Olivia Butterworth
Hi, and thank you so much for tuning in to this NHS England podcast. My name is Olivia Butterworth. I’m Deputy Director of People and Communities. My job is about how do we make sure that the NHS really does #StartWithPeople, the people and communities that work for it that it provides services to and that really passionately care about the NHS?
How do we really involve those people today? I’m really delighted to be joined by Patricia Miller, who is the relatively new chief executive of Dorset Integrated Care Board. So we get to learn a little bit about Patricia and we’re also going to explore a bit about what does involving people in communities mean.
Patricia, as a chief exec of an integrated Care Board, I really want to start with Patricia – just tell us a bit about yourself. Tell us what makes your heart sing. Tell us what helps you get out of bed in the morning with a spring in his step. A little bit about you and your background.
Patricia Miller
So, hello. I’ve been in the NHS for just over 33 years. I took a little career break in the middle to do a business degree and come back into the service because I wanted to be in a role that was more patient facing.
So the things that made my heart sing family. I’ve got two teenage girls and the centre of my universe. I think they keep me grounded. Tell me the truth. Always keep me grounded with a sense of reality, particularly when I set expectations for myself that are way beyond what are reasonable.
Other things that make me sing are music, which is as a really strong influence at home, particularly because myself and my husband have backgrounds of a Caribbean heritage. So there’s a lot of music in the house.
And, you know, Christian values as well. We were both brought up in a Christian environment, so wanting to be the best selves that we can. And that means also giving back to community, which is one of the principal reasons why I’ve stayed in the NHS for as long as I have, because it provides the opportunity to do something that adds value to people’s lives.
Olivia Butterworth
Oh, amazing. Thank you. Those teenage girls – I have, well, she’s not teenager anymore, but she’s in her early twenties. They really do keep you grounded. And that truth telling can be really painful. But there’s something about that truth telling, isn’t there, That we need to learn to listen to the truth, no matter how hard it is. Yeah, and I wouldn’t that that that might be a nice theme to explore, actually, in terms of people and communities when we involve people to tell us the truth.
And I wonder if there’s any reflections you have about how we support our staff, our colleagues, senior leaders to really hear and fit with that truth, no matter how uncomfortable it is.
Patricia Miller
I think that’s a really good point, actually, Olivia, And I think because I think some of the reasons why we haven’t addressed some of the fundamental issues in the health service over a number of years is because when the public constantly refer to NHS colleagues as heroes, it’s really difficult then to take a really honest look internally at the organisation, to look at where things need to improve in terms of cultures and behaviours.
When we were thinking in the year about developing our integrated care strategy, we were quite clear as a leadership team that actually that strategy had to be driven by the community and not by our staff, who with all the best intentions, would have taken a very paternalistic view to deciding what communities need in terms of service provision. And we developed a programme called 100 Voices where we trained lots of our staff to go into communities and interview individual members of our community from all different walks of life in their own homes to understand what their lived experience was, to ask them what things public service did well in support of their wellbeing and what things
We needed to improve or do differently or even stop, and is part of the preparation and training development of those individuals to do those interviews. There was a lot of conversation around how they would feel if services they developed that they were really proud of; actually, the feedback from the public was, well, they don’t add any value whatsoever.
Or, in some circumstances, actually made things worse, because if we’re not going to have honest conversations, there’s no point of starting the conversation and we have to be prepared to hear that stuff in order to improve the way that we interact with our communities.
Olivia Butterworth
That’s really powerful. It’s really hard, isn’t it, to hear the stuff that makes us really uncomfortable or that potentially chimes with our own values, but that’s the reflection of our own identities. So it’s a little bit about your family and your Christian faith-based upbringing, but tell us a little bit more about what’s shaped you as Patricia Miller as a person, in terms of your background.
What is that led you to taking on this massive job as being an ICB chief exec?
Patricia Miller
I think a number of things influenced me as I was growing up as a child. The fact that both my sets of grandparents were very heavily embedded in the church was the first influence. I think that sort of gives you a sense of honesty. Being transparent, being trustworthy, and a sense of a duty to be part of cohesive, connected communities.
And I think that played a really strong role. My father and his mother and his two sisters came over from Barbados in 1963 and life wasn’t comfortable if you were from a minority group in those days. And part of being the only black family in a white community means that you have to build a sense of resilience.
Also, that, you receive a message from your parents all the time, which is you have to be twice as good as any white person to succeed. And that, again, it makes you set your standard really high in terms of what is good enough. And I think some of those things have really shaped me as an individual, but also that lived experience and also growing up in an environment of my very early years, probably up to seven years old, being quite poor, it gives you a different perspective on life and it gives you an ability to connect with people on a different level.
Because once you explain that their experiences have been your experiences, then it builds a different type of relationship. My children, they’ve been very, very fortunate in that both me and my husband have got professional careers. They’ve never grown up in an environment where food security has been an issue. And so I try and keep them grounded in the fact that their life is not everyone’s life.
And so that they start to see there are different elements of society that actually need more support around social mobility than others simply because of their starting point. And this idea that meritocracy exists, and if we’re all given the same opportunities, we can progress. It’s just nonsense. Some parts of community will need support because of circumstance. They find themselves ahead of no fault of their own.
Olivia Butterworth
Yeah, it’s really powerful. So I suppose relating that then, so you’ve clearly achieved; you’re an absolutely fantastic leader. But all too often we forget when we’re working with local people and communities that they’re also our workforce or our potential workforce and there’s so many people who are living lives where they’re not necessarily living their best life and they don’t feel the careers in the NHS or care services is something that’s accessible to them because the face doesn’t fit.
So I wonder if you’ve got any thoughts about your role as a role model, but also how we really shift the way we think about our communities to seeing the potential in them rather than just the deficits the people who need the services.
Patricia Miller
I started right at the bottom. I didn’t have a degree when I came into the NHS. I didn’t want to go to university at that point because I just wasn’t ready at 18 and I didn’t actually take my undergraduate degree till I was 30. So I think there’s something about people like me talking a lot more, being a lot more transparent about the journey because it enables other people to think, well, actually that opportunity is open to them.
I also think that one of the best things we’ve done is introduce apprenticeships into the NHS, because one of the things I really struggle with is the fact that our whole academic system now is geared towards qualifications as in academic qualifications, and that being seen as the be all and end all of success.
When in reality that’s not the route for them, they’re not suited to it, they’re not able to do it and we should be offering them different ways of progressing through career structures in life. And so through more vocational training on the job training. So the fact that we’ve introduced apprenticeships in nursing and we’re looking at apprenticeships for doctors in other professions, I think is really important.
I’ve got a couple of people in the office that we really encourage to do apprenticeship degrees, to take them into different leadership roles because they’ve not had the academic development in the past. So I think that’s one route. I think we need to do a lot more work with further education colleges to make sure they are giving young people access to some of that.
The development that they’ll need to get into the NHS and help people understand the wide variety of roles and communities that are available. Because all the major talk is about is nurses and doctors. And actually whilst they are really important, the NHS provides so many more career opportunities than just those two pathways. We need to talk a lot more… when I go into schools and talk to young people about plumbers and joiners and they look at me like I’ve gone mad. How do you think we maintain hospitals and GP surgeries?
So we’ve got to talk a lot more about that and also recognising that there will be elements of society that need more help to get into the working environment and we have a role to play in terms of supporting them around the social value that we can bring to communities.
So things like the internships for people with learning disabilities that give them not just training and development, but then opportunities for employment in the NHS. The Care Leavers covenant that we are now starting to look at, All those things are important to enable people to be part of wider society and not be marginalised because of the background that they’ve come from.
And it helps with social mobility. And you know, the way that Cormac Russell talks about connected communities.
Olivia Butterworth
Absolutely. And I think there’s so much in that it’s really powerful about that shift then to really thinking about communities being in control; that people need to be in control of their own health, but they also have a massive contribution to make to their communities health. And all too often it’s services that get in the way of that. Because we think we know best. Because we don’t trust them. Because we go ‘Oh no, that’s too risky’.
And I think risks are a really interesting question around working with communities, because who’s risk is it? Is it a risk for us on our project management templates or is it something that people just do as a day in, day out thing? So that asset-based approach then, I know you told me before that you’ve been having a load conversations and you’ve mentioned the 100 Voices Project.
I wonder if the stuff that come out of that that has surprised you or that you’ve kind of gone, that’s really helpful because… what is it that you’ve heard from folk and what are you doing with it now? I suppose that’s the important bit.
Patricia Miller
I’m really pleased actually, that what we’ve heard is what we were expecting as a leadership team. And I think that that has given us some comfort that actually we understand and are more connected to our communities than we thought. Unsurprisingly, hardly any of the responses have been around health and care services. The responses have been literally around the principles of connected communities, because community recognising that if those foundations are there and they’re strengthened, that good health wellbeing comes as a consequence of that, because those things breed personal happiness and social mobility.
So the things they’ve talked about are wanting to feel connected to the community, wanted to have networks within their communities, wanting us to do more to strengthen non-statutory services because those are their first port of call when they’re recovering from physical or mental health issues. A really, really strong message repeated a number of times was: I’m a human being, I’m an individual. I don’t want to be referred to as a patient. I don’t want to be seen as the condition I present with.
That statement in itself is something that the NHS will need to grapple with fundamentally. One, because I think we love the term patient more than the actual individuals that we’re treating do, because it’s got a connotation to it.
But actually I’ve been saying for a long time, I think that word disables people from taking responsibility for their own health. And also because if you’re going to work with other agencies, local government, third sector, we need to start to use language that we can all appreciate, that our communities appreciate it. And if they don’t like the words that we use and we have to speak in a language that is a common language that we can all understand. Other things that came up were following the pandemic wanted to see as many services, health or otherwise provided locally, the economic development being seen locally, employment locally. Health has got a role to play in the fact that 20% of your health and wellbeing will dictated by health interventions. But the other 80% is where we see the real price around community, social and economic development in reducing health inequalities. And I think what we started to reinforce now in our minds is that health has its role to play in those wider determinants and it needs to start to do that more broadly, more deeply, because that’s the foundation that starts to create good health.
And we’ve got a role to play in that space. And it’s not just about what we do in terms of health service delivery, it’s about how we manage employment. It’s about, things like we’re contributing to zero contracts by the very fact that we have a Bank. And that means that people are struggling then to maintain a reasonable standard of living through universal credit supplement. So we’ve got to think about that. We’ve got to think about, you know, the way we bring people into service. As I said, in non-academic groups. We’ve got to think more about what we do to contribute to the greener agenda. We’ve got to think a lot more about how we procure our services and actually, why do we procure services from outside the local community, if there are ways of supporting the development of community interest companies that we can procure from that keeps local people in employment.
So we’ve got a whole lot of things to think about, I think Olivia. And even our pay structures, because we know already know that Band 2s are not paid to what the government would refer to as the living wage. I introduced some work in Dorset to understand what the real living wage needs to be, what the real cost of living is in Dorset.
And then we’ll need to have some really difficult conversations around all of our public sector organisations, around pay structures to say, actually, if we’re paying below what it costs at the lowest level to live in Dorset then we need to do something about it because we’re contributing to deprivation when we’re meant to be one of the key partners with communities to moving that into a different place.
Olivia Butterworth
Absolutely. There is so much I could draw out of everything you’ve just said. I think a lot of what you’ve described is very much this concept of the NHS as an anchor institution and recognising it’s not just, like you said, the services that we provide that make a difference to health. Actually the bigger difference to health is made by everything else that sits around those services.
Some might look at Dorset and say: “Oh, you’re really, really lucky. It’s one local authority. It’s one Integrated Care Board. You’ve got the dream world down there Patricia. It must be really easy”. Then you look at Dorset and go, oh, hang on a minute, you’ve got all this coastal area that is experiencing massive economic deprivation.
Jobs are really scarce, investments really scarce. You’ve got urban areas, you’ve got very remote rural areas where public transport is almost non-existent. And then within all of that, you’ve got people living in lovely, affluence who are very, very comfortable. So I suppose there’s an awful lot of challenges within that. Tell us a little bit about that and what does that look like from your perspective?
Patricia Miller
It’s quite a complex landscape. So you’re right, we’ve got areas that are very affluent and then two, three miles down the road, we’ll have a ten-year difference in life expectancy. Some of our most deprived areas are in the top 20% of deprivation in England. And we know that when you live in that level of deprivation, even before the issues with the cost of living rise, you have to spend somewhere between two thirds and three quarters of your weekly income to eat healthily.
So sometimes food is going to lose in that situation. If you’ve also got to keep a roof over children’s, and the house to be warm. So we know that the key to a lot of that is household wealth and the way that we create that through the local economy. We’ve also got rural poverty, which I would say in some of those areas is actually worse than if you live in an area that’s completely deprived.
So we know if you are poor in an area that for the most part is affluent, your deprivation level is worse than if you live in an area that’s entirely deprived, because there isn’t the infrastructure there to support it. We’ve also got the challenges of seaside communities were those communities appear to have full employment, but when you scratch underneath the surface, it zero-hours contracts related to hospitality.
And then we’ve got the mixture of urban and rural and the solutions in terms of care and the wider determinants for those different types of communities are different. And I think what we need to do with the insights we have through the work we’re doing with community is make sure that we form a partnership with our communities. So we are designing the solutions to submit those issues together, because they are best placed to know what will work for them.
And we need to listen to that and build on the strengths our communities have and where their strengths are not there try and create them through co-production with our community leaders. Because what we really want at the end of the day is a citizenship model, where they are in the driving seat, actually. My ambition in five years time is that when we look at our place based leadership teams that are driving service delivery at that level, that actually the officers are outnumbered by our community leaders because we’ve got the balance right in terms of who’s driving the decision making and what we’re spending taxpayers money on.
Because when we start to engage in those discussions, and work with our communities to prioritise worthy the investment goals. Because the reality is we are going to have differential investment because some areas will need more than others to reach a reasonable standard of living, that we make those decisions with them, because at the end of the day we’re spending their money.
And I think what we’ll get then is are services used more responsibly because people will start to see the impact of investment going into the right places and see the integrated care system is something that has value to their lives.
Olivia Butterworth
And see that their voices and their contributions have influenced the decisions that have been made. Because what they’re experiencing is what they said would work for them. It’s really, really powerful and I hope we can talk in five years time and see just what a difference that kind of makes.
I think one of the complexities around Integrated Care Boards and integrated care systems is that both the organisational egos between the NHS and voluntary sector and local governments, there’s a real challenge about how do you bring all of those people who work in separate organizations together with a shared and common purpose and a shared and common approach, and do things once rather than three or four times?
We hear from different communities “Well, the local authorities that come in asked us about this. The police have come in and asked us about that Fire Service, about this”. And every service talks to communities separately. And I know you’ve got, is it called One Dorset? – the work you do. And I just wonder if you might sort of reflect on that and how important it is for you as an NHS leader to hear and understand the whole of what communities are saying, whether that’s relevant to the police or the fire service or education.
Patricia Miller
We’ve got a couple of forums where all of those partners come together. So we’ve got health and wellbeing boards, one for the Dorset Council area, and one for Bournemouth, Poole and Christchurch. We’ve also got the Integrated Care Partnership where all of those partners come together. Where our thinking is at the moment is that place, the local area, should be the default for service delivery unless there’s a really good reason why something needs to be delivered across the entire Dorset boundary. And the partners from all those organisations should be engaged in conversations are in place. So that what they’re doing is taking the integrated care strategy in developing the local delivery that level with all those partners and doing end to end service transformation.
So an example would be that we are about to start a piece of work that is developing a plan for children from 0 to 25, Children and Young People. And police, health, social care, third sector will all be part of that conversation because if they’re not, then we’ll miss huge parts of young people’s lives and we won’t get it right. As in, healthy mothers before conception even happens, right into supporting people into young adulthood. This idea that suddenly that you reach 18, you’re an adult and you can fly on your own is just a nonsense. And also because we’ve got a lot of the legacy of old local authorities, we’ve got a lot of young people that are coming out from a lifetime in care and they need that support until they’re in the mid twenties to really start to form community networks around them and embed themselves into society.
So I see a lot of the partnership work being done at that level. And those relationships are really important. The other thing that we have, we meet once a quarter, is something called the Public Services Forum, where we bring health and care chief executives together with fire, police and local parish representatives. And again, that’s about making sure that the decisions we take are aligned and comprehensive across boundaries.
But we’ve still got a lot of work to do in making sure that we don’t all have the same conversation with communities, that we’re doing in a cohesive way rhat means that they’re not being asked the same question ten times by different organisations. But I think the thing that we’ve got that’s positive is that we have in the start of the legislation in July, we’ve had quite a change in leadership across our system at organisational level.
Leading up to that in the year preceding that.
And I think that’s really helps us because it’s meant that we’ve been able to start with a blank piece of paper and to say to each other, How do we want the partnership to work going forward? What do we want our relationships to be? What do we want our relationships to be with our community? And from that, those early conversations, we were able to agree three principles that were really important to us as a group of leaders, and those were that yer we wanted to be ambitious for our communities, and the partnership had to be the centre of how we worked together. And that meant being able to challenge each other if our organisations were about to make decisions that were not in the best interests of our communities. But the most important principle we agreed was that all of our work will be driven by our communities. All of our decisions would be driven by them. So the fact we’ve landed in that place with those three principles we can all stand behind, I think starts us off in a really positive environment.
Olivia Butterworth
I think that’s amazing and that holds into account and being able to have those honest conversations between agencies is so important because as an example, the police often know much more about the health needs of a particular neighborhood than the health service. They see things that we don’t see. And so we need that check and challenge across those different agencies. And amazing that you’ve got that shared commitment across the whole of the public sector system.
My last question is going to be about business. And all too often when we think about involvement and involving people in communities, we forget about local businesses. You’ve mentioned them in terms of the sort of economic regeneration and ensuring that you have a thriving economy, but again, I wonder if there’s anything you’re doing or thinking about around that relationship between involving people and how local business fits into that? Because again, corner shops, they’re part of community infrastructure, aren’t they? But often we don’t actually work with them.
Patricia Miller
Yeah, Again, I think that’s a really important point and we’ve just started to have that conversation around how we engage business because we’ve taken a decision that every group that we establish with our community that’s about redesigning services or starts in different services and third sector will be part of that. And community groups were part of that. And that led to a conversation about how we’re going to engage business.
One, because when we think about health and wellbeing in our most deprived areas, there’s nothing different than is in other communities. Usually you’ve got no cash machines there, or if you don’t, you’ve got to pay for them. And historically there’s more takeaways in those areas. So how do we really start to engage business?
We did a piece of work with public health looking at things like what supermarket it’s put on display, on offer on the day, the few days following when benefits were received. And we were really fortunate in some of our local supermarkets really took some of that evidence on board and started to change what they displayed on those days in terms of trying to put offers into healthy food options.
The other thing that we’re just having a conversation about now is how do we engage local businesses in conversations about wages? Because there isn’t a lot of competition in Dorset, especially in the west of Dorset, economic competition, which means wages are really low. We need to start to have some discussions about how we try and change that if what we want to do is enable people to be self-sufficient and socially mobile. And how do we, through our business park and our research innovation centre, encourage more business to invest in the west so that that provides the economic competition in the environment to raise wages.
So anybody that thinks being in an ICB is only about health… it really isn’t because there are so many other facets of community life. The impact on individuals and families ability to live a healthy and happy life. So we need to engage with some of those commercial conversations because they’re just as important in terms of the partnership is all us.
Olivia Butterworth
I think you’ve encapsulated one of the real possibilities that ICBs bring, is being able to see that really holistically. Because all we hear in terms of the media narrative generally is about demand on the NHS, the NHS being overstretched. We will stay overstretched and hugely under-resourced unless we get upstream and really start to think about the factors that help all of us to live happy, healthy lives.
Patricia Miller
If you only want to look at the economic argument, you know pre-COVID health inequalities cost our economy £37 billion a year. I mean, that’s like, well, a quarter of the NHS funding. For every pound you invest in health and wellbeing, the economy gets four in return. So even if the ministers only want to look at it from an economic perspective, investing in health and wellbeing and personal happiness makes a huge difference to the economy and we’ve got to start to think about it much more broadly.
Olivia Butterworth
And that includes our staff because we’ll continue to have overstretched staff if we don’t invest in their health and wellbeing and they are our people and communities.
Patricia, it has been a real privilege to talk to you today. I will come back to five years. Who knows if we’ll both be in the same role, but maybe I’ll come down to Dorset and ask “What is it like now?”
But your ambition and your enthusiasm and the perspective that you bring to this role is just, it’s a breath of fresh air.
I’ve been talking to Patricia Miller, chief exec of Dorset Integrated Care board. I’m Olivia Butterworth, I’m deputy director of People and Communities. If you’re interested in chatting to me or chatting to anybody from NHS England about how we involve people in communities, please do get in touch. There’ll be links beneath the podcast.
If you’ve enjoyed this podcast, you can listen to more episodes available by searching NHS England on Spotify, Apple Podcasts and SoundCloud, and it’s also available from www.england.nhs.uk/podcasts.