we? But really it's the population, isn't it? It's the person, and what would you want, and how would you want your family to be treated? And what you want for your area around all the services. You know, we're all the same in terms of, you know, we want the best for our area and our families. And that's not necessarily, if you want to improve the health, I say it's not necessarily a conversation with the NHS you want. It's a conversation for, you know, others and particularly local authority, spend the vast amount of the local authority budget will be spent on adult social care and, you know, children's social care, that's the lion's share by a huge amount, yet we don't necessarily associate the local authorities with that. You know, people tend to think of roads and potholes and libraries and things like that.- Yeah.- The biggest chunk of money is going to be spent on the social care, by some way.- Yeah, yeah. No, no, it's a, that's a good reminder. So, well my last question, which obviously I couldn't resist, about you having admitted earlier as being an accountant, and now we've just touched on money. How, where do you see the flow of funding go? Because there was a traditional model where CCG was one, specialised commissioning stayed with the NHS England, joint funding went through the better care funds to cross that blue line between local authorities, and CCGs, there were personalized healthcare budgets. And, now the ICB's coming into play. And a sense, that will all the money go to the ICB, and then that will decide. So where the money flows is different, but we've still got primary care contracts, the new primary care contracts that's just in circulation. But what's your sense of where that, where the funding flow will be going forward?- So I guess, at a national level, I think we are still going to see the, you know, the leveling up agenda. So you know, the areas with the lower life expectancy and the higher sort of deprivation, you know, we're seeing money moving into those areas, and that's been happening for the last, probably sort of 10 years now. It's certainly happened throughout the CCGs lifespan. And I think that that will continue,'cause when you look at the picture of the country as a whole, it needs to happen. That will make things difficult for those areas like Dorset, and quite most of the southwest really, where we've already got a higher life expectancy, which means you have a higher elderly population who actually use, you know, the majority of the funds tend to go on, you know, the elderly. So you know, you are struggling 'cause you're spending the money already. But I don't think that will change this leveling up in terms of, we've got to get life expectancy up elsewhere. So at a national level, I think that will continue into those types of areas. I think the desire seems to be there doesn't it, to move more of the funding at local level down into the ICB. So, you know, we've seen the dentistry and the optums and stuff come back, and I think that's, I think that was right. I always remember thinking this is very odd that they're moving away from the CCGs. You know, they always were in the PCTs, and it was moving away 'cause it was like, but these are part of the services delivered locally. You know, the teams here know the local dentists and the towns and the villages and stuff, and these are high street services. So, to move them to a more regional procurement seemed odd, really. I always felt that. So moving the primary care stuff back to local, I think is, you know, is the right move. And I think you'll see much more focus on that 'cause it, it'll suddenly be, you know, very much in the face of the ICBs, you know. The dental problem was one. I remember the MP saying to me, you know, the majority of the complaints I get is my residents can't get an NHS dentist. That suddenly becomes a very real conversation now in each ICB and what are you doing about it? What's your local plan? And if you do stuff locally, I think you'll get more, much more innovative ideas around that and trying to find local solutions to that. So I think the funding will go there. Whether you'll see what we've seen with, say Manchester, and the devolution deal, which really is putting stuff down locally. I think it's probably too soon to tell, you know, you could look at the ICB and say, well actually this was a way of trying to do devolution and get much more stuff locally between the public sector partners without actually doing the devolution deal.- Yeah, yeah.- Can we virtually create what was created with Manchester's devolution deal? Can we virtually create that, and get the public sector partners around the table to do that? But it, it would seem at the moment, certainly in the foreseeable future, moving more money closer to the systems, and closer to the patient is certainly the direction of travel we've seen. And I think that will continue, would be my thoughts on that. Some of the specialist commissioning stuff has come back. And again, these were the services that we used, really the local district general hospitals were using. So again, I'm not, I don't really think they were specialists in the first place. You know, they may have been specialists at one point, but they've become much more the norm recently. So, you know, moving them back in seems right as well. But some of the stuff I think that did go back up. So the true specialist stuff I think should remain there. Some of the things around some of the prisons and military contracts, they feel right to be left, I think personally at regional sort of level really, and build those relationships, you know, with the fact that the fewer organisations there. But I think you'll continue to see more funding, more stuff getting devolved on that devolution down to, down to your local ICBs, I think is the way it'll continue to go.- Okay, good. Now that's really, really helpful insight. Thank you. Because, I think some of the conversations are muddled, and I think, you know, I think you've described it in a really clear way, so that's really good. We've come to the end of our time. Thank you, thank you very much. It's been brilliant to get an immersion into the world of general practice integration and the impacted wider care, and also to see how Dorset's continued to evolve with your leadership into, continues to be an exciting example of what is possible, and what's about to become possible. All those two things taken into account. So thank you very much, Tim, for your time. Thanks for giving us some really clear, candid answers to the questions. And I'd also like to thank the audience for listening, and to say, any questions we were asked that I couldn't ask Tim today, we'd be very happy to follow up, and we'll do that after the webinar. And if anybody needs any help on sign posting or advice on what we've talked about, then please do get in touch. So thanks everyone. Thanks again, Tim.- Thank you.- Look forward to talking to you again soon. Okay, thanks everyone. Goodbye.- [Voiceover] 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.code.uk, or visit our website, at mtechaccess.co.uk.