Prof Sir Chris Ham: We need a culture of commitment to improvement, not compliance

Prof Sir Chris Ham on system improvement, good practice and shifting the dial on health outcomes.

21 November 2023

The NHS has renewed its focus on improvement, with integrated care systems charged with becoming ‘self-improving systems’ across England. While a necessary challenge, no other country in the world has undertaken improvement at this scale. In this episode, Matthew Taylor sits down with Prof Sir Chris Ham to unpack the system model of improvement – what it means, where it is working well and how it can shift the dial. It draws out key lessons from Sir Chris’ report, commissioned by the NHS Confederation, Health Foundation and Q community, on how to improve health and care at scale

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Health on the Line

Our podcast 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

    Hello and welcome to the latest edition of Health on the Line.

    Now this is an edition I’ve been looking forward to for some time because I'm going to be talking to a friend of the Confederation, Sir Chris Ham, the health policy academic, one of our most, I think, influential high-profile health advisers, he’s had a number of roles: chief executive of the King's Fund, professor of health policy and management at University of Birmingham's Health Service Management Centre, co-chair of the NHS Assembly. 

    Now, Chris wrote a report for us, I think it was a couple of years ago on the future of the centre in a world of systems. I think was a really influential piece of work. So when we wanted to explore improvement in systems, what does the idea of improvement mean as a kind of system level, well there was no one better that we could turn to than you Chris. 

    So that's what we're going to be talking about, that report. So, so welcome, Chris. How are you? 

    Sir Chris Ham

    I'm very good, thank you, Matthew, and thanks for asking me. 

    Matthew Taylor

    So this report: Improving Health and Care at Scale: the Role of Systems, which has been jointly sponsored by us at the Confederation and the Q community at the Health Foundation. Let's start with the basics. What for you is the aim of the report Chris? 

    Sir Chris Ham

    The aim of the report is to take the ambition that integrated care systems should become self-improving systems by having the capability to innovate and to improve care delivery, indeed improve health outcomes, and to rely less therefore on central direction and regulation and all the other levers mechanisms that we are familiar with.

    So, I was asked by the Confed and by the Health Foundation jointly to do a quick study looking at how some integrated care systems are going about that ambition. How are they trying to deliver improvement in their systems with their partners, and to interview system leaders to review their plans and their documentation and to really form a view on the basis of that in these very early days for ICSs as statutory bodies. 

    What progress is being made? How optimistic can we be that they can deliver on this ambition? And what concrete examples are there of where that's already beginning to happen? So I got a lot of energy out of doing this work because I had the opportunity of speaking to about 40 leaders in eight systems up and down the country identified by people who are close to ICSs and to the improvement movement as being at the forefront of this work.

    And what my report does is to bring together those findings, then draws out from that empirical evidence what some of the lessons might be in taking this forward. And perhaps the last thing to say by way of introduction, Matthew, in the context now, and it wasn't the case at the beginning, of Amanda Picard's initiatives through NHS impact to make the NHS in England continuously improving and learning system within which ICSs clearly have a major part to play.

    Matthew Taylor

    And I want to get into some of that good practice in a moment, Chris. But just to kind of step back, because you wrote that report for us a couple of years ago on the role of the centre in a world of systems because of the Hewitt review, because of many things you've written over the years and to a much lesser extent, some things that I've written, it can sometimes be perceived that this attempt to get systems to ‘do more’ as it were, is a kind of a zero-sum where we're kind of arguing, well, systems should do more, so the centre does less. But I think it's important to say that what underlies this - or certainly from my perspective ultimately - is a view of what it is that makes systems broadly - and I'm talking about the NHS as a system now - dynamic. 

    And for me the evidence suggests that what creates dynamic self-improving systems is ones that both articulate and align and balance top-down pressures for improvement, which are important and necessary, which is to do with kind of strategy and accountability, resource allocation; lateral drivers, which is to do with peer learning, challenge and support, professionalism and culture, shared values; and bottom up drivers, which are to do with responsiveness to patient choice and preferences, community engagement, etc. That's what creates that dynamic system.

    And we're on the 75th birthday of the NHS, of course. The major think tanks, including the King's Fund that you used to run, came together and said one of the big problems, the NHS is kind of centralised political short-termism. So I think it's important to say that in writing a report like this, ultimately, what underlies it is a kind of vision of what ultimately creates a kind of overall dynamic improvement system. 

    Sir Chris Ham

    That’s exactly right and it’s not zero-sum, it’s not either/or. Clearly, within a national service, which is funded through taxation, where there’s accountability to parliament, we should expect or welcome some central clarity about the purpose of the NHS, its priorities and how it should move forward. But in a very large, complex adaptive system to use that language that the NHS undoubtedly is - there are limits to central direction and indeed there are limits to regulation through CQC and other bodies. What we need – and what you see in high performing health care systems around the world – is a culture of commitment to innovation and improvement, not a culture of compliance with targets and standards set by others. 

    So all of the elements that you’ve mentioned are important, but it’s how you can calibrate and assess the balance between them, and the view I take and I think widely shared by others, is that now is the time to give more emphasis to these bottom-up and the lateral drivers for improvement you’ve alluded to, including a greater focus on peer-to-peer collaboration, peer-to-peer support. And one of the things I do in my report is to draw on the experience in local government of sector-led improvement, which seems to serve local government pretty well. And there’s a direct read-across into what ICSs are now doing.

    So it’s a complex picture we’re looking at and your question very much alludes to that. But absolutely, you’re right, it’s not either/or. It’s how we combine these different elements and do so differently in future than has been the case certainly in the recent past. 

    Matthew Taylor

    And one of the things I thought was interesting in the report, Chris, is that on the one hand you encourage us to learn from good practice in other places, whether it's the kind of consistent, pretty long-term approach they've had to improvement in Scotland or to New Zealand or to the Veterans Association in America.

    And you point out that none of these examples are perfect and none of them necessarily succeed forever, but they're important things to learn. But you also want to emphasise that we shouldn't have an inferiority complex in the NHS, because arguably the NHS on the one hand has been thinking about this question of systematic improvement for, you know, a long time in comparison to other systems and its capacity, its potential as a national service to be oriented to improvement is enormous.

    That's absolutely true. It’s a kind of good news/bad news point here in response to that question, Matthew. So the good news is that the NHS has been working to develop its capabilities to innovate and improve for over 20 years now. I worked in the Department of Health in the strategy unit when the money was flowing and the then Labour government, when the modernisation agency was the national body responsible for leading improvement work, when over time an increasing number of NHS trusts and other organisations drew on support from the Institute for health care improvements in the states or from European examples like Yolshipin County Council in Sweden to emulate what the best organisations around the world are doing to create that focus for self-improvement. 

    So we've got a lot of experience on which to draw. Not all of which, by the way, is positive, because I know there were high hopes for the modernisation agency when it was set up, but actually it was given too many responsibilities. It took on too many programs of work, and that often meant it was confusing for those on the receiving end in the NHS, in trusts at the frontline, to really focus where they could make a difference. It also had the effect of taking some of the most skilled people in terms of improvement, understanding and capability away from the frontline into these national roles and therefore it depleted and downgraded of the capability in the NHS itself.

    So we need to hear these warning signs, but that's the good news. The bad news is the ambition that's being set is huge and I don't want to criticise that at all, but at no country in the world - can I be blunt about this - has done anything like what NHS England is now attempting to do. No country in the world has done improvement at the scale of a population of 50 million plus across very many organisations in a very complex and very challenged environment.

    Scotland has done very good work through Healthcare Improvement Scotland, and I provide a summary of its work in my report so we can learn hugely from that. But Scotland is a 10th of the size in terms of population of England, and therefore we've got to do even more and more effectively over time to emulate what the best systems and the best organisations in the world have done.

    But it can be done. I think we need optimism, we need hope, we need belief. And I'm encouraged that the people I've been speaking to in ICSs absolutely exhibit that. And can I say too that the eight systems that I've focused on have been really, really resourceful so far, even in the absence of a national drive in this area to draw on all the resources in the organisations that make up those systems, to bring in outside help where that's relevant, and to make the most of the inheritance that they had when they took on their statutory roles.

    So there are reasons to be cheerful here, even in the conditions we find ourselves. 

    Matthew Taylor

    So, Chris, I should have probably prepared you for this question, but I'm going to ask you to pick two or three examples. You know, the core of the report and one of the reasons it's so rich is these eight case studies of things that systems are doing.

    So I'm going to ask you to choose one from amongst the kind of largest ICSs, one from the kind of medium-sized group and then one from the smaller one system type systems. And just to pick out a couple of features of those case studies. So let's start with the kind of largest the larger systems, London and the north east, choose one of those and tell us a bit what interested you in that case study? 

    Sir Chris Ham

    Well, this is invidious, isn't it? Because they all have wonderful examples to offer about the work they've been doing. And I think this is the nub of what I've been fascinated by so far that you asked me to do is move beyond the theory of improvement to the practice of improvement and to give these concrete examples.

    So, let me give you three which stand out for me. Up in the north of England, I actually had three of my eight were in the North; Lancashire, South Cumbria, North East and North Cumbria and West Yorkshire. If I talk about West Yorkshire, then - two aspects of that. 

    First of all, the provider collaborative. The West Yorkshire Association of Acute Hospitals, which has been in existence now since 2016. So it predates the ICS, set up by Rob Webster and Julian Hartley when he was a chief exec in Leeds Teaching Hospital Trust.

    And that's a very well-established, mature provider, collaborative, working very closely with the integrated care board on a variety of issues to do with improvement in acute hospital services, particularly where that requires working at scale rather than working in the individual NHS trusts. 

    And also in West Yorkshire, there is a strong emphasis on place. There are five places and five place-based partnerships, and I interviewed colleagues in Wakefield, which is one of those five.

    Joe Webster is the lead of the Wakefield place. She has a variety of roles. She's an ICB leader. She has a role within the local authority - Wakefield Council - and she also has a major role within West Yorkshire NHS Trust. And I think Wakefield illustrates how a lot of improvement work needs to take place at place, at those units within systems where there's an identifiable community, a link between local government, the NHS organisations and the voluntary and community sector.

    What they've done is to analyse data - and data analysis is at the heart of improvement - to identify a cohort of people who are high-intensity users of local acute hospital services, and then to find better ways of meeting their needs by the partnership with the local authority. So to reduce pressures and demand on the acute hospital by providing alternatives, which are more effective and more cost-effective.

    And they've been able to take out acute beds. They got some buffer, some spare capacity as they approach winter and Len Richards - who’s the chief exec of the trust in Wakefield - was incredibly positive about that use of data, identifying those high-intensity users and being able therefore to bring about concrete improvements for the local population. 

    At the other end of the scale. My second example briefly comes from Lancashire and South Cumbria. Andy Knox is a local GP who is also working as one of the associate medical directors for the integrated care board, is working with all of the PCN directors in Lancashire and South Cumbria with a focus on inequalities in health in their communities. And of course each community is different, so they've chosen what those priorities should be.

    But they're working as a network - a PCN improvement network - facilitated by Andy Knox and his colleagues, and they're also investing in the development of leaders in those networks, including, not just the PCNs, but a variety of other partners too. And every PCN in Lancashire and South Cumbria has chosen its own priority for reducing inequalities in health through that partnership working.

    My third example is rather different, and I think it's interesting. It's to do in the south of England with the work on a shared care record in Thames Valley and Surrey. Now this is interesting because it's a collaboration between three systems going back to 2018, again pre-dating ICSs being statutory bodies. And the aim is twofold; is to make data from different sources - GPs, hospitals and so on - readily available wherever a person, a patient happens to access those services. But secondly, and really importantly, which you can do that, you can use that data to improve population health management. You can compare GP practices, for example, around how well they're managing high blood pressure in their patient communities. You can look at the variability of that and then you can enable the high performing practices to support the less well performing practices to improve.

    And data again, is at the heart of what they're doing. 

    So those are three examples. But in the report there are very many more at all levels. And I think the general point here, Matthew, is the role not just of the system leaders, but of the place leaders, the PCN leaders down at that neighbourhood level. And given that many of the ambitions for improvement relate to population health - not just care delivery - local authorities have a vital role to play and already are playing that role in most of these systems.

    Matthew Taylor

    Thanks, Chris. And as you say, the report is full of fascinating examples. You spoke at the beginning about NHS England's NHS Impact programme, which as you say, has been championed personally by Amanda Pritchard. When I look at the NHS impact material and have spoken to the NHS impact team, it does seem at this stage more focused on a kind of organisational model of improvement rather than a system model of improvement.

    So let's just explore this question. What do you think is different about thinking about improvement in a system context as distinct from organisational context, which has tended to be the way in which we've approached it over recent decades, and arguably the way we're still primarily describing it from a kind of NHS England perspective. 

    Sir Chris Ham

    I agree with you. I think that is the focus of NHS impact on trusts, in particular. Nothing wrong with that in that; most patients have contact with trusts and they expect to get high quality care and we need trust to continue the journey they've been on, embracing improvement approaches and doing more and doing it more effectively. It's different from working on improvement at a system level really because of scale. The big systems in the north of England, for example, typically cover populations of around 3 to 4 million, have very many NHS organisations and an even larger number of local government and voluntary community sector partners within those systems, which is why, of course, in doing improvement work, they're also breaking it down into the places that make up those systems and the neighbourhoods that make up those places. So it's scale, it's complexity, it's a number of organisations on the improvement pitch that you need to work with and to make sure that you are all working to a similar vision and similar objectives and doing the best you can to share the expertise and capabilities that exist. All of the systems, whether big or small, that I focused on, have been concentrating on developing, learning and improvement communities.

    These are virtual communities drawn from the improvement experts within organisations in those systems, working together to ensure there is a degree of collaboration. And that improvement expertise isn't just concentrated where it always has been - often in the large NHS trusts - it's made more equitably available to organisations, including in primary care, community services, mental health and the voluntary sector, that haven’t benefited in the same way.

    The other thing I'd say about what's different, and I was really struck by this in talking to system leaders, their ambitions are very much focused on population health improvement as well as care delivery. So I give you Dorsa as an example here. The big objectives they're aiming for are improving the lives of 100,000 people impacted by poor mental health, saving 55,000 children from being overweight by 2040, and reducing the gap in healthy life expectancy for the most deprived populations by 2043.

    Big, bold, hairy population health ambitions that cannot be delivered by the NHS on its own, but which requires that collaboration partnership with local government, the voluntary community sector and with others. Just to finish this point, Sam Allen up in North East and North Cumbria, the ICB chief executive, she made a powerful point to me and said: look, in the North East and North Cumbria, we have a long tradition of providing good, if not excellent quality of health care delivery as assessed by the CQC and others. But we also have a population in poor health with widespread health inequalities. The role of the ICB and its partners is to support the continued delivery of that high-quality care which is in the hands of the NHS organisations, the trusts at the forefront of that. But to go well beyond it through these wider partnerships are what's really important, and that's about improving health outcomes and reducing disparities in those health outcomes. And that can only be done at scale or a place by the system.

    Matthew Taylor

    Thanks, Chris. So I want to use the final part of our conversation to go into this kind of question of: “What do we mean about improvement?” or “What do we mean by improvement at system level?” And how is it how is it different? And I want to kind of approach this from three perspectives into three elements which I recurrently see as I speak to system leaders, but also speak to trust leaders who are very involved in system conversations.

    So I guess the first is this question of kind of value added, which is that, you know, when you're an organisational leader, you know, you've been an organisational leader. I'm an organisational leader. In a sense, the kind of value-added proposition is relatively straightforward. You know, we're just going to become better organisations. We're going to achieve more in whatever is our chosen kind of domains of success are.

    But I think for systems it's quite different. Because systems are so different in their size and their scale, there's a question of what is their value-added proposition? But in a sense, systems have both got the challenge, but in a sense the opportunity of choosing themselves to define how it is they are going to add value, working with the partners within their system.

    Was that an aspect that you saw as you went around speaking to systems, Chris? That they had a quite a different account of how they thought they were going to make a difference. 

    Sir Chris Ham

    Absolutely. And I think all system leaders I spoke to were clear that they were not trying to, if you like, ignore what's been done in the past. They were building on the inheritance, the legacies of the organisations that make up their systems. They were being respectful of those legacies. So, none of them were trying to impose a single methodology for improvement in place of the multiple methodologies that already exist. 

    The added value was to act as a convener, to act as a facilitator, to be an enabler, not directing, but really making the most of all the resources and the expertise that exists.

    And if you like, making the sum greater than the individual parts, rather than the other way round. And that requires a different set of leadership skills of those that traditionally we've had in the NHS in the past. It needs those system leaders to be very skilful in deciding what to do themselves and how they can best support all the other people they're working with to perform to the best of their abilities.

    So I think that's the added value in part. The other added value is reaching the parts of health and care that haven't been reached previously by the investment in improvement capabilities and skills through the Q community and elsewhere. And I highlight again here that particularly applies to improvements in health outcomes for the population and tackling inequalities in health outcomes.

    And one of the fascinating things for me, one of the points of learning is that there is a toolbox, isn’t there, around improvement: Plan - Do - Study - Act, using data. One hundred and one other things come out from the IHI and other internationally recognised experts in improvement methodologies. 

    When it comes to, for example, the ambitions in Dorset, I mentioned - reducing disparities in healthy life expectancy over the next 25 years - it's not at all clear that that well-established toolbox will work. And I think what I’ve be picking up in the case studies is a great interest in using community development, with leaders going out into their communities, partnering with the voluntary sector, listening to what matters to the people they're serving, and using all the assets. 

    Asset-based community development, as we saw in the Wigan deal, for example, as you see in the work of people like Cormac Russell and the important contribution that he and others have made. So, I think this is relatively new territory and I'm excited to do more in this area to really produce some case studies and examples. 

    And this is what Andy Knox, the example I gave earlier on in Lancashire in South Cumbria, is doing with the PCN leads and other PCNs in other systems are doing other versions of that where it's the community that's the focus of what they're doing, it’s the complexity of working with communities and it's drawing on assets of different kinds over a long period of time to make measurable progress. 

    Matthew Taylor

    Now that's fascinating, Chris. And of course we at the Confed hosted a place leaders forum, which is interesting because many place leaders are actually from local government rather than the health service. And they often talk in these terms. And we're also developing our work at neighbourhood level, thinking about the future of primary care in particular.

    And again, I think the model of neighbourhood is very much a kind of community engagement model, or at least I think it should be. I mean, part of this value added question, Chris, is around challenge and support, isn't it? I think it's a kind of truism that the kind of deep culture that drives improvement is a culture that is characterised by this balance of challenge and support.

    And that's an issue for systems because on the one hand they do need to challenge their providers and partners and they'll be expected to do that if things go wrong, they are there to challenge their providers, whether it's in terms of performance or finance or whatever. But also generally they want to convene and they want to support and encourage their providers and partners to succeed.

    But that's quite a difficult balance, isn't it? The fact that you're sometimes going to be the kind of policeman and you're sometimes going to be the mentor and supporter?

    Sir Chris Ham

    It is a difficult balance, but there are ways in which you can find progress, make progress. For example, drawing on all these peer-to-peer approaches, which are very well established in local government. And I've heard a number of cases in the eight systems that I've been looking at where that's already paying off up again in the North East, North Cumbria, identifying variations between different parts of that system in, for example, ambulance waiting times outside A&E in the last winter and then the system facilitating those places that aren’t doing so well to come together with those that are doing better in this spirit of learning from each other, and drawing on those internal success stories to help, if you like, even up and strengthen overall performance.

    And that doesn't have to be done in a challenging way, which is being difficult to the organisations that are struggling. Because what I think Sam Allen and her colleagues there said to me is that even in challenged places or challenged organisations, there are examples of good practice. 

    The philosophy they talked about was all teach, all learn and be respectful, that where there are difficulties, there are also examples of good practice. It's back to being a skilful system leader, understanding what different levers you have available to you and developing the relationships which are at the heart of all of this, that enable you to have those difficult conversations, those challenging discussions alongside being supported and facilitating the wider sharing so the whole system improves, not just the individual parts.

    Matthew Taylor

    And another dimension of that, Chris, is the short-term/long-term challenge, which I hear every time I talk to system leaders, which is that system leaders have a genuinely have a transformative vision. They absolutely get that, in quite fundamental ways we are not going to achieve the health outcomes we want to achieve without pretty profound changes in the way in which we think about health.

    So, I'm not going to ask you to comment on this, but, you know, I remember one system leader saying: look, we've got to move from funding organisations to funding pathways and people and we've got to move from incentivising activity to for incentivising outcomes. Now that's a huge transformative kind of shift. But yet, what our system leaders are thinking about right now? Well they're thinking about how they reduce their head count, they're thinking about how they get through winter, they're thinking about the pressure on them to deliver on the elective recovery. 

    So it seems to me this is a second big dimension for system leaders and probably, again, slightly different from organisational leaders, which is how do we answer these short term, deal with these short-term pressures and in ways that align with a really pretty radically different long-term vision?

    Sir Chris Ham

    It's another of the generalities which your earlier question alluded to, isn't it? It can't be either/or. We can't ignore the short term, particularly in the next year or so, given the politics around the general election and the pressures on the NHS. But we equally need to keep in focus the longer term, those population health ambitions and goals and the new service models which are at the heart of innovation and improvement.

    Putting it simply, I think we need ambidextrous leadership. People in different roles, not just the system leaders, but organisational and public sector more generally, who get that, who understand the complexity, and they've live with that complexity over many years in their working careers. So they are attending to delivering on the must-dos in the here and now, but they're also creating time and space for working on the longer term questions.

    I had a fascinating conversation with Kevin McGee, who’s just left the Lancashire and South Cumbria system as chief exec of Lancashire Teaching Hospitals Trust, a great leader committed to improvement, with a track record of delivering in the Lancashire system, and a loss to the NHS, since he's decided to head off to pastures new. 

    But he was saying: look, we are very challenged financially in Lancashire and South Cumbria. We're all working our socks off to get back into financial balance as best we can, but we can't let the short-term measures part of that, crowd out the investment we're also making on the longer-term improvements. 

    So I think at all levels we need to be ambidextrous in that way and there's no simple solution. It's about the hard yards of improvement, long term and short term combined.

    Matthew Taylor

    Yeah, we're going to have to line up our metaphors here. You talk about ambidextrous. I always talk about split-screen thinking, which is have you short-term screen and your long-term screen and you need to kind of try to make sure that what you do in the short-term screen aligns with what's in your long-term screen. But maybe we can be pluralistic about that. 

    So, Chris, let me just look at a final dimension of what I think is very different about system leadership, and that's collaboration. And the point someone made that I thought was really interesting, and said when the NHS introduced competition, the government I was part of, the Blair government - an enormous amount of money, consultancy time expertise was put into making competition work, you know, hundreds of millions, billions of pounds was put into making competition work.

    We've now moved to a collaborative way of working and we know that collaboration is difficult. It's challenging. One of the things I often say to people about collaboration is that for collaboration to be real, it implies that I will sacrifice my interests and my organisation's interests in pursuit of a collective sense of what is necessary.

    Now, that's the kind of level of generosity and self-sacrifice I normally only make in relation to my family and good friends. So if you're going to do that in a system, if you're going to be willing ultimately on occasion to put the collective interest first, it's a big ask. But yeah, I think sometimes we just thrust people together and expect them to collaborate without doing the kind of investment of time, the development of process that is necessary to make collaboration real.

    Would you would you agree with that Chris? 

    Sir Chris Ham

    Absolutely. I think it was Rob Webster who once famously said: if you think competition is hard, you should try collaboration. And he’s right isn’t he? 

    At one of the roundtables that we held, you might remember during the work I'd just done for you and the Q community, one of the participants said: the enduring challenge we face here is that when people come to partnership meetings, it's the club and country challenge.

    They're coming representing their organisation that every person who comes is also part of that system. They play for their country as well. And I first heard the Club and Country Challenge mentioned in about 2017, a year after STPs were set up as informal voluntary partnerships, and I keep on hearing it today. So there's a message there. We’ve still got work to do through helping people to recognise the duality of the roles that they perform.

    I think the best systems have understood that for some time. So there may not have been the national programmes to support the development of collaboration system leadership, but certainly there's been the local commitment through local organisation development programmes, local system leadership programmes. So, the work that Claire Fuller did in Surrey around developing system leaders; the work I've heard about in some of the other systems now emulating that in different ways. And whereas the initial focus might have been on clinicians, increasingly it's more broadly multi-professional and multi-organisational based. 

    So I'm encouraged by the fact that at a local level, in systems where it matters, there is that investment being made in organisational development, building the relationships, building the trust, building the understanding. And there's that I love that phrase, that single currency isn't there, that progress in collaboration occurs at the speed of trust.

    And trust isn't about flicking a switch to go from one mode to another. It's about helping people to get to know each other, to like each other, to understand the pressures they're under, to have the difficult conversations that surface, the complex and the tensions, because that's very real too. But if you can make that investment over time, then I think you can begin to move in the right direction.

    But I recognise absolutely that is the core club-and-country challenge that we're all trying to address. 

    Matthew Taylor

    And Chris, that leads me to a final question, which I'll need to be the final question, because a lot of hammering is taking place in the background of where I am. But this report aims to be very practical. It's a piece of work to support the partnership between the Confed and the Q network in its offer to systems.

    The report ends up with some thoughts about what does that offer needs to be so that systems really feel it's useful to them in the face of the challenges they've got. So what is your advice to us and the Q network as we develop that offer that we want to make to systems? 

    Sir Chris Ham

    My advice is: let’s recognise all the expertise that there is currently. The Q community is a well-established example of that, bringing together many hundreds of people from different parts of the country, and we can build on that. The Health Foundation has developed a treasure trove of reports, resources, case studies of improvement work. Not so much related to ICSs is but pre-dating. And we need to make that easily accessible to people who are now doing the improvement work. 

    The Confed through its networks of ICS leaders and ICB leaders and ICPs, the wider partnerships, is playing a vital role in that too, is bringing in that peer-to-peer learning approach from local government to support that activity. I heard an example from Gloucestershire, one of the smaller systems in my study, where they've done that around their clinical leadership, with success. 

    And I keep on coming back - sorry to be repetitive here - to it is very much about the leadership you need, the leadership behaviours and styles differ from typically what we've had in the NHS in the past. So I really encourage the Confed with the Health Foundation to continue in that vein and to provide the training and support for system leaders now and in the future at all levels - neighbourhood, place and ICB.

    Matthew Taylor

    Well, thanks, Chris. It's a fantastic piece of work. Thanks for doing the work and thanks for joining me on Health on the Line. 

    Sir Chris Ham

    My pleasure.