Integrated care systems are all about equal partnerships, getting into communities and improving life outcomes, according to Tim Oliver. Sitting down with Matthew Taylor, Tim, the integrated care partnership (ICP) chair for Surrey Heartlands Integrated Care System and leader of Surrey County Council, explores why joint appointments help avoid turf wars and how the ICP holds the key to delivering a strategy for addressing the wider determinants of health.
- Governing the health and care system in England: creating the conditions for success
- Building common purpose: engagement and communications in integrated care systems
- Split-screen thinking: handling immediate pressures without compromising future vision
- A peer network can help ICB leaders navigate the new NHS era
Health on the Line
Our 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
Matthew Taylor’s opening
Hello and welcome to the latest edition of Health on the Line. By the time you hear this, the worst of the heat wave would have passed. But these few days have added yet more pressure to a system which is already finding it hard to deal with the combination of unprecedented demand, stretched capacity and yet another wave of covid.
Despite the progress we've seen on the longest waiters and other vital areas, many leaders I speak to say the pressure is in some ways more intense than during the pandemic. And yet already thoughts are turning to what is bound to be an incredibly tough winter.
As I've written in a Confed blog this week, we need to try to approach winter in ways that model the future we want to see. Greater collaboration within the health service, with our local government and third sector partners. A greater focus on prevention, health inequalities, richer public engagement. Of course, this is a tall order, but we have somehow to try to use today's challenges as a way of building a bridge to the future. But a bridge can't be built on delusion and deceit.
As we watched the race to Downing Street unfold, we have said that the NHS and the public need a realism reset from politicians. The 40 new hospitals pledge is a cynical hoax. Social care is not being sorted and our colleagues in social care are in desperate need of extra support. Nor is the NHS awash with money. Soaring inflation and ongoing covid costs actually mean a real terms decrease in funding this year.
And we've seen the latest figures in the Royal College of Physicians showing that staff shortages are particularly acute and worsening within qualified medical professions; something that's really worrying. I've met many hardworking NHS staff who are doing their utmost to help services recover from the pandemic, but they remain severely overstretched and under supported. That's why we urgently need a commitment to deliver and publish a fully funded workforce plan across health and care.
Without one, the NHS will not have the capacity to make greater progress in reducing treatment backlogs, or deal with surges in demand due to rising covid cases or extreme weather or anything else. It's that simple.
In other news, we've also called this week on the government to urgently reconsider its decision to scrap vocational BTECH courses in health and social care. Unless they do so, we think it risks severely exacerbating the workforce crisis. Why? Because this could put at risk an important health staffing pipeline that allows thousands of potential nursing and midwifery recruits to join degree courses each year. Healthcare leaders have told us clearly that this could stymie an already very fragile health and social care recruitment sector at a time when both the NHS and social care are plagued by staff shortages. So, we've been following closely the debate about the BTECH in parliament.
And as we're talking ICSs in this podcast, I should tell you that part of our support offer at the Confed includes our leading integration peer support programme, one that we run in partnership with NHS providers and the LGA. The programme delivers a range of free bespoke support for local health and care systems to help leaders to strengthen their leadership and accelerate their partnership ambitions at system, place, and neighbourhood levels. For more information, email firstname.lastname@example.org
I hope you enjoy this edition of Health on the Line and will tune in for the next one, in which I ask Sir Gordon Messenger to talk about his review of management and leadership and what he hopes will happen now.
The NHS Confederation is proud to be the home of the Integrated Care System Network and delighted that all 42 ICSs have joined. Integrated care systems, as legally defined and mandated bodies, are only a few weeks old. But questions about how ICSs should work, how the different parts of the ICS construct fit together, how ICSs can add value working through partners at system, place and locality level.
These questions are at the front of health leader’s minds. The Confed is providing a range of resources and services to ICSs, and I'll talk a little more about one of them at the end. But for this edition of Health on the Line, I'll be talking to someone who has a great deal of experience in developing an integrated care system, in leading a local authority, and who will now be leading the Integrated Care Partnership.
So how does it all fit together and what will be the key success factors as we try to make the new system work in the very challenging circumstances in which we find ourselves?
So, I'm delighted to be joined by Tim Oliver.
Tim is chair, now I think, of the Integrated Care Partnership. But you were chair of Surrey Heartlands ICS and you're leader of Surrey County Council. I've got all your titles, right?
Indeed, you have. Absolutely.
Wow. There must be times you're not sure yourself.
Well, I could add on to that, actually, that I'm also the chair of the Surrey Health and Wellbeing Board.
Oh, right. And is that a place-level body?
Well yes, for the whole system.
So, I guess I want to get into all sorts of issues, but this is part of the challenge, isn't it, that those of us who are in this kind of world have an understanding of what these different terms mean. But it's not easy if you're outside the health world to understand it, is it?
Oh, absolutely not. I made that same point that the NHS has its own language and so does local government and it's very, very easy for all of us to fall into the trap of talking jargon. The NHS is probably a little worse than in local government in terms of its three letter acronyms. But part of this whole reset has to be about engaging and communicating with our residents in a way that they understand.
So, I think I'm right in saying that Surrey Heartlands started working as an integrated care system three years ago. Although your status has formally changed on the 1 July, this is a kind of smooth transition. So, I guess the first question, Tim, is what has been your experience? What have you learned from these years leading up to the point at which it all becomes legal?
So, I think the biggest thing I've learned or reinforced is that this is all about partnership working, that no organisation within the whole ecosystem can do it on its own. Some of this is about personalities, but actually if you get the structure right, you can make significant steps and improvements. So, bringing together all of the key influences and stakeholders in a room so that actually you align the agenda or get behind a vision. If you can do that, then you can really have a significant impact.
And what do you think is different this time? I remember local strategic partnerships, and that was one of many attempts really to bring together, particularly public service leaders, but also third sector, sometimes business as well. What do you think makes this different?
The recognition that the NHS has an inordinately difficult job to deliver the services that it has to deliver. We've got to move the focus, I believe, away from the acute system and more into community settings and down into prevention and early intervention. And when you start to look at that agenda, that moves you further and further away from the sort of pure NHS and down into the need for that partnership working. Certainly, post-pandemic, I think that is absolutely the case. The people now do want to make the system work better, they want to improve and have to improve people's health outcomes and that has to be done in a truly collaborative way.
And as somebody who's got a foot in two camps - in the health camp and the local government camp - what insights can you offer as to how you get local authorities and the health system to work most effectively together? What are the enablers and what are the kind of potential pitfalls that you've got to avoid?
By chairing both the health system, the ICS and leading the council, it's sort of taken away any kind of turf war, so that slightly sort of protective attitude that we probably all have around our organisations is gone. And we very early on in the setting up of the ICS made some joint appointments, genuinely joint appointments, between the ICS and the county council.
So, you then started to change the lens that people looked through. And I think that has meant that the focus of the conversations has absolutely been about the patient or the residents. It's also removed some of the perhaps contention around shared budgets. So, we have used Section 75 and the Better Care Fund really effectively.
So, I think what I have seen, and that's absolutely what I want to make sure we don't lose, is that we do have a joint focus and the same ambition. And I think that we've got to a sufficient level of maturity within Surrey Heartlands that it doesn't now need me or any single individual to sit across both systems.
I think we now have a set of people, executives, that are absolutely focused on continuing delivering that way.
One of the aspects of the system that is opaque, I think, Tim, is this what is the difference between the role of the ICB and the ICP? And I wrote about this quite a while ago and I also met officials in DHSC and it wasn't clear to me that they really understood this difference. We were talking about workforce planning and the importance of combined workforce planning for the health service, for social care, for public health.
And I said to them, look, this has got to be something that's overseen by the ICP because if you're asking for planning to cover local government, in fact there are more people I think working in social care than health, you can't do this to the health body. It's got to be done through the genuine partnership body.
And there seemed to be some confusion among officials about the status of these two bodies. So, tell me from your perspective, what you see as being the difference between the ICB and the ICP and what value added the ICP brings to the construct?
First of all, the ICSs are being set up in theory on the basis of equal partnerships. You're absolutely right, I don't think even at an official level they really understand the difference between the ICB and the ICP. We are now 14 days into the new system and yet the guidance on integrated care partnerships is yet to be produced by DHSC.
A lot of time was spent in setting up the constitutions of the ICB, but very little time and focus on the ICP. So, the way I see it is if you take the 100 per cent of the wider determinants, those things that impact on people's life expectancy. My expectation is that the integrated care board will own and oversee the 20 per cent that really relates to direct clinical interventions - the work of the acute hospitals and the work of GPs and so on.
And that I think is a very defined space, an NHS space, and it's quite right that the ICB leads on that. Whereas I see the integrated care partnership leading on the other 80 per cent of those wider determinants and that includes the quality of housing, education, the socioeconomic factors, access to green space, many of the things that local government and other partners already have responsibility for.
So for me, the ICB, very NHS orientated, but of course stretching over into those other areas as well, but less so the other way. Perhaps I can use Surrey as an example. We have a ten-year health and wellbeing strategy. Obviously the ICP in the system now has the responsibility for developing a strategy for the whole system, so to include both local government aspects and also the ICB. And we will use that existing strategy as the basis. And I see the ICP really very much as the delivery arm. That is the body that will make sure that all of the partners, whether that's the health system, local government, the voluntary, the charitable, the face sector, all the other organisations that need to come together, those will be coordinated by the ICP. And it will be the ICP that will be very visible within our communities.
So if you take, for example, an issue like mental health, it seems to me that mental health strategy in a system needs to be the responsibility of the of the partnership initially, because so many of the factors that determine mental health are outside the health service and indeed many of the ways in which we can respond to poor mental health, not possibly at the kind of most acute end, but we can respond to mental health on non-clinical interventions there around the third sector, around friendship, around employment, around support - all those kinds of things.
So, would you agree that if, for example, you were asked to produce a mental health strategy, it would start with the ICP?
Absolutely. Absolutely. And again, I would split it into two areas. So, I look at it as the ICP driving the particularly the prevention and the early intervention agenda. So, these are low level interventions often through schools. But really identifying the issues around mental health and getting on and addressing those that may be social prescribing or something like that, whereas the medicalised solution in the mental health trusts, again, I see that perhaps looking more towards the ICB as a specialist trust.
Now one of the dangers of that structure, I guess, is if you're sitting in the ICB, you're being commissioned. And I don't mean commissioned in the kind of traditional sense, but you're being kind of commissioned by the ICP in the way that you've described to look at the kind of health element of these strategies.
But at the same time, you're also being, as it were, commissioned by the centre, you're being given instructions by NHS England and by the region. Is the responsibility of reconciling local priorities and national priorities lie, do you think, with the ICP or with the ICB?
Well, I think it starts with a conversation with NHS England about the role of the centre and the role of region, because I think one of the perhaps missed opportunities with the roll out of ICSs is, first of all, to not to standardise it because there are local geographical variations and some people have one acute hospital, some have five and so on.
But I do think that I would have like to have seen sort of 80 or 90 per cent standardisation of how ICSs were set up and structured. And actually, I would have probably gone one stage further than that and created one single trust so to dismantle all of the existing individual trusts. Because if the ICB own their strategy for health delivery and the budget, there's a potential conflict of that level between the individual trusts and what the executives and the non-executives might see and who they're responsible to.
But I think we have to use this as an opportunity to stop or reduce the top-down approach of NHSE. I understand absolutely the need for data, but there’s a massive thirst for it and I'm not absolutely sure what that data is used for. At the end of the day, those ICSs locally will know their own communities, they’ll know their own systems and provided there are certain sort of metrics that they are measured against really this is an opportunity to let them get on and deliver those in a more flexible way.
And obviously, there's some movement towards reducing the size of the centre. And that is to be welcomed. But this really needs to be a bottom-up approach. This is about getting into our communities and really improving those life outcomes.
So, this conversation is really about you, but I can't resist trying out on you a couple of the ideas I've been sharing with leaders as I've been going around the country. So first, in terms of the ultimate way in which we should kind of measure the success of ICSs in terms of how they change the health service. And I've suggested that there are kind of three things that we should try to achieve kind of structurally, which we've been trying to achieve for a long time, but we haven't succeeded in.
So, the first is how do we move from a system that incentivises activity to one that incentivises outcomes? Because at the moment in the health service and this is what the internal market did to a certain extent, we incentivise people to perform processes, operations, or whatever. Ultimately what should matter to us is outcomes.
Secondly, and this may not be such an issue for you in Heartlands, because I know you’re the least deprived of the 42 ICSs. But nevertheless, how do we focus not just on expressed demand but on need? Again, the health service tends to kind of treat those people who turn up. And what we saw, of course, in covid was the importance of reaching out into communities who may not be seeking the help that they need.
And then thirdly, as you've mentioned, how do we move resources upstream out of acute and secondary and into community, primary and into prevention? Do you think those are the kind of structural changes we want to achieve over the next few years? And are you hopeful that the ICSs will be able to accomplish some of that?
Yes, absolutely. I think the outcomes your first point is absolutely crucial to this. So, I have in some of our areas in Surrey, in adjoining wards, two adjoining towns, a ten-year difference in life expectancy. That cannot be right. So, if we can understand what's causing that and it will be a combination of all sorts of factors, but if we can understand that, then we can really start to put in the right interventions and support.
So, it isn't about activity. Yes, of course there's elective surgery and that needs to happen. But that's why I think this is the opportunity to really focus on the prevention and preventative agenda and to do things soon to stop people falling into chronic conditions.
So, you're right in terms of Surrey heartlands, but we do have five areas in the county that are in the top 20 per cent areas of deprivation. It is relative. But actually, it's sometimes more acute if you are in an area of deprivation and surrounded by areas of wealth. But we have people with significant needs, so we’ve got to look at those.
During the during the pandemic, we did a lot of work in terms of the assessment of the impact of covid on our communities. And we did collect a lot of data. The national statistics are helpful at one level, but they don't really tell you what is going on down at a PCN level, which is where we need to be.
So, for me, it is moving the resources right to the other end. It is about primary care. The Fuller Stocktake, I think, absolutely encapsulates what residents want to see, which is ideally an easy access to GPs, the ability to get dental appointments and eye tests and all those sorts of things.
Those are the things that people routinely want to access, not necessarily going to A&E or into the acute system. So, I think your three things are absolutely right.
And I was intrigued by what you said about how things would be easier in a sense if there was just one trust. I spend a lot of time talking to acute leaders, and the conclusion that I've kind of reached is, I don't if you remember this a few years ago when we were talking about general elections and we used to talk about Worcester women and we talked about Worcester women because they were the key swing constituency, as it were.
If you could get Worcester women to vote for you, then you'd win the general election. And I've come to the conclusion that acute leaders are, as it were, the Worcester women of the ICS project. We in ICSs will think ICSs are working and will be committed to making them work. Other people might be for all sorts of reasons sceptical. But if acute leaders come to see ICSs as helping them, adding value, making their life easier, they'll be on our side. And no structure lasts forever but we could be here for many years and really make a difference.
If, however, acute leaders think ICSs are bureaucratic monsters, second guessing what they do, interfering with what they do, then they will be marching into the DHSC, they'll be marching into Number 10 and saying this isn't working. And I know because of my experience working for Tony Blair that acute sector leaders, politicians understand who they are. They understand what somebody who runs a hospital is. They seem like they're all impressive people. So, if we don't persuade providers, and particularly, I think acute providers, that ICSs adding value, we could be in trouble.
Do you think that's right? And how are your relations with the acute sector in Surrey Heartlands?
Well, if we don't get to the acute chief executives on side, this won't work. They will fight their corner quite rightly so, too. I've routinely heard them use the phrase patient safety as a reason why, as much as they might like to support and comply, that they can't. It's a little bit analogist in the world of local government in a two-tier local government system where you have a county council with responsibilities for adult social care and children's services and highways.
And then you have the district and borough council's that do planning and waste collection and so on, and there's a different sovereignty for those organisations, different responsibilities. But coming together and working collaboratively can extract significant benefits, both in terms of improved services, but also take out duplicated costs. For me, I think with the acute system in Surrey, we have five acute hospitals and what would be good as a starting point perhaps for that conversation is to recognise those hospitals that have particular specialisms and create sort of centres of excellence.
So, they're not all doing the same thing or having to do the same thing as a sort of district general hospital. But they specialise in areas. And I think that that would be good for recruitment and for retention. And then I think you sort of start to move the conversation into a slightly different space because at that point, they're not then feeling threatened that the ICS is going to abolish them or take them over. They’re being recognised and investing in those specialisms.
We in Surrey have had some very, very strong personalities within the acute system and have had a lot of respect for. But we have to move this conversation on. We have to really now start to look at ways in which the health system can modernise, if that's the right word. But we can't be in a situation where there is a continual need for additional funding.
We've got to address the integration of health and social care so there's an early conversation we all need to have between the social care providers and the acute hospitals around stepdown down facilities. That's got to be good to empty acute beds and also to have a centre where you can assess people properly before they're put back into a social care package.
That’s really interesting because in a sense, what I've been saying to acute leaders is that the deal here needs to be this… Acute leaders need to roll up their sleeves and help ICSs become the organisations they need them to be. And I had a great example of this a couple of weeks ago.
I was invited by an ICS chair to come into her system and there were acutes in a system that did have a collaborative. They had a committee but hadn't really done much together and levels of trust weren't that high. And I just went into facilitate a day, and that day was not really about the ICS telling them what to do, it was about the ICS convening them and encouraging them to think about what their strengths were, what their challenges were, and to get them to work more effectively together.
So, I think the chair of the ICS was saying as long as you as a collaborative are using your resources effectively, as the most effective as you can, I don't want to interfere with the day to day running of things. You'll know what's best. But what you've got to do is you've got to demonstrate to me that you're going to use resources as effectively as possible.
And I think that if we can get this right, if acute leaders can see ICSs as an enabler, and if ICSs can behave as an enabler and a convener, rather than, as it were, trying to get too much into the operational weeds, that's how it could be different. And one of the reasons I say that, Tim, is that I remember, I've only been in the Confed for a year, but I wrote a set of blogs in the RSA, which I ran before several years ago. And what I wrote about, about public service reform and about places is that we invest in bricks, but we don't invest in mortar, we invest in cogs, we don't invest in oil. That very often the problem in places in public services is the connectedness. And for me, if ICSs fundamentally saw their role as binding the system, enabling it, getting the different parts to work effectively together. We've never had really a big public body that sees itself in that role, is that naive?
I hope not because I think that's absolutely what needs to happen and what the how the ICS should be positioning itself. I'm an elected politician so I spend my day living and breathing what my residents want and every four years they test that. And everything I do has to be genuinely in the best interests of my residents.
And I think that is a test that we should all apply. So, if I'm an acute hospital chief executive, what is absolutely in the best interests of my patients? And sometimes that will be me delivering that service, sometimes it will be enabling it, but actually often it will be passing that individual or signposting them somewhere else.
So, I think if we start to lose sight of that and really start to think about our own organisation as the being rather than the patient, we get ourselves into all sorts of difficulty. And I often use that the same analogy with children's centres. In Surrey, we've moved away from having children's centres because it wasn't the building that delivered the service, it was the people within the building. And actually, taking the social workers out and putting them into the community, into people's homes, actually meant they were getting to the people that really needed it rather than those that turned up at the children's centre.
This has to be used as an opportunity to reflect as a system, can we do this better? And let's put aside our own sort of agendas and sort of protectionism and look at it through the eyes of the patient, because you know more than anybody, I'm sure you hear it every day, the sort of complaints that the patients have about navigating their way through the system. And I've had personal experience of that with my younger daughter. My wife was a GP. She was a translator for me whenever we went to see a consultant. It's a very difficult system for people to understand and find their way around. So, let’s have that conversation and let's make sure that people aren't feeling threatened, but that actually can see a way in which doing this collaboratively can be better.
My sense is that whether a system level or place level or even in particular areas of transformation that we're aiming for, that I come across the same kind of four big things each time and want to test this out with you and maybe get your reflections on how they feel from a Surrey perspective.
So, these four things are firstly kind of vision and purpose. Secondly, data, thirdly, finance. And fourthly, relationships. And so, let's start with the first. So critical to effective collaboration is to invest the time to ensure that people really do share a common vision, a common sense of purpose. Why are we doing this together? What do you see? Do you feel that there is a merging in Surrey, that strong sense of shared mission and purpose?
In 2018, we went out to all of our partners to create a collective 2030 vision for Surrey. And that vision in one line is that no one is left behind and it is addressing the inequality of life expectancy and the inequality of opportunity. And we have three priority areas through the Health and Wellbeing Board around addressing mental health, physical health and opportunity.
And I've created in Surrey, a forum for all of the system leaders. That’s the police, the universities, the BCFS, health. And we come together on a quarterly basis, and we constantly test that vision. Is that still the right thing? So yes, I think in Surrey we do have a system that is absolutely behind that. And tests and measures, whether it's actually delivering it.
So that's the first thing is vision and that big vision. But also, what are the kind of priorities that you share. I know, and it's not surprising given that Claire Fuller is your chief executive, that primary reform is one of your big priorities. So, this is the first thing is shared vision, shared priorities.
The second is data. And for me, data is the great enabler. You talked earlier about feeling that sometimes NHSE require you to generate data for the sake of it, but I'm talking here about data is a real enabling tool, partly in terms of understanding what's going on in the health service and flows of patients, etc., but also in terms of population health, the scope to share data between local government health service and other partners as part of that project of trying to intervene further upstream.
You cannot run any business without data, without understanding what is going on within the business. Again, we’ve set up the Surrey Office of Data Analytics. It's chaired by the chief constable of Surrey and that is creating effectively a data warehouse with NHS data, with local government, with the police. But we've also got involved with the University of Surrey, and in particular their analytics team, but also their sociologists. Because if you're looking at a community, it is all about people and people's behaviour. So, understanding that and what drives people and motivates people actually can be really useful information when you are working out what interventions would be helpful. So, you can’t do this without good quality data.
And then finance, which feels to me as though it's more often on the kind of negative side of the ledger than the positive side. And not just because often there isn't enough money, but I mean that financial incentives can often feel like they contradict the objectives of collaboration.
We talk to people and say, why are you not collaborating, integrating? And the say that's not the way that the money incentivises our behaviour. So, making sure the financial system incentivises people to collaborate, that's another really critical component, isn't it?
It is. I've lived in a world of local government for the last 20 years. Every year, our funding from government reduces, but we're still expected to deliver the same services, the same level of services for our residents. I do wonder sometimes actually if there were the same discipline within the NHS, if there was a defined budget at the start of the year and you have to deliver within it.
Some would say, well, that's impossible because it's a demand-led service, but so is adult social care and so is children's services, for those with a child with additional needs. The budget for the Surrey County Council is £1.5 billion and the budget for Surrey Heartlands is £1.5 billion. So, we have exactly the same the exactly the same issues.
So, it is important that people understand how the finances work, how you can take out costs and that may well be coming together around shared back-office services. But equally now, again, which is why the collaboration between the system is so important. We can make that public pound go so much further through the Better Care Fund, through Section 75 agreements.
Stop duplicating effort and really focus on how you how you use that money effectively. So, I think, the structure of the financing of the NHS is very different from local government and I think probably there are some things it could learn from the way in which local governments operate their budgets.
And then that takes me to the final kind of dimension, which is relationships. And I don't just feel this about ICSs, I’ve felt this for many, many years, that often we try to build collaborative bricks using relational straw that we expect people to trust each other, to be generous to each other, to take risks together.
But we don't actually invest the time in ensuring that people really have got that kind of quality of relationship. And this event I did a couple of weeks ago for the ICS chair, I spent quite a lot of time in that event just enabling the people there to have quite a deep personal conversation with each other, to get to the point at which they felt like they were the people who were part of the same team.
Do you agree that we are going to have to have really strong relationships if we are going to make this collaboration work, aren’t we?
Without question. And I think the really interesting thing sort of post-covid is we all got used to remote working and Teams meetings and so on. And at a level, those were absolutely fine. It kept everything going and was essential. But you don’t build, couldn't build, those relationships, those personal relationships.
And within Heartlands and within the county council, we regularly have awaydays, we find time to sit down and whether it's having a quick bite to eat or something. But just to get it away from that transactional relationship to really knowing a little bit about that other person and what motivates them and so on. That is what then makes the wheels turn more easily and faster.
So, I think you can't run these organisations digitally. People are hugely important within the system and finding ways that people can work together, trust each other, definitely delivers a much better outcome.
Well, Tim, it's been great talking with you. I know that our paths will cross often at ICS network events, but it will be great to get you back on to Health on the Line in about 18 months or something and see how things are working out. But until then, thank you for joining me and good luck.
Matthew, thank you very much.
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