Marie Gabriel

With over 14 years of NHS board experience, Marie is currently the chairperson of East London NHS Foundation Trust (ELFT), an ‘outstanding’ provider of mental health and community health services in London, Bedfordshire and Luton. Recognised nationally for staff engagement, internationally for quality improvement, ELFT is working with NHS Improvement and The King’s Fund to support inclusive cultures. A member of the workforce race equality standard advisory group and chair of the London mental health trust chairs group, Marie’s contribution was recognised through her incorporation on the inaugural HSJ Inspirational Women list.

 

We work with multiple commissioners and across the mental health and community sectors. We benefit from having two big sustainability and transformations partnerships (STPs) in north east London and Bedfordshire, Luton and Milton Keynes where we can achieve best value for money and highest quality for our local communities.

It’s also interesting to have different commissioning climates and styles, so we can then say ‘we do this over there and it works and helps us’. We also have collaborative system arrangements in two parts of our trust – so we can work system-wide, but keep our local focus.

The contrasting challenge is that we sometimes end up going through the same process several times. It varies depending on external pressures and what’s happening in the relevant local authority.

We are also specialist commissioning providers for NHS England, and that gives us opportunities to influence national policy slightly. And our local authorities are also our commissioners.

STPs

STPs are a new challenge: how can we work effectively with boroughs and health providers and commissioners to improve? They imply much more commissioning in partnership in collaborative ways, rather than via the tender process.

STPs are a new challenge: how can we work effectively with boroughs and health providers and commissioners to improve? They imply much more commissioning in partnership in collaborative ways, rather than via the tender process.

   

Another challenge arises because we deliver a financial surplus. Increasingly, people say 'you've delivered a surplus so you clearly don't need more money for services'. McKinsey analysis said this is because we are productive, hence we are not in the red. Finance is a challenge for the whole system: the rest of the system locally is in deficit, and we are not but we readily recognise our responsibility to support the system to be in balance and equally importantly to develop truly integrated care.

There is quite a variation in commissioning styles with some narrowly contracting as opposed to commissioning which is a process about the whole cycle. It would be better to have relationships where commissioning was five-yearly, as opposed to annual and recognised system challenges. Commissioning support units (CSUs) also need to be able to provide the support and information that the clinical commissioning groups (CCGs) need as we move towards outcome-based and system-wide arrangements.

There is much discussion of the relationship between local and national commissioning. As more responsibilities get devolved to local commissioning, we as a provider would like to understand more about how that transition will work, and the role of CSUs in that.

Then public health commissioning sits in local authorities: understandably, their priorities can differ from CCGs’, and we have to get used to that difference. To be really radical, let's look at where commissioning fits, and social care being an essential element of what we do. Have we got the right fit? This issue keeps on raising its head: how can health and social care commissioners and providers collectively work together, with current funding and structural challenges?

The need to avoid acute sector dominance

The STP process needs to align overarching priorities to make sure it is not entirely focused on the acute sector and the financial challenges many providers face. We have expertise as an out-of-hospital provider and there must be just as much focus there.

To tackle health inequalities, STPs need a broader group around the table, including the voluntary sector.

The STP process needs to align overarching priorities to make sure it is not entirely focussed on the acute sector and the financial challenges many providers face. We have expertise as an out-of-hospital provider and there must be just as much focus there.

   

It’s too early to tell whether STPs can help support more joint commissioning (or at least alignment) between primary care, social care, public health and secondary care. And it depends which STP you mean. We’re involved in two. In one, there is an accountable care organisation-type vanguard, which brings a different flavour to how organisations work together. This is on a more sub-STP-wide footprint – addressing a big financial problem. In our other STP, the option to close the financial gap is more workable.

The importance of place-based care

The development of new care models is not, for us, that much different to our work transforming services in east London. It’s all about place-based care, and about existing local relationships at sub-regional levels. Sometimes it can be quite hard, as local authorities or other health colleagues may see relationships differently to us. What we believe is that the emerging NHS system requires a new type of leadership.

Local authorities’ drivers are different. We have four mayors across our east London patch and four local authority leaders in Bedfordshire and Luton, and it is different working with each individual. Ultimately, it is about successful joint working across the health and care systems, and politicians do have an important impact on that joint work.

Local authorities have to think about services for the whole community: parks, roads, rubbish, libraries. These are all key parts of determinants of health. They think about everybody, not just about needs for health conditions.

Local authorities have to think about services for the whole community: parks, roads, rubbish, libraries. These are all key parts of determinants of health. They think about everybody, not just about needs for health conditions.

   

The challenges facing CCGs as currently configured are hugely variable by CCG. There is even variation within CCGs and, like boroughs, they are all different and have differing priorities.

Avoid structural reform unless it is needed

CCGs have varying maturity profiles. We believe that we should not fiddle with CCGs unless there are real problems. CCGs may work better together, and there is a clear move for them to do so. When there are good relationships locally, CCGs work well together.

We are unsure how nationally-commissioned, specialised services will interact with local commissioning in future – there does seem to be a move to push STP systems and as part of devolution we may be moving to a specialised commissioning board for London.

Some of this remains unspecified. Think about forensics: you can’t have really local relationships. It has to be done on a larger footprint. The connection needs to happen when someone leads on a geographical footprint. That involves transition, and part of our job is to put services and support in place to help make patients part of the community.

We have heard that, for example, if a commissioner wants to buy mental health services for the whole of north-east London from the relevant trusts, they will say they currently get different outcomes and deals per provider, so we start talking about better standardised quality pathways or joint work as possible ways forward.

Payment reform

It’s all developmental. We were told last year that the centre was thinking about changing the tariff, and so we couldn’t progress on a local mental health tariff as it was all going to change. But then it didn’t. Trusts need to be nimble and fleet of foot to manage this uncertainty and keep their focus on the patient.

We were told last year that the centre was thinking about changing the tariff, and so we couldn’t progress on a local mental health tariff as it was all going to change. But then it didn’t. Trusts need to be nimble and fleet of foot to manage this uncertainty and keep their focus on the patient.

   

The ongoing talk about ‘granulising’ tariff – we’ve been looking at capitated budgets and the different possibilities there. We’ve also been party to national discussions on tariff and whether it’s an obstacle to the new world. We are not keen to go back to block contracts, but outcome-based commissioning means we’d need much more analytical capacity, business intelligence and agreed outcome measures. Fees for service is good when you want more of the service; less good when there’s less money and more demand.

Co-commissioning for primary and specialised care

In terms of co-commissioning both for primary and specialised care, we know that co-commissioning in primary care makes sense as it brings a greater sense of ownership. It works well, for example in Tower Hamlets and our expectation is that this will spread across our STP areas in some form.

For specialised commissioning, it may be an issue of having providers work out among themselves how to manage across the whole system (in an anti-competitive way, of course). We are having those discussions on medium secure mental health services across north and south London and looking at wider collaboration across north central and east London. If confirmed, this means we would be responsible for all patients including those in the private sector: i.e. to oversee best value for money and recovery.

A more personalised approach

Discussions about a more personalised service, and the concept of personalised budgets, has had very little impact so far. We could be interested. Local authorities use personal budgets, but still restrict what service users can access through those budgets. GP colleagues do much more of this: some support it, some do not. That agenda has yet to get far in mental health.  

Discussions about a more personalised service, and the concept of personalised budgets, has had very little impact so far. We could be interested. Local authorities use personal budgets, but still restrict what service users can access thorough those budgets. GP colleagues do much more of this: some support it, some do not. That agenda has yet to get far in mental health.

   

By contrast, we have been very involved in capitation budget work in Tower Hamlets and other parts of east London. We also have some shadow outcome-based alliance contracts in Hackney, but these are still being tested so success is yet to be seen.

The future of the purchaser-provider split

We’re gradually moving away from the purchaser-provider split as traditionally understood, recognising that it may not allow shared accountability on the whole care pathway. Although it’s very helpful to know which services you deliver and are accountable for, surely it is best if all players in the system know their role is delivered through collaboration (which does not mean merger). That's what devolution and vanguards should be about: providers working together to interact and wrap the right care round the patient.  

Commissioners may struggle with parts of this – and CCGs may often have their primary care provider heads on. We have to be more innovative. That’s not just about acute providers running everything: there has to be a more equitable process, to move care closer to home on the patient care pathway, and mental health has already made extensive and successful headway with that shift.

In our view the best NHS leaders will be those who understand complex systems, can bring the anxious and worried together to achieve a common purpose and  are willing to take personal risk. They need to be authentic and to believe in doing the right thing for the communities they serve. We hope the NHS system supports that type of leadership from whichever sector to make STPs and other collaborative arrangements a success.