Chief executive officer lead
Cumbria and north east STP/ICS
Alan Foster was appointed chief executive in September 2007. Born in County Durham, he is committed to improving services and the quality of life for people in the north east of England. He was awarded an MBE for services to the health service in 2013.
Our starting point was to agree the key principles for working as a system. From our perspective, it was about putting patients first and protecting frontline services as far as possible. We also wanted to preserve local clinical leadership and autonomy as far as possible. Coming together to develop integration was basically a means to those ends.
We acknowledged that we would have to respect the NHS legal framework, but in fact, there was already local integration work under way – the local authority’s place-based approach, the health and wellbeing board (HWB), prevention and joint working methods – and we wanted to preserve, and build on, this.
Local relationships are the key. Changing organisational structures takes too long to deliver anything meaningful, so it has to be about collaboration. We felt there were some things we could do more effectively and efficiently at system-wide level. We had already made progress here with good clinical networks and joint services, and we were keen to protect that.
Walking the walk
It’s easy to 'talk the talk' of integration, but we must 'walk the walk' locally and in terms of national policy making. Locally, we still see evidence of the systemic barriers between commissioners and providers but ultimately patients must be at centre of what do. That can only happen if we work together to make the best use of resources, which requires a common message from the top to incentivise the right behaviours. We need that joined-up approach across the system leadership board.
NHS England and NHS Improvement have now recognised there was, at times, a lack of coherence between them and have started sharing non-executive posts. They need to speak with one voice and Ian Dalton, chief executive, NHS Improvement, has talked about that greater alignment, which we welcome.
Locally, we still see evidence of the systemic barriers between commissioners and providers but ultimately patients must be at centre of what do.
We also need much better nationally-led messaging and communications for colleagues in local authorities. If health and social care come together under Matt Hancock, as the department’s name change implies, this could be another significant step towards putting more focus on social care funding and aligning messages. Joining up health and social care at each level of the system is important.
However, we’re making progress. The new planning guidance allows us to take forward a strategic planning exercise across organisational boundaries, to develop more strategic approaches and to use vanguard projects as models for how to support delivery at the frontline for the wider STP.
A collaborative approach to workforce planning
A move towards looking at population health management and developing workforce plans is vital – both of these must be done system wide. As a health economy, historically, we’ve been using staff from the same pool due to a lack of skilled people, especially on the provider side.
Instead of undermining each other in that way, we now network to sustain services across our footprint and meet the seven-day NHS challenge on weekends and bank holidays. We can still do some of this better at scale, but we are keeping sight of the fact that the main benefit for patients is local health and social care integration. The general public is not interested in who employs their doctor, nurse or social worker, or if the service is voluntary, as long as it’s joined-up. This is another point for the arms’ length bodies to consider – devolving the workforce planning agenda to STPs could be very helpful.
A move towards looking at population health management and developing workforce plans is vital – both of these must be done system wide.
Building on stable leadership: stable organisations
A factor that helped us in the north east and Cumbria was that we already had an existing stable set of organisations, more so than in many other parts of the country. Our leaders already know each other which is a real benefit and enabled us to use those relationships to move things forward. I'm not saying any of this is easy, it isn't, but that was a helpful base from which to start.
By national standards, on some targets (four-hour A&E target and cancer treatment times) we do relatively well, but we always want to stay ahead of the game in delivering the best services we can for local people.
Getting the right incentives
We still see trusts seeking to maintain a degree of independence on the issues which they are judged externally by the national bodies. This understandably includes finance, performance and recruitment and retention issues. We have to incentivise the right behaviours as a national health and care system.
There are real consequences for individual leaders and organisations taking the risk to effect change which is collaborative and delivers better services for patients. That cannot be right. There are still big financial consequences for trusts if they try to manage demand and provide more services in community and home settings. If that proves successful and drives less activity, or activity in cheaper settings, it still affects a trust’s bottom line and if their financial position deteriorates, that has consequences which can be hard to manage. Likewise, there are heavy sanctions for breaching the agency staff bill or overspending.
The national bodies want to see change driven locally but if that change knocks a key performance target off the beam as a consequence, in my experience, there’s not a lot of forgiveness.
We need to get a common understanding of 'doing the right thing'. The local system overall should benefit from initiatives to collaborate and integrate care, but the financial consequences may well sit in different places. For instance, CCGs could benefit but providers lose but overall if patients benefit, it is the right thing to do. Maybe it’s time to move from tariff based payments to something more intelligent, which will incentivise the right behaviours. We have to find the right currency or compensate each other when change drives financial loss.
We need to get a common understanding of 'doing the right thing'. The local system overall should benefit from initiatives to collaborate and integrate care, but the financial consequences may well sit in different places.
What does the future hold?
If STPs/ICSs prove successful, digital transformation will have played a big part. I’m a believer that technology can help us move at pace and transform how care is delivered – phone apps, sharing records, interoperable systems, telemedicine and telehealth at scale out in communities will all have a part to play.
There is so much we can do and should be doing. I foresee people being able to manage their long-term conditions much more easily using apps and having phone conversations with specialist nurses remotely to help manage their own conditions. Similarly, technology can make a big different to frontline clinicians’ ability to make a quick and accurate diagnosis.
In the future, I can see airline style check-in to hospitals. Patients will put in their own data, register themselves, make e-appointments and e-book with GPs. Delivering care to patients through technology should be quicker, safer and provide better access.
The digital capital fund will help but we should also give exemplar trusts a remit to roll things out across wider footprints, which will enable it to happen more quickly. This is one area where I would support greater direction and a mandate from the centre. You could push and use mandating and licensing regimes to speed things up and spread good practice quicker for the benefit of local people.