Our challenges as a health system are the same as everyone else's. Workforce is our top priority – we have a very high elderly population (well over national benchmarks) and we’re under national benchmarks on the available workforce. Our providers have been recruiting from Portugal, Spain, Ireland, Italy, the Philippines and Dubai.
Finances are another major challenge – we're doing better than most areas, but our providers have been in overall deficit. We're totally reliant on our providers earning the sustainability and transformation fund to keep things manageable money-wise.
With regards to quality, until recently all our providers were CQC-rated as 'require improvement'. Three of them have recently been rated 'good', which is very positive news.
Coming together as a health system has been rewarding. It's pleasing to see organisations within our health economy acknowledge that they can't solve these problems on their own. That approach has been tried and tested and it leads to a degree of in-fighting.
"Coming together as a health system has been rewarding. It's pleasing to see organisations within our health economy acknowledge that they can't solve these problems on their own."Chief officer
Dorset's 'can we do this together?' mindset and approach predates by some time the advent of STPs and the move to ICSs.
By bringing all the local players together, as the CCG we can give a strong steer. We have collectively set our system up as an ICS.
Our priorities are:
- prevention at scale: helping people to stay healthy and avoid getting unwell
- integrated community services: supporting individuals who are unwell by providing high-quality care at home and in community settings
- one acute network: helping those who need the most specialist health and care support through a single acute care system for Dorset
- leading and working differently: giving the health and care workforce the skills and expertise needed to deliver new models of care in an integrated system
- digitally-enabled Dorset: increasing the use of technology in the health and care system to support new approaches to service delivery.
Our work as a system is most advanced in tackling the financial challenge. We agreed to work as one finance system and stop focusing on payment by results (PbR). Our aim is to get each organisation to hit its own control total, but more importantly to ensure that we can hit our overall system control total, combining all providers and the commissioner. We monitor the Dorset system, coming together as group of finance directors and chief executives. The approach we take is 'this is Dorset's system wide finance number: are we delivering individually and collectively and is there more we can do to help across the system?'.
It took a lot of background work to get to a system-wide approach to the finances. We agreed in 2017/18 we would have flat cash across providers, then a 1% increase for 2019/20.
At the end of 2017/18 we moved money between organisations to hit all the individual control totals, we wanted to get everyone over the line and hit their numbers. This would never have happened without our journey to see ourselves as a system. To work as one on finance is just a huge step to take.
"It took a lot of background work to get to a system-wide approach to the finances. We agreed in 2017/18 we would have flat cash across providers, then a 1% increase for 2019/20."Chief officer
We're now trying to repeat that across the workforce, and are implementing a 'Dorset passport' approach, so that staff can move freely between any organisation. Our recruitment campaigns will start promoting working in the NHS in Dorset, as opposed to individual organisations. We recruit to the county, and then agree with staff where they will work.
We hope this will allow for easier change in the workforce, so a career is not just in an acute setting, for example, but mixed with working in the community – and clearly not so organisation-specific.
Ours is an all foundation trust provider economy, and there are all foundation trust communities around us on all our borders. This is important because of the tensions with 2012 and 2003 legislation.
The whole NHS system is not set up to work as a system. Every foundation trust has its own board, governors and members. Regulators assess providers as individual organisations.
We try to communicate that we understand why they do as a regulator, but a person will not just receive services from one provider organisation. Their main contact will be with their local primary and community services, be it their GP, pharmacists or community teams. If they have acute care, it'll be for a short spell and then they go back into the community.
As a system, we're trying to create that 'whole life story', not just focus on one organisation's bit. Our providers are keen to be involved in that conversation for the benefit of the whole system and it must be better for individual patients.
"The whole NHS system is not set up to work as a system. Every foundation trust has its own board, governors and members. Regulators assess providers as individual organisations."Chief officer
We are aware this goes against some of the legislation and it's taken quite a brave move from NHS England and NHS Improvement to give us permission to be flexible and to encourage our system approach with flexibility on PbR and system wide performance targets. Their view was that if we all agreed to work differently (which we did), we didn't need to hide behind the 2012 Act, as there are enough flexibilities to work as a system and still meet individual requirements.
At some point, this work will require some legislative changes to progress. Our ICS coalition functions on the basis of providers, commissioners and the local authority all agreeing to work together.
Local authority and public health perspectives
We have three top tier local authorities in Dorset. When public health transferred to them after the 2012 Act, we managed to keep the staff who moved over from the primary care trust together as one team hosted by one local authority, but working out of all three. That was helpful to keep the consistency and critical mass for constant public health messages.
Those staff act as NHS-local authority 'go-betweens' as they understand both sides' issues,and that's been a useful conduit for conversations. Our local authorities are keen to look at the wider determinants of health through the health and wellbeing boards (HWBs) – something that has a really strong emphasis in our STP.
We want to focus more on employment, housing, open spaces, education, travel and transport. That is our foundation for our people's future health. Our STP restarted local authority engagement, as things had become quite clinically driven. Developing the STP reignited an opportunity to collaborate more effectively with our local authorities and public health. The police and fire service also sit on our HWB. We're doing as much as we can to get that population view.
We now work more closely with the local authorities than we have done for a number of years. The local authority is core to our ICS leadership meetings. We meet with portfolio holders and council leaders and it's important to get their political support and buy-in. It does now feel that this is a Dorset system.
"We want to focus more on employment, housing, open spaces, education, travel and transport. That is our foundation for our people’s future health."Chief officer
Public engagement and social media
We started with a public opinion survey with our local authorities across Dorset – 'The Big Ask' – to find out what they thought of services. That was five years ago and set the landscape.
Then came our clinical service review, predominantly focused on how best to organise health services. Throughout this review, we held numerous public engagement events and publications supported by traditional media and social media. We wanted this to be very open and transparent and we put everything online (recorded events and plans).
The formal consultation ended in February 2017, and while it ran, awareness about the NHS review and proposals for changes to acute, community and mental health services was very high in Dorset. We dealt with petitions, marches and demonstrations, as our plans were fairly bold. Even now, we are awaiting the judgement to a judicial review which was heard in July.
Much of the commentary about accountable/integrated care seems to focus on a fear that it means bringing in a health insurance system or is a prelude to privatisation. This fear is still prevalent on social media, especially Facebook.
Equally, we used social media to promote our actual plans which was a huge opportunity to share these with people who would not have seen them previously. Even though we did numerous drop-in and pop up events and printed hard copies, the real public momentum was through social media.
We also used paid-for advertising to take people to our website and over 50,000 people clicked through this link. It was a really cost-effective way to target the demographic that we wanted to reach, and meant that they looked at our proposals. Social media is useful, but its power cuts both ways – there's a lot of misinformation posted as well.
Read our third edition of Provider Voices which explores the journey of integrated care.