In the latest episode, Matthew Taylor speaks to Sir Richard Leese, chair designate of Greater Manchester Integrated Care Board, about provider collaboratives and making tough decisions, lessons the system has learned from COVID-19, and the extent to which central government ‘gets’ devolution.
- Provider collaboratives: opportunities and challenges
- Collaboration must be at the heart of the future of health and care
- Levelling up the UK: what you need to know
- Best practice and innovation during COVID-19: what we've learnt so far
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Health on the Line
Our new podcast series offers fresh perspectives on the healthcare challenges of our time and ways to confront them. Tune in for interviews with the movers and shakers making waves across health and care.
Hello. To general approval, the recent levelling up white paper called for more elected mayors and more devolution. Equally, reflecting a broad consensus, the integration white paper called for better joining up between health and local government. Most of the leaders of integrated care systems that I speak to talk about the importance of place-level accountability and coordination.
So, what can we learn from the part of England that's already operating with devolved powers, already has joint leadership of health and care and well-established working at place level? These are some of the questions I'll be posing to today's guest on health on the line.
I'm delighted to welcome to Health on the Line Sir Richard Leese, who was elected to Manchester City Council as a Labour councillor in 1984, became leader in 1996 and just a couple of months ago stepped down from the council after 38 years of service. Sir Richard was one of the signatories to the city region's health devolution deal with government back in 2015, and Richard is now chair designate for the Greater Manchester ICB. So, Richard, welcome. How are you?
Sir Richard Leese
I'm very well. Thank you. Very happy to be here to talk about the journey we've been on in Greater Manchester.
So, let's just start with the big shift that's happened in your life. It must have been a real wrench to leave the council after 38 years, but you've made a kind of bigger shift which is really from focussing primarily on local government to focussing on health. What lay behind that decision, Richard?
Sir Richard Leese
Well, I we go back more than a decade within the city, Manchester and Greater Manchester, to a recognition that if we were going to address some of the fundamental problems we've faced really going back to the collapse of our traditional industries, that we needed a different approach to public service delivery and particularly a different approach to public service delivery for those people in greatest need and that includes health need amongst a range of other needs. And that is services, instead of being delivered on massive national programmes, being delivered in silos, needed to be built around people, their families, their communities, the places they live, that public service reform was going to be an absolute necessity in order to address deep seated underlying problems across Greater Manchester, and that is what led us on the journey.
The reason we wanted health devolution was not to run hospitals. It was to be able to join up health services with other council services with Jobcentre Plus, with policing, with the activity of voluntary and community organisations to try and address the root causes, rather than simply the symptoms of the issues we faced.
But still, in the end, the health system and the local government system are different and you've made this choice to focus your energies primarily on health going forward, the ICB, and I'm just interested in why it is you decided that you're going to make health the focus of your next few years of activity?
Sir Richard Leese
Well, I think if you look at the responsibilities of the ICB within the ICS, those responsibilities around population health, about tackling health inequalities, of having regard to the social and economic contribution of the health service, as well as of course, meeting constitutional standards, being effective, delivering good clinical services, it appeared to me to be a real opportunity to get really deeply into those issues I've been concerned with, actually probably going back 30 years, and to ensure, as far as I can, that the health service is making its full contribution to that wider agenda.
Yeah. And I think it's a very welcome element of the appointment of chief executives and chairs in ICSs that we are seeing quite a lot of people who have a strong local government background. And I think that's really important, partly because for reasons we’ll get into, there are some issues of the credibility of all of this, to the reform of the health service to people in local government. But let's try to open up exactly how things work first in Greater Manchester.
So, I mean, this whole area of ICSs is an area I've described us as one of ambiguous complexity, it’s not only complex, but it's also inherently ambiguous in terms of ways in which different things overlap. So, I tend to think of this in terms of systems - so that's the ICS level Greater Manchester. Then of places, which tend, in a metropolitan area like yours, to be the metropolitan borough councils. And then the third part is collaboratives - we're speaking, you and I, the day before Secretary of State, I think, is going to make a big speech about collaboratives - so, the third part is the way in which parts of the health service are coming together and horizontal and vertical collaboratives.
So, in terms of that, those three pieces, Richard, the system, the place and the collaboratives, how does that how does that work in Greater Manchester?
Sir Richard Leese
Well, first of all, I think about, if anything, the other way around, and thinking about it the other way around is quite important. And I have another spatial level, which is the neighbourhood, perhaps not the really local, and most of Greater Manchester is operating on neighbourhoods of 30 to 50,000 people, large enough in order to deliver a full range of community services, but small enough to have real contacts with communities within that area. Place, the local authority area comes next. And what you've described as the system level, the Greater Manchester level comes at the end of looking at that and it's what draws things together across the broader template.
Collaboratives can operate at any level; they can operate at the Greater Manchester level or they can operate at the neighbourhood level. But I think building up from neighbourhoods to the system wide is really, really important. And of course, it's the opposite of the way that the NHS traditionally does things, it does tend to be a very top-down model.
So, building up from the bottom is important. And then it is, what are we trying to address that neighbourhood level, yes, we want people to have fast access to services when they’re ill, but it is you know, the issues we’ve been successful in, it is smoking cessation. It's school readiness, getting people back into work. It is those things that really do start to deal with the social determinants, not just the symptoms of poor health.
So, tell me about the configuration of the ICP and the ICB in Greater Manchester. So the kind of way I've tended to think about this is that the ICP sets the strategy for health as a whole, recognising the social determinants, the wider public service determinants of health and then, as it were, devolves the health elements of those broader strategies to the ICB, which oversees the health component of those strategies, which then in turn, it in a sense, commissions, although not in the kind of hard-edged commissioning way that we have had in the past, but it commissions the services that are required from those provider collaboratives. Is that how it looks to you?
Sir Richard Leese
Well, I think you said earlier on it's inevitably a complex system and it can be slightly more complicated than that. And that's absolutely the case that we would see the partnership board as being the strategy. That's where the overall Greater Manchester strategy is designed. Even then, we expect that to be built on the ten locality plans that each local authority area has. So that's a bottom-up exercise rather than a top-down exercise.
In terms of delivery and where delivery is devolved to, some of it will be to the individual trusts, some will be to the provider collaborative that they are all party to, a big chunk will be to locality boards, which will bring together at a local authority level, local authorities with health and other partners. And of course, that is where we join up local authority budgets and particularly social care budgets with health budgets. And that's a really important part of the mechanism.
So, we are in the process of establishing locality boards very much with the aim of them being local authority led because it's councils that are the leaders of place, but on a genuine partnership basis. So that local partnership is just as important, if not more important than the Greater Manchester partnership.
So how do you, Richard, in this system avoid what appears to be excessive bureaucracy or kind of confusion of roles that you've got decision-making of the locality level, decision-making at the place level, decision-making at the system level, decision-making in the health part of the system, decision-making in the broader kind of partnership body. Does this feel when you're in the middle of it all that it all works reasonably well and that people understand it all? Or is there a sense, I hear from sadly, you know, many people, which is that already there's a sense that the ICS structures have a tendency to generate quite a lot of bureaucracy and confusion.
Sir Richard Leese
I think there is a risk around that. I think it's also the case in Greater Manchester that we're not starting from scratch, we're not saying right, we've got this new system and all this guidance we’re going to set up a new system. This is very much building on what we've been doing now, really for seven or eight years, although formal devolution only began in 2016. Actually, work on it probably went back to 2012, 2013. So, we're building on a lot of practise that's been established, well established in Greater Manchester, and in some cases, very, very mature structures. That's the first thing.
I think the second thing is we're not overcomplicating the rules, we're trying to minimise the requirements of the constitutional arrangements at a Greater Manchester level to leave more flexibility at the local level, but then they do need to be rules. So, we need schemes of reservation and delegation, for example, that allow people to get on and do things not that stop them from doing things. And that's something we are still working through, but that is doable.
My perception and I'm going to kind of parade some prejudices here, Richard. But you know, my perception of Greater Manchester is that you've all been working together for many years, all one political party in terms of the kind of leadership of the of the councils. Everyone seems to be kind of meeting each other in different contexts, day in, day out, and that's great in many ways, the quality of the relationships, the continuity that you describe. But the danger, I guess, is a certain amount of cosiness and where is the challenge, would you say in this? Because part of it seems to me, it's a part of what has to happen with ICSs, is we have to have a bit more challenge to the health service.
Sir Richard Leese
If you go back through the history, at the time that we established the combined authority in Greater Manchester, and that certainly underpinned a lot of the work since. At that time, of the ten councils, five were Labour, three were Liberal Democrat, two Conservative. We've very rarely been all Labour in Greater Manchester. And as well as being able to work across geographies, we've also been able to work across political divides as well in common interests. When we did the devolution deal, there was a Conservative leader and there was a Liberal Democrat leader signed up to the devolution deal. There is only one non-Labour council at the moment. Again, though, Bolton Conservative that fully part of the arrangements for Greater Manchester as well. So, we have been able to do that.
If you look at the analysis of the first five years of devolution in Greater Manchester, we’re, in terms of population health and if you make comparisons on population health with national comparisons, we improve pretty much everything at a faster rate than is happening nationally. Of course, population health work takes a long time to sink into what's happening in the clinical end of the spectrum. But improvements in early years can often take 20 to 30 years to come through, but we were making those real improvements. I think one of the faults within the system in Greater Manchester, it was a partnership, it was consensus, and we didn't have that challenge. But I think one of the things that the ICB/ICS allows us to do is to introduce that level of challenge into the system, but challenge with authority?
Well, that’s interesting “challenge with authority”; let’s delve into that because I mean, one of the things I've been saying, Richard, is that I think it's important to protect ICBs from getting too involved in day-to-day performance management or intervention when things aren't working in the health service. Because what I think ICB should really focus on above all else is this challenge to achieve those things which we've been talking about for 25 years and we haven't achieved. So, these are three interrelated shifts.
The first is from a system that incentivises activity to a system that incentivises outcomes.
Secondly, from a system that meets demand to a system that meets need, which is at the heart, of course, of tackling health inequalities.
And then thirdly, this kind of shift of resources proportionately not absolutely, but proportionately from acute and upstream into community primary prevention and public health. Now, we've been talking about these shifts, but we haven't accomplished them.
And my argument is that if ICBs could focus more than anything else on achieving those shifts and we might actually be able to do it, but if ICBs get weighed down and in the end start to feel like health authorities, then the likelihood is kind of business as usual.
Sir Richard Leese
I think I'd make two comments on that. First of all, I think any system we need to be in the business of solving our own problems rather than expecting somebody to come from outside to solve them at for us. And I can look over the last six, seven years and just looking at two pretty fundamental problems within the acute sector of basically failing hospitals, and they were very clearly failing, that as a system we weren't very good at intervening to support those systems, to improve them. But ultimately the solutions were found from inside. NHSI, as it was then, couldn't solve those problems either.
The ultimate solutions came from within the system rather than from outside the system. Now clearly that's going to be replicated at different scales all over the system, we have to take responsibility for sorting our own problems. So, there are issues around the provision of some procedures and again I’ve had the conversation with the chair and the chief executive of our acute provider collaborative. These are problems we failed to solve for years, so actually it's now the provider collaborative's job to resolve those issues and make sure we do it right. I think taking responsibility within the system is absolutely crucial.
I think the ICB does have a job in making sure that we do take responsibility within the system. The other point is that it is getting upstream, as you've described, is absolutely right because it is about managing demand. And that's again, it's got to be pretty fundamental that we do manage demand, but I think we need to take a different view about the role of health in doing that. So, for example, being able to do a knee or hip operations actually relatively early on rather than waiting to the point where people can barely walk. To be able to do it when they're able to sustain relatively normal life and be able to go to work and do other things is a preventative act rather than a last-minute act.
And there are things we've got, for example, where care homes have got video links into general hospitals, so if somebody has a fall, they can get triaged by video through the acute sector. So, I think we need to bear in mind that within this, it's not necessarily moving resources from one part of the system to another part of the system. Quite a lot of this is getting to the existing parts of the system to do things different.
No, well I absolutely agree with that, Richard, and I think that there's a lack of clarity sometimes about the different rationales for horizontal and vertical collaboratives. It feels to me as though horizontal collaboratives, particularly acute collaboratives, the test of them is the distribution of resources. So, horizontal collaboratives should enable us to use our resources more effectively by configuring services so that we use staff, we use expertise, we use capital investment in the best way now.
The challenge there, of course, is that is going to mean that places don't necessarily have the full range of services in each place, and I'd be interested, and a question there is whether the politicians will back the health service if it has to make those decisions around configuration, which might be good for the system, good for the patient ultimately, but might mean places losing some part of that kind of full offer. And of course, places always want to have the kind of full NHS offer.
To what extent do you are you confident that your collaboratives will be able to make those kind of brave decisions about the most effective use of resources?
Sir Richard Leese
Well, I think to a certain extent, we passed that point in Greater Manchester a number of years ago and have made some of those decisions about, I suppose, those real specialist services where you simply cannot effectively provide them all over the place.
You have to reduce the number of locations, and for some of those, politically it's a relatively simple question is that for your population, you want them to go to a hospital nearby or do you want them to live? And that's really quite a powerful argument.
So, I think as long as it is justified and explained properly, I think politicians will buy into that. It's probably been a bigger issue with clinicians, actually, about their willingness to see services go to other places.
But it's like this example that came from the chair of the provider collaborative of a significant number of vascular cases being moved from one hospital to another in a different trust, and five years ago that would have caused a complete uproar amongst most clinicians, never mind amongst politicians; now it’s seen as being a very rational way of being able to do; this is about volume work, being able to do volume work in a safe way in the covid environment. And a lot of this is about proper case making, it’s about proper evidence, and it's about taking people with you. And in those cases, it's making sure that the people who might get upset, the clinicians, are part of the decision-making, not simply having it done to them.
Yeah, now that's a very important point. And I'm not going to resist the temptation to test out with you that you share the Confederation's view that it's really important that we rein in the secretary of state's powers over reconfiguration because those difficult choices locally, I mean, it's hard and it takes courage to do it, to do it and then find the reconfiguration is rejected by the secretary of state is not going to be helpful.
Sir Richard Leese
No, it's not going to be helpful. And I think that there are some principles about how we want to design services and I think move to collaboration is really, really important. Distributed leadership is important. It goes back to an issue you raised earlier about are the rules going to get in the way of people doing things. Well, not if you have properly distributed leadership.
Co-design, co-production, absolutely crucial. And of course, when it comes to clinical elements, the patients to be part of, the lived experience needs to be part of that co-design as well. It's fairly fundamental for us and it's something we've been working on now for five or six years is the strength-based or asset-based approach. That we start from the point of view people can do rather than people can't do, so that there are going to be some principles underpin the approach that we take and the rules have to fit in with those principles.
Now I'm really glad you said that, Richard, because one of the pieces of work which we're growing rapidly at the Confederation is around collaboration.
So, it's around collaboratives with a capital C, but it's really more broadly about collaboration. And our argument is that if for 20 years competition was the kind of big idea in the health service and other parts of the public sector, and we think about competition, there are a whole economics departments focussed on competition, competition law and competition authorities, expertise in competition. Yet when we talk about collaboration, we don't yet have the kind of fully worked through understood kind of battery of methodologies and skills that we need to make collaboration work, and we are fundamentally shifting from a competitive mindset to a collaborative mindset. We need to think, we need to know what are those skills, what are those processes, what are those techniques to make it work?
But Richard, going back to something you intimated a few moments ago. You've been in this kind of business with greater devolved powers now going back to 2015, helping to accomplish, with George Osborne at that stage, a kind of shift in the way that the centre worked. But have you found the centre kind of gets it?
So, we published a paper last week by Sir Chris Ham and basically he argued that the centre needs to change if systems are to work. And my experience of the centre is that whilst there is a commitment to system working, it's far from clear that everybody in the centre gets it. So, a kind of system first mindset is far from ubiquitous at the centre and still many people, whether it's in DHSC or in NHSE or No10, still have this kind of I want something, so I'll pull a lever and make it happen, mindset.
Now you must have been dealing with this for many years where there are bits of Whitehall that kind of get the devolution argument and bits that don't. How have you worked? How have you managed to get things done in that kind of context?
Sir Richard Leese
I think there are large amounts of Whitehall that don't get devolution still. If we switch slightly from health to the levelling up white paper, which I think Michael Gove probably does have a very good understanding of what's required in levelling up, and one of the challenges for him is the extent to which he can take his colleagues in cabinet with him. And I'd say that the white paper shows that there is a long way to go to take his colleagues with him.
The Department for Education, Department for Work and Pensions still appear to be pretty resistant to devolution and doing things in a more joined up way. And those are pretty fundamental to what we need to do in the long term. Unusually, this is a process, a programme that is a very long-term programme, and that's where we need to be.
You asked the question about how we get around it. It's something I think we've done in Greater Manchester for quite a long time now certainly going back to 2008, 2009, probably back to even further than that, is to have evidence-based long-term plans, normally ten years plans not inflexible because a lot can happen in ten years. And then effectively what we do is, whatever happens to be the government programme at the time, work out how we can use that to deliver our long-term plan.
So, if government doesn't do long-term integrated planning, we kind of do it for them.
I think that's right, Richard. And I think it's going to be great working with you through our ICS Network. And I wonder whether one of the things you'll want to share with your colleagues is that in a sense, you've just got to kind of grab the initiative yourself. You can't wait for the centre to give you permission. Is that one of the lessons?
Sir Richard Leese
Oh, absolutely. I can remember the debate in meetings with local authority and LET leaders around what became the Northern Independent Economic Review, a really impressive piece of work done probably back in 2016 to 17, I was meeting with local authority leaders saying we need government to tell us what we can do. And I said, no, you need to decide yourself what it is you need to do and then find a way of way of doing it.
It might be that after probably 30, 40 years of increased centralisation that some of the get go is being knocked out of local government, but actually local government, who are the standard bearers for localism, for place, they need that get up and go.
But I think in Greater Manchester, we've got that back some time ago and really are determined to make decisions about our place. If you go back to the health devolution deal, which was always a partnership with government, it was and it was never just government saying get on with it, it's a mixture of devolution and decentralisation, in reality. But what underpinned that was not that we expected to make all the decisions about everything, but there would not be decisions being made about Greater Manchester that we were not party to, that we were not part of those decisions. That’s where we need to be.
And that’s a big shift in the health service. So if you take that idea and you say the future has to be one in which ICSs are not required to do things to their populations without being involved in the determination of that policy, I mean, that is not where we all now, policy emerges almost continuously from the centre and the first people know about it is when they read about it in Health Service Journal or whatever. So, it is a big journey.
And I think that, you know, from our perspective, on the one hand, what’s great, the great opportunity of ICSs is 42 experiments where leaders can really learn from each other, where different ICSs can focus on different priorities and generate shared knowledge, tools and understanding for each other. But the other is that we can turn this group of 42 chairs and chief executives into a really cohesive group to help train central government, as it were, into how it has to operate if system working is going to be successful.
Richard, before we finish, I just want to turn to a couple of more kind of core issues for you, as you are now a health leader. So, the first is, you know, obviously you've been presiding in various ways during covid and during the vaccination programme, I’m interested to know what you think are the lessons that we should derive, we all hope are now at last emerging from covid, what do you think are the lessons that we should derive from the last two years?
Sir Richard Leese
One is the collaboration, mutual aid works so as something to underpin the way we go forward, that those lessons of collaboration are work that we need to take over.
I think the second is that there is through covid a recognition that every part of the system is equally important. Without it, then things don't work. And I think it's been particularly the case that my colleagues in the acute sector have an understanding and appreciation of adult care, for example, that they didn't have previously because discharge, the end of the patient journey, has become such a crucial part of how we've managed, or need to manage covid.
So, I think that understanding that every part has a part to play is crucial and we need to keep that going, the notion of equality between the different bits of the system.
But I think the third bit and this will, I think, will only come out through a proper analysis, if you look at elements of how we've tackled covid, test and trace is the most obvious example, there has to be a balance between national action, national decision-making and local action, local decision-making.
It's pretty clear to me that most of the time we didn't get the balance right. And we could have had even better responses if we have the balance right, and that does come back to that fundamental issue, which is we're not expecting the NHS nationally or national systems to simply say here you are 42 of you just get on with it. I think they do have a role to play. We don’t, for example, want 42 different vaccination policies in England; that would not work.
So, I think there is a lot of learning from covid about what is genuinely national, what is genuinely local and being able to operate in that way.
I agree. And I think that the lesson from the vaccination programme is that that kind of hoary old kind of dichotomy between central control and local discretion is blown apart because, actually, what you saw in the vaccination programme is a really, really powerful national infrastructure, particularly when it came to data and supply and all those things. But the delivery relied upon the capacity of local authorities, voluntary sector community organisations being able to reach out into the community, particularly those communities that were that were vaccine resistant. So, I think it's a great example of how you need to get both sides of this right.
Final question, Richard, and one that I think is a really pressing one everywhere, which is, we've talked a lot, you and I, about the desire to kind of achieve a deep shift in the way we think about health, to think about health policy in broader terms to move to a focus on outcomes rather than activity to tackle health inequalities, all of these issues. Yet, the really pressing issues in the health service is the elective backlog, is the kind of state of crisis in our emergency care system, delayed discharge.
How do we deal with these immediate and pressing short-term issues in ways that don't drive out our capacity to achieve that longer-term shift that we've talked about, Richard?
Sir Richard Leese
I think in terms of delayed discharge, this will continue to be a long-term problem until we resolve, properly fund, properly, staff properly invest in staff within social care. And until we do that, it will be an ongoing, ongoing problem, and we're clearly a long way away from that still, so there is a fundamental to be tackled there.
In terms of elective backlogs apart from, I know it’s something you've talked about, the need for a long-term, medium-term people plan around this, clearly it does need to be long term, but it's not going to deal with the elective backlog as it is. We're going to have to do that with the staff we've got, or the staff we can get relatively quickly. And that does imply the things like establishing the variously described as the green centres or the cold centres where you're able to do, relatively, volume work without it being disrupted either by a pandemic or being disrupted by ED work is got to be part of the way forward. And that does mean being able to basically relocate particular services into particular places; that does actually give a real issue about access to services, particularly to people who are public transport dependent.
So, I think there is a real challenge there. But again, it says that means there's got to be joined-up work with transport authorities in order to be able to address those issues. It's not just going to be ambulances moving people around to solve those problems.
I know from the work in Greater Manchester, I'm sure there are parallels elsewhere, that our acute provider collaborative in the middle of last year developed an accelerator programme for dealing with the elective backlog, it requires a relatively low amount of capital investment, probably about 140 million for the whole of Greater Manchester. So, in the scale of things, it's not a vast amount. But with that, they’d be able to increase elective capacity by around 30 per cent, not just on a temporary basis, but on a permanent basis.
So going back to what I mentioned earlier about getting those knee and hip operations early, that may be on the back of that in three or four years, we're able to start getting those that knee and hip operations early. Look, I think that the people with expertise have got really coherent plans about what they can do, what we need to do, and this does require national decision I’m afraid, they need, and the Treasury needs, to get behind those plans properly.
It seems to me, Richard, that one of the disciplines we need to operate in is what my friend David Aubrey called split-screen thinking, which is having a vision of where we want to end up, but then making decisions in the short term, those immediate issues, in ways which align with that longer-term vision that we've got. But you need the long-term vision because it will shape the short-term choices that you make.
Well, Richard, it's been great talking to you, and I'm really looking forward to working with you through the ICS Network in the months and years to come.
Sir Richard Leese
Thank you very much.
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