In a media interview discussing my time working in Downing Street for Tony Blair, I tried to capture his sense of self-assurance. “The only time I ever heard Tony admit he was wrong,” I said, “was when he said he should have listened to himself earlier.” I was reminded of the dangers of hubris the other day when I realised that a conversation with a very effective and thoughtful health leader has made an impression, in part, because it reminded me of something I wrote about some years ago.
This leader is in one of those systems that has a particularly challenging geography (in other words, it is neither one of the single place/single system integrated care systems (ICSs) nor one of those that exists in an already quite cohesive sub-region). Indeed, in this system the places that comprise it have a great deal more history, identity and relational infrastructure than the system footprint.
While most health leaders I speak with are enthusiastic about system working, I have occasionally heard scepticism in some geographically complex systems about the capacity of the ICS to add value. However, the leader I spoke to last week enthusiastically accepted their own responsibility to enable the ICS to be the organisation it needed to be to add value.
The role of the ICS is to make things happen by facilitating the relationships between the institutions, collaboratives, partnerships and places within the system
At the heart of his enthusiasm was the ideal of the ICS as a convenor and enabler. In other words, rather than adding to the complexity and ambiguity of the NHS system, the role of the ICS is to make things happen by facilitating the relationships between the institutions, collaboratives, partnerships and places within the system. And many ICS leaders absolutely see themselves in that facilitating role, as well as helping to empower communities and populations to help themselves.
As this leader said to me, partnerships and collaboration for improvement are something healthcare organisations that predate the NHS have done for decades; ICSs and place partnerships are our current way of making this work in a systematic way given the complexity of the health and social care environment we now operate in. But in most places they can build on long-standing shared history and relationships.
Our conversation reinforced two earlier perspectives: one from my time before the NHS Confederation, the other a recurrent theme in our ICS work.
The former view is that very often in public service systems and places, we invest nearly all our resources in organisational cogs rather than in the oil than enables those cogs to turn together and generate the power to drive change. In my past job at the RSA, commenting on public service reform or place-based change I often argued that we have underinvested in the spaces between institutions and systems. ICSs have the capacity to meet that need and I know many ICS leaders absolutely see themselves as enablers and facilitators.
Key opportunities flowing from this enabling role are promoting service integration, enabling resources to move upstream and widening the conversation about health outcomes and health equality to the social determinants of health and not just the actions of the NHS.
To fully grasp the opportunities of this enabling role requires a model of leadership which is simultaneously modest in terms of amassing exclusive authority, and ambitious in terms of the generation of collective power and solutions. As ICSs move on to a statutory footing and start to build their own capacity, this question of how they see their role and how others see it will become ever more important.
The latter perspective is the vital importance of NHS England and NHS Improvement (NHSEI) and its regions in facilitating this model of enabling leadership at system and place level. The centre needs to understand that every time it tries to use ICSs simply as mechanisms for delivering over-specified central priorities it is likely to undermine the capacity of ICSs to add value.
Governance alone will not bind systems together: it’s the relationships, shared goals and ambitions that will strengthen systems, as long as they are allowed to ‘get on and do’
It is very hard to be convenor and facilitator if you are being compelled to spend much of your time achieving centrally driven must-dos to the possible detriment of locally determined priorities. Of course, integrated care partnerships and integrated care boards must be a source of challenge (something my interlocutor recognised), but the capacity of systems to do this effectively will in large part reflect the degree to which they can remind providers and other partners of the system and place goals to which they have collectively signed up.
ICS leaders are clear: it’s not governance alone that will bind systems together, it’s the relationships, shared goals and ambitions that will strengthen systems, as long as they are allowed to ‘get on and do’.
From speaking to ICS leaders I know it is not their desire to ‘build empires’ (and NHSEI must resist the temptation to make them do so), and work in partnership with trusts and places to develop their potential as system enabler, they can convince even the sceptics, including those with the most challenging geographies, that they are just the kind of organisation the health and care system most needs.
This may be the fruition of a pre-pandemic plan, but the genuine partnership and shared ambition to improve people’s health is absolutely what our communities and populations need right now.
Matthew Taylor is chief executive of the NHS Confederation. Follow Matthew on Twitter @frsamatthew.