Professor Sir Chris Ham: My vision is that ICSs should feel different to any organisation we've had before

Matthew Taylor

Hello. Today on Health on the Line, I'll be talking to one of our most respected health service leaders and commentators. He's headed health strategy for the government and for almost a decade ran one of our leading health think tanks. He co-chairs the NHS Assembly set up by NHS England, but he's not afraid to speak out when he thinks the centre is getting things wrong, as he did recently over the winter crisis. He's written with enthusiasm about the potential of a system working. But he declined to stay on as chair of his own likes, citing worries about over-centralisation as one of the reasons for his decision. When it comes to assessing the state of the NHS, the prospects for integrated care systems and indeed the long-term challenges the health and care system needs to face, there really could be no one better to hear from than Sir Chris Ham.

New ideas, big debates, meeting the change makers, transforming services. I'm Matthew Taylor and this is Health on the Line brought to you by the NHS Confederation.

Chris, welcome, how are you?

Chris Ham

I'm very well, thank you very much, looking forward to our chat.

Matthew Taylor

Chris, let's start with where we are. You wrote a piece just a few days ago about your concerns over winter. The NHS Confederation kind of led the way in calling the government to introduce some of the measures that are sometimes called ‘Plan B’. What's your sense now of where we are Chris, for the winter? And what do you think can be done to try to alleviate the pressures?

Chris Ham

Well, Matthew, we've come through, I think, the toughest summer in the history of the NHS, certainly since I've been involved, which goes back now over 40 years. And by that, I mean the increasing pressure we're seeing not just on GP practices and hospitals but on our mental health and community services as well. We're in the middle of October anticipating a very challenging winter as well. I'm particularly concerned about what's happening at the front door of hospitals with growing concerns, quite rightly, about ambulance waiting times, patients having to be cared for at some risk in ambulances until they can be safely discharged into very, very busy EDs, and then sometimes to the waits that follow on when it comes to finding a bed. And of course, at the end of the hospital care, finding a way of timely discharging those patients back into their own homes or into social care.

These challenges, these pressures are unprecedented, and I think they are partly on the back of the pandemic. But there's a longer-term perspective we need to bring here, too, which is that for many, many years, and particularly in the last decade when funding has been so constrained both for the NHS and particularly for social care, we've not been able to invest in the capacity we need. So very sadly, and I mean that sincerely, it feels to me we are at a critical juncture now moving into the winter and covid is only one part of that. I really want to emphasise that if you've got 8,000 hospital beds occupied by patients with covid, clearly it poses a major challenge.

But the wider issues I've alluded to are the fundamental reasons we find ourselves in the position today. So, I am concerned, and I'm concerned, above all, for health and social care staff who have been working incredibly hard since the beginning of 2020, continue to do so around elective recovery, and we're asking them to go again in this current winter. And I worry about the impact that's going to have on their health and wellbeing, as well as, of course, on patient care and patient outcomes.

Matthew Taylor

So, Chris, let's look at the different kind of dimensions of this. And of course, you're right that one of the things I've been trying to get across to people I've been speaking to in the last week or so has been that this is a kind of layer cake. You know that you've got the winter pressures that the NHS always faces, which in some senses reflect both policy and politics, the politics of austerity, but also the policy of minimising hospital beds, which leads to efficiency and is based rightly on the view that you want people in hospital for the minimal time. But the problem, of course, is that you have very few hospital beds. It means you've got not much wriggle room when something like covid comes along. So, you've got the fact that we always have tough winter pressures because of the way in which our health service works. You then add in covid, which is the second element, but then critically, the third element, which is the pent-up demand from the last 20 months or so. And that's not just about people on waiting lists, that's about people who haven't been seeking treatment or people who are on a waiting list, but their situation is deteriorating. Or even, as you said, people who rely on social care visits and they're not getting their domiciliary care visit because of staffing shortages. It's the combination of these shorter- and medium-term elements that's contributing to where we're getting, we've got to, isn’t it Chris?

Chris Ham

Absolutely. It's all of those things. And I think the problem sometimes is the media. Politicians focus on one set of challenges without thinking about the interrelationship between those challenges and the rest of what's happening in health and care specifically, for example, and understandably, a lot of concern around elective care and the over five million people now on waiting lists. You're not going to address those elective care challenges effectively unless you're also paying attention to what's happening in general practices, what's happening in urgent and emergency care, because unlike some other countries, it's not easy in the NHS to separate planned care from unplanned care. And if there's a surge in unplanned care of the kind that we've been witnessing throughout the summer and into the autumn, that's going to pre-empt the use of beds and staff for dealing with the elective backlog. So, we need to adopt a mindset that sees health and social care as one interrelated system of care; where there's pressure at one point, it impacts on other services and other aspects of patient and user care.

Matthew Taylor

So, we at the Confederation have called for Plan B or similar kinds of measures. We've also called for a kind of a national mobilisation, if that doesn't sound grandiloquent, just the kind of sense that we had during wave one of covid, of people thinking hard about how they could support a health service. That's, on the one hand, using it appropriately - there are lots of things that you can use if you're concerned about your health before you need necessarily to visit the GP, much less to go to ED. So, you know, there's 111, there's the website, there’s the App, then, you know, using services appropriately. But there's also being aware of the kind of pressure health service staff have been under, though I've been worried about the pushback and stories of aggression towards GPs that we've heard recently. And I guess even just kind of looking out for your neighbours because if social care services are not being provided, there may be people in your street who are not getting their vital daily visit. Is there anything beyond that that we can do in the short term, Chris?

Chris Ham

Well, we learnt, didn't we Matthew, during the pandemic that the role each of us played as citizens within our families, within our communities, in following the rules made a huge contribution to mitigating the adverse impact of the pandemic, alongside the successful vaccination programme. And we all have a part to play, as well as having a right to expect quick access to high-quality health and care services. And I felt for some time now we could and should do much more to recognise the reality of that, how we can use all of our assets wherever they might be, not just funding for public services, but the assets in our communities, calling on every citizen to play their part in a very positive way. Recognising, of course, it's much easier for some people to do that than others, and recognising the health and care system itself needs to make it easy for people to play their part by giving them the support they need at different stages.

I think there's a huge prize here - I’m so impressed by the work that people like Donna Hall and Kate Ardern and colleagues did in Wigan in developing the Healthier Wigan Partnership, a broadly based partnership led by the council but involving the NHS and voluntary and community sector organisations. And they have the results to show that when you do that consistently, over time, you can improve health outcomes, the wellbeing of the citizens you're serving. You can begin to make an impact on health inequalities. Even at a time when Wigan Council had to make deep cuts in its budget because of the austerity period we were going through, and I think the NHS has a lot to learn from that kind of example being much more open minded about not just how we deliver things better on the supply side of health and social care, but how we work on the demand side and how we mobilise the energies and the commitment of people and communities themselves.

Matthew Taylor

So, moving on from these immediate pressures to some of these broader questions, Chris, I'm sure you, like I, have been involved in various conversations about the forthcoming integration white paper. What have you been saying to folks in, you know, No10 or the department or NHSE when they've been asking you for your perspective on the integration white paper?

Chris Ham

We need, first of all, to see this as a long-term project. It's not like flicking a switch where you leave behind competition and contracting and move towards collaboration and partnership working. I've seen that up close and personal in some of the work I've been doing. We've got to be in this for the long haul and have the patience to understand this will take a number of years to become the reality as we experience it.

Second thing we need to do is go back to what Simon Stevens said about four or five years ago. He memorably said, if you merge two leaky buckets, you do not get a watertight solution. And that's partly what we're experiencing now. We need to ensure there is sustainable staffing and sustainable funding for both social care and the NHS. The announcement, made a few weeks ago, is welcome, but it's really only the first step on the road to that sustainability that is essential.

The third thing I'd say is that the benefits of integrating care first and foremost arise when teams at the frontline of care break down the barriers and the silos, and they come together around the patients in the communities that they serve. It's clinical and service integration, which is the big prize here, that makes a difference to the people we're serving, not just organisational integration.

I can think of many examples where there's been a move to bring organisations and budgets together at a large population level, but actually that's made no difference at all to the people who need that integrated care because the silos remain in place out there in the field. And that's where we need to start. We need to support the teams to do what I believe almost all teams want to do, to share information, to improve their communication, to do the very best they can for the people they serve, and particularly in the population we have at the moment, the growing numbers of people who are frail people with multi morbidity, those who absolutely will only get the best possible outcomes if that clinical and service integration is in place.

So, let's complete the organisational changes that are now in train, subject to the legislation going through parliament, and then please, let's have a moratorium on further organisational change. Let's create the time and the space for the teams on the ground to do what I've been describing, because if we do that and we'll allow those teams sufficient time to develop new ways of working, then good things will follow.

Matthew Taylor

Focussing just for a moment on this question of integration, which I think we can assume is at place level, you know, local authority upper tier levels, so we'll talk in a minute, Chris, about ICSs, systems, because that seems to me, from what I can tell, where the kind of focus of this integration white paper is going to be. A big part of this is going to be about primary care, isn't it, Chris? Because on the one hand, primary care is the entry point for most people into the health service. And so, if you're going to achieve placed-based integration, primary care has got to be fully part of that. But also, arguably the primary care model is under a lot of strain, and I think many people would go further and say primary care, as we understand it, just isn't really working. What's your perspective on how we integrate primary care at a local level more effectively than we necessarily do at the moment?

Chris Ham

So, for me primary care networks are a good starting point for that because yes, it's a system, yes, it's place, but it's also neighbourhood and locality, which is the locus for PCNs. And if you take PCNs and PCNs are a basis for which you can then begin to build clearer linkages with the community health services, with mental health services in the community, with social care and with all the other contributors to the integration that we are talking about. I think that requires us to think harder about the models of primary care general practice what we need in future. Partly because the capacity constraints at the moment, fewer staff, more demand, lots of frustration on the part of patients around not getting access to face-to-face appointments or timely appointments, and huge frustration on the part of the staff in general practice at the pressures that they're under, even if they're seeing more patients than ever before with fewer staff, still feeling that they are being criticised, and sadly, in some cases they're being abused because of the frustrations that exist in the system.

So, we can't carry on with what we've got. We've got to embrace new ways of delivering care, as practices have done during the pandemic. The way in which digital and other methodologies and technologies have been used has very quickly transformed how practices work and the experience of patients not always to the good, but certainly with some benefits. We need to be open minded about other ways in which we can improve care. We need to make sure we invest in the staff, not just the doctors, not just the nurses, but the wider team, because primary care has to be about teamwork in future. And we've got to make it easy then for practices to call on the community nurses or indeed the mental health services, to be able to reach into hospices and draw on the expertise of the voluntary sector. And there are great examples of where that already happens, but we need to universalise the best.

Matthew Taylor

I want to ask you a little bit more about primary care, but going to back to the core issue of primary care is one of the issues here, Chris, and I know this is simplistic, almost anything that one says about the NHS is simplistic because it's so complex, but you've got two very different types of people walking through the front door of their local primary care centre or GP surgery. You've got the kind of worried well who really just want a diagnosis. For these people it's just about their health, really, it isn't about the kind of wider quality of life or anything else. They just have a problem and they want a kind of medical solution to it, a medical understanding of it.

And then you've got the other group to whom you've just mentioned Chris, which is, you know, people with long-term conditions, multiple conditions, and there I was very influenced by a thought given to me by Charlotte Augst who runs National Voices, who’s splendid, and she just pointed out to me that the relationship between acuity and quality of life is attenuated, that there are people with quite challenging physical and mental issues who have a reasonable quality of life and people with much lesser, ostensibly lesser problems, medical problems and have a very poor quality of life. And so, for these people, the second group, it isn't just about medical interventions, it is much more about a more rounded offer to enable them to live an empowered and reasonable quality of life, living with conditions that are going to last. Now, they’re two rather different groups, aren't they? If you were starting from scratch, you wouldn't necessarily want them to both be channelled through the same front door.

Chris Ham

Well, I'm not sure I agree with that. First of all, I think there are more than the two groups that you've described that they certainly exist, but they are a subset of a larger population of people and the whole point of general practise. And the reason that we are so lucky to have the system we have is it's about generalism, it's about having a group of people in the primary health care team who can deal with whatever comes their way and know what skills to call on and if they don't have those skills, where to go to find those skills, to respond to the needs of their patients. And I've always been resistant to the idea that somehow we should differentiate and have different front doors for different population groups because, I can understand the logic behind that and what you're saying, but I think there'd be some disadvantages too. And can I link this in to one other point we were discussing, a wise paediatrician from another country said to me a long time ago, the most important member of the primary health care team isn't the family physician and isn't the nurse, it’s the person who is seeking care and support.

And there's an eternal truth in that statement because what he was pointing out was the decisions that each of us makes every day about taking our medications, taking exercise, our diet, our sleep, the contact we have with our loved ones and our friends. Those personal decisions make a huge impact on our sense of health and wellbeing and the limited time we have every year in contact with the family physician or the nurse, of course, adds value to that, but it is, by definition, a limited time. And the point that came out of that for me is that let's recognise the agency that everybody has, recognising too it varies between different people, depending on their background and their circumstances. But if we start from that position at agency, the question then becomes what more can we do to support people to make the right decisions? Because often it won't be clear what they are. And, also, to give them rapid access when that's needed to professional advice and support, which is why the person is the most important member of the primary care team and we need to build on that.

Matthew Taylor

Yeah, I hear that, Chris, but I guess for me, the issue is what is the kind of relationship that you want? And that's why I differentiate between these two groups because it feels to me as though those people whose lives, as it were, are kind of fine, apart from the fact that they have a worry about a particular kind of symptom or whatever. They don't necessarily seek a kind of relationship or an ongoing kind of conversation. Their issue is the thing that they're worried about, whereas for those people who are living with conditions and possibly with a number of conditions, what they need is a much more relational response. They need people that can talk to them, not just about their health, but potentially about their housing or about their benefits or about their employment.

And so, when we talk about integration between community services, primary health, adult social care, that feels very relevant to addressing the quality of life of people who are living with illness. It doesn't feel so relevant to people who simply, as it were, you know, want a diagnosis. It feels like that second part almost could be part of the broader acute offer. But are you saying that in a sense, even though these are two different types of group that still in the end, the family doctor, as you put it, the GP has to be the kind of first point of call, because I'm just not sure about that. I mean, as we see the diagnostic revolution, it's going to become more and more possible for us to check out any of our health worries without necessarily needing to spend time sitting down with the professional.

Chris Ham

So, I would say that that's what general practices have learnt to deal with, the fact that different people in different circumstances require a different response, and there's no reason why practices can't continue recognising the need to provide that reassurance for what you've called the worried well, I don't like that phrase myself, as well as the more broadly-based holistic response to people who've got more complex needs. It's become more difficult simply because of this collision between rising demand from patients for appointments and for care and support from their general practices and constrained supply. That's why there needs to be, I think, more openness about using other approaches integrated within general practices, you know, there are various commercial offers out there that some practices are using. There are some home-grown offers like E-Consult in some practices in London that provide that as well. It's not beyond the wit of the wider primary health care team, and it's about, of course, using the full strengths of that team, enabling the nurses and the assistants and the AHP to practise to the top of their licence because we can't load everything onto the GPs themselves.

Matthew Taylor

Let's turn Chris to the system level, to ICSs. You've been a great champion of system working and indeed you've written a lot, I know you're a great fan of the work of Elinor Ostrom, but you've written a lot about the kind of ecology you need to create for collaboration to take place. But yet, I think that your own decision, which I'm sure had lots of different reasons for it, but your own decision not to put your hat in the ring for the Coventry and Warwickshire post, the long-term post that you're holding at the moment, suggested that you're concerned that the core thing that systems need, which is autonomy the capacity to be able to respond to local issues, is already being eroded by the unsurprising sense in the centre of the need to tell ICSs what to do.

Chris Ham

Yeah, that's partly the case, Matthew. But let me just sort of take a step back. So, we're on a journey with ICSs, starting with STPs coming in in 2016 and having been a student of the health service, as well as a practitioner or a leader in the health service for many years, what was refreshing about what happened in 2016 is NHS England said the future is around partnership and collaboration in place and in system. And there was no blueprint. There was hardly any guidance, basically said, ‘Go figure’. Forty-odd systems across England, you work out for yourselves how best to do that? And they allowed literally a thousand flowers to bloom. It's felt very liberating the opportunity to be quite creative during that period around issues like the governance, the population level at which you work, the priorities that you focus on. And there's been huge amounts of ownership. A lot more energy behind STPs, now ICSs, than I've seen in previous reorganisations going back many, many years.

We've got to the point where that's changing, understandably so, because of the requirement of legislation. And therefore, there are now far more rules in place about what ICSs should do, their governance, their leadership arrangements and so on. It's become much more prescriptive and there's less latitude than there was to figure out what works for you in your system. And I think there's a risk that we're going to lose quite a lot as a result of that.

My vision, you alluded to Elinor Ostrom, my vision is that ICSs should really look and feel quite different from any organisation that we've ever had before in the last 70 plus years of the NHS. And specifically, what I mean by that is if we're serious about ICSs and placed-based partnerships as being genuine partnerships of the NHS, local government, voluntary and community sector, then they should take ownership of responsibility for the use of money, performance, the quality of patient care, the outcomes they achieve for their population and what Ostrom’s work showed us, and the studies that she did in very different settings, is there is a different way of achieving that ownership and that commitment. It doesn't have to be through hierarchical top-down control, targets and terror. It doesn't have to be through market mechanisms. You can develop an approach which she calls self-governing, the partners taking responsibility for finances, for performance, coming round the table together and holding each other to account rather than being overseen in a very directive way by other parts of the NHS. And I still believe that's possible. I see more risk associated with it now than I did three or four years ago, but I think if we are giving ICSs that possible role, then the people now being appointed to chair and be CEOs need to focus on that and building that culture a way of working because in that direction lies the difference and I hope we will see in practice.

Matthew Taylor

So let me test out with you, Chris, my perspective on this, which is also taking kind of system lens, slightly different from Ostrom, but actually, there are echoes of this in Ostrom’s work, which is to say, if you look at a system, any system actually in organisations or between organisations or in places, you've really got three things that drive change in that system. So, you have top-down pressures, which are to do with, you know, wherever the centre of power is and to do with strategy and regulation and control. And then you've got kind of lateral pressures and that's to do with a kind of shared values, but also a kind of a spirit which at its best is one of, kind of, challenge and support amongst colleagues at all levels. And then you've got kind of bottom-up pressures which come from, you know, in this case, patient citizens, communities or it could be in other contexts, customers or whatever. And the most effective self-improving systems are ones that both articulate these three types of pressures, but also critically balance them. Because if you push too hard from the top, you push away the capacity to respond bottom up, you push away the reasons for collaborating kind of laterally.

Now when I talk to folks in the centre in NHS England, I get a sense of recognising this, of wanting a system where we do get the right balance of top-down, lateral and bottom-up kind of pressures to self-improving system. There's a kind of understanding of that. But yet, as you and I both know, because we both worked there, the centre, whenever it comes up against anything, always tends to assume that the answer is new guidance, new regulations, new instructions, new targets, new announcements. So, the challenge is what can ICSs do to help the centre really be a kind of source of added value and resisting this continuous temptation to overreach and over interfere?

I think what's critical to that is two things. First of all, that ICSs despite their incredible diversity, and that's one of their characteristics and can be one of their strengths, their incredible diversity, need to speak with one voice. So, ICS chairs, ICS chief executives need to work hard to be a strong voice towards the centre to be able to help and guide the centre to focus on where it's adding value. And at the same time, ICSs also need to create a really strong culture of challenge and support, the ICSs, they are 42 different experiments, that they really do learn from each other and challenge each other and drive that capacity for lateral improvement, one that actually local government has been become rather good at over recent years. So that's my kind of analysis, and that's why I think, for example, the work we're doing at the Confed with the ICS Network, it's really important to turn this into a very cohesive group of people speaking with one voice and challenging each other. Does that accord with your view of the world?

Chris Ham

You summarised it very well. I couldn't have put it better myself. I think on the points you make, the involvement of local authorities has been very powerful in my experience. Certainly, Coventry and Warwickshire, the City Council in Coventry, the County Council in Warwickshire has really been helpful in enabling us to start to look out to our communities at bottom-up pressure. That accountability to the people we serve has become much more prominent in our thinking, and I very much have valued that. Also, I agree with you that we need to encourage much more networking and sharing between the 42 ICSs. I always say the real knowledge and understanding of what an ICS does, how it works and the solutions to the problems that exist in other ICSs are in ICSs themselves, because for five years during this permissive environment that we were talking about, they have developed that knowledge and understanding. And then the Confed and others can play a vital and valuable role in helping in that sharing as local government, as you've said, has done for many, many years. If we can do those things that bottom-up focus through local authorities, that sharing between ICSs, it should mean that we rely less on that top-down intervention.

My only caveat to that is, having worked in Whitehall, this is dependent on government itself playing its part, behaving in a way which makes it possible for systems to take the ownership and the responsibility for self-governing and self-improvement. And sadly, old habits do die hard. And actually, some of this comes from the very top of government. You and I worked in an era when there was more focus on delivery of public service targets and objectives. We're seeing a revival of that interest at the current time. And NHS England itself, you know, behaves in a way which reflects the environment it operates within and the pressures it finds itself under.

And let's be honest about this, Matthew, the NHS now accounts for about 40 per cent of total public spending. It's been the beneficiary of much more in the way of increases than other public services, despite competing claims. So, we should expect to live in the next two or three years, at least, in an environment where there is increasing scrutiny of the NHS from outside and increasing scrutiny of systems from within the NHS hierarchy. So, delivering on what you and I are talking about isn't going to be easy, but I do think it's possible if we all work together on it.

Matthew Taylor

Now. There's one final thing I wanted to ask you about Chris, and that's, you know, one of the pleasures I've had coming into this role is a coming to a couple of meetings of the NHS Assembly, and I get the sense that you're you relish the role that you have as co-chair of the Assembly. Just to finish with tell us a bit about the Assembly, people who perhaps don't know much about it, and do you think we could be doing more with it? That it could be reaching out more and that the public could know more about the Assembly as a place which brings together so many really interesting voices who care about the NHS and care system?

Chris Ham

Well, I'm glad you said that, Matthew, and we're pleased to have you as a newish member of the Assembly. So, the Assembly was set up by NHS England to advise on the implementation of the long-term plan published in the beginning of 2019. It's one of the most fascinating groups that I've had the privilege to be associated, with about 50 people, some of whom are well-known national leaders in their field. The medical colleges, the Confed, NHS Providers and so on, some of whom are local leaders in health and local government and the voluntary and community sector, and some of whom you'll never have heard of because they are intentionally appointed to bring the voice of patients or frontline staff or other stakeholders into the room. And we meet about five or six times a year with the leaders of NHS England on topics that we determine, and it's been a wonderful experience co-chairing with Clare Gerada, who will be known to many of our listeners today. And we focussed on some of the really big issues facing the NHS and social care.

We've had sessions on population health, health inequalities prevention, what more needs to be done. We've talked a lot about leadership, and leaderships and cultures in health and social care. How do we create the right kind of compassionate cultures, kind leadership, to support staff, not least on the back of the pandemic? And of course, we've used some of our time to talk about the response to the pandemic and what more and better can be done within that response. You ask about what more the Assembly itself can do, and I think it relates to where we started today. We are at this critical juncture where I think in many respects, many places now, there is evidence that the NHS and social care are beginning, sadly, to fall over. Really struggling under the pressures that they are under.

Clare and I hope there will be a really important and timely discussion of that at the next Assembly meeting, and we'll be seeking the support of the other Assembly members to make representations to the leadership of the NHS and to the government, and also to make a public statement expressing our views. Not just on the problem, you know, the diagnosis is now well-rehearsed through the Confederation and others, but to be practical and to be focussed on solutions. What needs to be done by whom around the pressure points to make sure that we're doing our very best by the people we serve.

Matthew Taylor

As well as an Assembly member, Chris, you can count me in. Thanks so much for spending some time with me today.

Chris Ham

My pleasure.

Outro

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