Speaker 1 [00:00:11] Hello and welcome everyone to Integrated Care Systems. One year on this special episode brings together a panel of system leaders to discuss their reflections on the first year of integrated care systems being live. My name is Adam Doyle. I’m a national director for system development at NHS England, but also I’m the chief executive officer of the Sussex Integrated Care Board and I’m your host for today’s episode. In today’s episode, our panel will look at the challenges systems face, the progress they’re making to better integrate services and their hopes, priorities for the future. It’s also an important time as we start to look forward to the 75th birthday of the NHS, and I’m sure we’ll get into the conversations about the future when we speak to our panel. Naomi, would you like to introduce yourself?
Speaker 2 [00:01:03] Thank you very much. I’m Naomi Eisenstadt and I chair the Northamptonshire Integrated Care Board, and I also share the chairing of the Integrated Care Partnership with Northamptonshire, with local councillors, one from Northamptonshire and one for West Northamptonshire.
Speaker 1 [00:01:17] Thanks, Naomi. And Tim.
Speaker 3 [00:01:18] Thank you, Adam. I’m Tim Swift. I chair the Integrated Care Partnership in West Yorkshire and I’m also a council leader at the moment in Calderdale.
Speaker 1 [00:01:34] Thank you both, so I suppose my first question for us to get into this you know, looking back on the last sort of 12 months. Like, what are you most proud of? What do you think you’ve achieved? Naomi, perhaps. Let’s go to you first.
Speaker 2 [00:01:46] I think it’s been a very tough year and therefore there are things that I am really proud of and a lot more to do. But if I do it in terms of the four aims, in terms of things like Health for All, we’ve done a huge amount of work on joint working with both local authorities and the NHS on elderly care with West Northamptonshire we have a project on getting people out of hospital who aren’t quite ready but making sure that there’s care in the home that’s put together by the NHS and local authorities. We’ve also done a lot of work on virtual wards and a lot of work on digital monitoring so that you don’t have to do the home visit, you can check people’s vital signs remotely. So, there’s a lot that’s happened in terms of patient care that I think is about everyone in terms of health inequalities. I’m most proud of the work that we’ve done on having an outcomes framework which identifies for our population based on our data. What are the things that we could do that could really shift the dial on health inequalities on a lifecycle approach? So, for early years and the beginnings of life, what are the two things you could do for working age adults? What are the two things you could do? Obesity, smoking comes to mind. For older people, what are the things that you could do for prevention? But all of these things are things that data tells us have a very strong, what we call the social class gradient, where the poorer you are, the more likely you are to be affected. So, I’m very proud of that. And I have to say on the on the money side, the system really came together mid-year where we had tremendous financial challenges and it was very hard work. But in the end, we got there. And on the fourth aim, I think it’s probably the area where we’ve put the least effort and have to think in the future. But you know there’s a lot going on, but it’s not put together into a narrative.
Speaker 1 [00:03:50] Thanks Naomi I think we will probably explore a bit looking forward about how we take forward our responsibility for social and economic development and growth in our systems. Tim, from your perspective, you’ve been part of the ICS agenda for quite some time. What’s your two reflections in the last 12 months?
Speaker 3 [00:04:06] Yeah, that’s right. So, it’s been interesting for us because we all we were already working effectively as a partnership, partnership board and partnership model. So, it’s been a bit different for us because the governance process focused more on the development of the ICB. I think one of the things that I found really encouraging is the way as we’ve been required to do the new five year strategy for NHS England, actually we’ve been very much able to build that on the strategy we already had in place and we’ve really got this shared understanding. Of course, we accept there are top down pressures and priorities but we want to be in a place where we can continue to use our local knowledge to say what’s important for West Yorkshire and make sure we fit those priorities within that national framework. I think there has been some really good examples of that. We’ve given a lot of time and attention like Naomi has to all of the issues around inequalities. We did some work particularly on black and minority ethnic experiences of inequalities in the follow up to COVID, and we’ve built on that with our strategy and I’ve been very pleased by the way we’ve been able to find some resource to invest further in the voluntary sector, supporting the voluntary sector, but also develop our strategy about how we involve and talk to people, which obviously across an area like West Yorkshire with a lot of systems. The challenge is to demonstrate that we’re listening to what people are saying, but also not to duplicate the consultation that’s taking place through lots of organisations at different levels, I’m sure there is a lot to do to get better at that, but I think we’ve made a great start on it.
Speaker 1 [00:05:53] It’s interesting here, both reflections, because in Sussex what we’ve done, we’ve taken the life course approach that you’ve framed Naomi and getting that right but we’re also quite a large system. So, we’ve also had to consider how we also make sure that through our partnerships we’re building on our local government assets or the local community assets. But I’ve been really encouraged because I found writing the Joint Forward Plan with a very future looking end point has a. been very exciting, but I think on the back of the pandemic and the pressures we see in the service today, I think it’s given, given colleagues quite a lot of hope for the future. In terms of your Joint Forward Plans if you were to go five years hence, what would be different would you say in your system then it would be today.
Speaker 2 [00:06:41] What we’re really trying to get to the nib of is not five years in the future, but two years basically. I think we need some quick wins. I think we need to demonstrate to our population something that they feel is an improvement. And I think that there are things that are the most important things to do, but there are things that you have to do first before you can do the things that are most important. And that’s why I feel things like, you know, the fourth thing is really, really important. But I think we have been working in partnership like, like you both for a number of years. I think that what we have to do now in terms of the next two years is begin to demonstrate that early intervention can yield something. And there are areas where early intervention doesn’t yield anything for years. My background is early years, so I know that a great start for young children will have an impact on their middle school years, on their secondary school years, right through their life course. But I know that impact won’t be felt for years, so we have to find things we can do now that will begin to shift the curve so that people feel much more confident in this way of working, building on what we already know, but using the new technologies, using all the different kind of skill mix, are the things that I think will set us up for the five year picture, but we have to make some real progress in the two years.
Speaker 1 [00:08:14] Tim, I saw you sort of nodding along at that, really. So, from your perspective, how are you framing the sort of immediate priorities and the future ones.
Speaker 3 [00:08:23] I think one of the things we tried to do early on is identify, you know, quick wins where there are things that are working well in one area that we can share quickly as best practice. So, for example, we’ve rolled out the Bradford Healthy Heart Project and that has enabled us really to have quite a radical increase in the number of patients who are recognised as being at risk of hypertension and are then receiving treatment for that which we think will bring obviously real benefits. I think some of the work we’ve done early on around health services for people with learning difficulties where we’ve recognised the really wholly unacceptable scale of poor health outcomes suffered by people with learning disabilities. We started very practically with moving towards meeting some of the targets on health checks, but then encouraging, for example, the Calderdale Trust has looked at prioritising people with learning difficulties for surgery rather than them sometimes being disadvantaged and things like that. So, I think there are some good quick wins that have come from that. I think sort of looking to the longer term, I think over the five years, really maximising the benefits of making the connections between health and economic wellbeing is really, really important. You know, seeing that actually the investment we’re making in health is actually a huge driver for the economy, but of course people’s access to decent jobs and decent homes is one of the key drivers for people being in good health as well. And the more we can make those connections in very real ways, around workforce, for example, you know, I hope in five years time, you know, all of our key health employers will have really good links with our key communities, apprenticeships and routes that help people into many of those great opportunities that are actually there.
Speaker 1 [00:10:13] We’ve all been working in our roles for some time and there are always barriers that get in the way, always things that you think if only that were fixed or was different and I think to your point, there is something about has been really clear about how we make sure these new things that you set up are really successful. And so when you are chairing meeting or having a 1 to 1 or sat having a coffee at home, what are the things that you think are the barriers that get in the way of some of the progress that we can therefore make. Naomi, what do you think?
Speaker 2 [00:10:48] I will answer the question, but I want to pick up on something that Tim said, which I think is really important so completely right, the importance of health to economic growth and economic sustainability. But part of that is the importance, the factors that impact on health have very little to do with health services and everything to do with quality of housing, quality of environment, public transport, a satisfying job. So, the logic of the working together across health and social care is absolutely clear, you know the reasons for doing it. What drove me to do this. So given that we all accept that the barriers question is a really interesting one, and I will say, and it’s embarrassing now after two and a half years, what really surprised me when I first became a chair of an integrated care board is I thought the job was about bringing together local government activity and NHS activity and I did not appreciate how much of it was about the internal workings of the NHS across community acute primary care, mental health. I just did not understand how strongly the culture of the internal market works against what we were trying to do. And given that that was the culture for the last 12 years, flipping a switch in terms of changing culture is very, very difficult. It’s always easier to change structure than culture. So that to me is the biggest barrier, is the culture both within the NHS and between the NHS and local government. Part of that culture, a big barrier is language, and the NHS in terms of acronyms is absolutely impossible. And again, after two and a half years, I still have to stop and ask people to say, what does that mean? You know, we have I see ICBs, ICS’s, ICPs, I do understand what they are, but I still don’t really understand what the word transformation means. And I’m not sure what an operating model is. And I kind of get by with it. So those cultural things I find are a huge barrier, and the last big barrier is competing priorities. So, on the one hand, yeah, we really want new localism and we really want an emphasis on place and in my view an emphasis on neighbourhood, because that’s where the really important joining up happens. On the other hand, the national priorities in terms of waiting lists, elective and cancer, which are really important to our populations, I’m not saying they aren’t, but I think it’s very hard to balance all the competing priorities that face both local government and the NHS. So aside from that, it’s all really easy.
Speaker 1 [00:13:37] Crikey, we can all get it done by Tuesday I think. And I suppose for me, as I sit as an accountable officer there’s something about, isn’t there, how you do both. We have a responsibility to the public to make sure that all of our NHS is run and operating as effectively as possible. One of the challenges that I find often we speak about integrating the wider public sector, but I think the NHS itself has a lot more it could do in its own integration as well, I think, which I think is in some ways a bit missed when we describe integration. What is the NHS element to that. I think it’s about, there’s two parts for me, it’s about delivery and change, I think. And my view of that is, if we’re going to create thriving neighbourhoods in thriving places, in a thriving system, every part of that system has to change. And I think post the pandemic, getting into integrated care, my sense is success will look like a model where everybody has felt the change, but everybody has accepted the change and wants to go forward. But to your challenge Naomi the cultural change cannot be underestimated. We worked a certain way, and now we’re trying really hard to work a different way. So, I suppose I often think one of the barriers is just giving time and space to make sure these things have the ability to go forward, but also recognising we have also to respond to the NHS mandate for our communities. And there can be a tension. But if we’re really clear the role of the Integrated Care Board and the partnership and the wider ICS, I think it’s doable, but I still find times people can use those terms a little bit too interchangeably and we have to be clear about who’s got the responsibility for what. But Naomi, how do you find that sort of slight culture clash of the local versus the national?
Speaker 2 [00:15:40] It’s very interesting because I am a non-executive chair, and I think as a non-executive you have greater freedom to argue the case for the local because I think it is very, very important to really concentrate on what’s important for the population that we see in Northamptonshire. And that doesn’t and I accept the issues about about national government. But what I would also say is that the working together requires a respect for what somebody else brings. And I think that respect for the contribution of others is really important and the opportunity. And that’s why for me, the outcomes framework was so important. And within our Integrated Care Partnership plan, we have ten ambitions for Northamptonshire that everybody’s agreed to. You know, the important thing is to agree what we’re trying to do and respect the respective contributions of partners in doing it, not to assume I’ll only get them to work together if they understand why they need to help me do what I need to do.
Speaker 1 [00:16:48] That’s really about that mutual accountability and shared ambition to get that piece right. And Tim, knowing your system quite well, because in Sussex and Hastings and Bradford, we’re doing better planning with each other at the moment because our populations are a bit similar in terms of that. Any other reflections that you’ve got in terms of that sort of local versus national kind of thing that plays out.
Speaker 3 [00:17:11] I suppose reflecting on the way this conversation has developed. And yeah, the role of local government within the ICSs is I think is still developing, isn’t it, and the focus has been very much on the importance of local government in terms of services we provide for wellbeing, in terms of integration. But that question of how far involving local government also brings in that local democratic accountability. I don’t I don’t think we’ve really fully, you know, fully, fully tussled with. You know, it’s potentially very important but also very challenging. You know, we just had local elections and actually within those elections, the things local government is directly responsible for, like social care actually feature very little. You know, local elections are about potholes or streetlamps and not about two thirds of our budget. Talking to the people I represent as a councillor about what our role is in health is actually quite risky because they’ll then say, Right, well why aren’t you doing something about why I can’t see my GP then? So, there’s, there’s some interesting challenges and work to be done there, I think.
Speaker 1 [00:18:23] I mean, we’ve got a responsibility to look forward. It’s, you know, the birthday of the NHS, which is a huge milestone, you know, in terms of it is something that was created on the back of, you know, the Second World War and how we get a welfare renewal of society. So a huge a huge cultural change happened that created the NHS. But of course it’s changed so, so much. We’ve changed and technology has changed. The whole thing is really different now. As we start to look forward now and to be rethinking, over the next couple of years, what do you think will be the really innovative things or things that we’ll start to have to consider as integrated care leaders in our respective roles?
Speaker 2 [00:19:05] I mean, the obvious one is, is the use of technology and the cost of technology and will some aspects of the technology increase inequalities rather than reduce inequalities? I mean, the thing that frightens me most about the future is the demographics. I mean, it’s great news that we’re living longer, but as consumers of health service, of course that increases as we get older, we have to find ways to make things less expensive. We have to find ways to keep people healthy longer.
Speaker 1 [00:19:37] We as an NHS have to integrate because in reality we need to therefore get the population as healthy as possible for as long as they can be. And when you look at WHO or health policies or one health approaches, they’re all about are they not worth in terms of the wider value chain of public sector and some private sector organisations to to have a different approach in terms of keeping the population healthy and well. And I suppose that the challenge we have as leaders who may have been a bit more NHS centric is to be able to speak to the advocacy of other services of being of a benefit to us so that we have the resources allocated to the right part of the system so we can therefore give people a really good end of their last two years because the economies are healthy up until then. So, Tim that’s a huge change, a huge mindset shift for us, but really exciting to go forward. And in in your system, you know, are you having these conversations about the future? How does that how does that sort of play out?
Speaker 3 [00:20:51] Well. Yes. Where we’re starting to have them. And that comes back to some of the barriers, doesn’t it make sure we’ve got the time for what can sometimes feel a little bit esoteric conversations when the financial pressures are biting at the door all the time. But I think an echo that across. It’s not just the 75th anniversary of the NHS. It’s also the 75th anniversary of social care. And, you know, I’m very clear that both social care and health ultimately should be about how people how we enable people to lead the fullest lives possible, not fixing them when they’re wrong, but letting people continue to have, you know, the best possible life and the best possible life experiences. But that sometimes feels a very long way distant from the model, not just of health, but of social care as well that we have now. I think the challenge is that whilst you can see where we want to go, the gap between what we’re actually capable of delivering and what we would like to see feels enormous at times.
Speaker 1 [00:21:57] We’ve got to confront some pretty live issues that we across all of our systems about how we take that forward. But I suppose there has to be also a sense of leadership and hope across. It’s all about how we can therefore help to shape that across all the constituent parts as we go forward. I suppose if if you had the chance to give a key takeaway message to people listening today about either things you’ve learned or your hopes for the future, what would that be?
Speaker 2 [00:22:25] People for my own system will laugh because they will know what I’m going to say. I think in my career, which has a lot of been cross-agency working and also the voluntary sector as well as central government, two things matter to make change happen. Both are essential. None, neither are sufficient on their own. And it’s love and money. I mean. And the love. What I mean is the relationships between professionals, the relationships between professionals and the people who they work with as users, clients, patients, whatever you want to call them. The relationships, the vertical and the horizontal relationships will oil the wheels. And money is essential but not sufficient. And the difficulty we have is that the tighter the money gets, the more essential the relationships are, but the more protective people become of their own organisation. And getting the real success of systems working is to, you know, what does my organisation contribute to the health and social care of a population. Not how much money does my organisation need to keep going. And I think that’s very hard and I think it’s asking people, you know, is asking people a lot. But I do think love and money are the two things that are most important.
Speaker 1 [00:23:41] Thank you. I’ve written that down to keep that in mind when I go back to the office on Monday. Tim, what’s your takeaway message for colleagues who are listening?
Speaker 3 [00:23:49] That was fascinating from Naomi, obviously I was going to say kindness in culture rather than love, perhaps, but that it’s very much the same thing is and it’s easy to forget. People work in health and care at the end of the day because they because they you know, they care for people, you know, people matter to each other. And that should also be at the heart of our relationships within an organisation as well. I think the heart of that, you can’t spend too much time on getting the culture right. If we if we get the culture embedded and we set the expectations that seeing things as a shared problem, a shared responsibility, not as an organisational, siloed one becomes the way that we do things. It becomes the expectation of new staff as they join the teams and as they they develop. Then then in a sense will be creating a system where it almost doesn’t matter well, what national changes and reorganisations happen because that culture and understanding will be part of how we do things going forward. And I think that for me is at the heart of the change we want to make.
Speaker 1 [00:24:59] I suppose listening to you both. My key takeaways, I suppose, is the more you learn as a leader, the more you realise you have to learn. And I think that this for this discussion, I’m learnt a heck of a lot listening to the both of you. But also there’s something about I think the relationships of a system are things that need constant gardening, so they’re never there, they always need a bit of water, a bit of light and a bit of attention. And, and for me, sometimes I think we can assume we’ve got them and then they’re really easy to lose, particularly under times of pressure, I find. So I think I think as are seeing our leadership role as really giving that constant attention, I think for me it’s sort of like my key main takeaway, I think from what I’ve has, I’ve learned so much from hearing you both. And thank you so much for taking the time to speak to us today. I think the colleagues that are listening probably in summary, I think we’ve heard quite a lot of what three systems are proud of in the first year of the statutory footing of ICSs. And there’s a wealth of things. I think we have to remember that we’ve managed together across health and care, across the previous commissioning and provider landscape. We’ve had a challenging winter, we’ve had waves of industrial action and we’ve also had significant pressure on delivering the financial sort of challenges that a number of systems have had. But what I’ve really learnt today is that there are some barriers, but people look and work to really change those and really get them driving forward. And I think it’s really important that we see that there is a way forward for how we come together across every part of the integrated care system to be successful. Well, that’s it. That’s all we got time for today. Thank you to our expert panel Naomi and Tim for your valuable insights. We really hope you’ve enjoyed listening. I’ve been Adam Doyle and this has been integrated care systems one year on an integrated care podcast from NHS England. Thank you for listening.