Coventry and Warwickshire partnership NHS Trust
Jagtar has over 28 years' strategic leadership experience in senior public service and national roles, including 20 years in the fire and rescue service and 18 years in non-executive roles in the ambulance service and hospital foundations. In 2015, Jagtar was named by the HSJ as one of the top BME influencers in the NHS.
When STPs were first announced, as a non-vanguard area we saw this as an opportunity and were quick off the mark to take up the challenge. We soon realised it would be a much slower process for our STP opposed to those geographical areas that already had more developed partnerships under the new models 'vanguard' banner.
Working as a system
When I was appointed chair, there were limited local system meetings. With our local CCG chair, I set up more regular chairs’ meetings to discuss strategic issues informally and to start to build trust, essential in all partnerships of course. We already had good health and wellbeing board (HWB) engagement in the area and we also had a good memorandum of understanding between Warwickshire and Coventry.
Under the umbrella of the STP we have built on these 'building blocks' and have a good working STP structure, involving chief executives, medical directors and other directors. I am also fortunate in that one of my trust’s non-executive directors is a pro vice-chancellor at Coventry University and also chairs the clinical design authority of the STP. Along with that additional level of involvement in the clinical design, it also helps inform the board on progress with the STP. As a board, we have a good collective grip on our STP, but we would like to make faster progress that is well understood by all in the STP and by NHS Improvement.
Our strategy is one of partnership and collaboration with anyone where we can see a clear benefit for patients and staff. This enables my chief executive and board directors to work well in pushing the STP agenda.
Our strategy is one of partnership and collaboration with anyone where we can see a clear benefit for patients and staff.
The STP has enabled us to develop and improve in a number of key areas, for example in implementing a new model of stroke care, and has helped ensure mental health is higher on the partnership agenda. It has helped secure additional mental health staff into A&E to support patients who need our care at that level, and we are working with our acute, CCG and local authority partners to build a better out of hospital offer in the community, provide care closer to home and improve discharge rates at the acute hospitals. In short, the STP will lead to better joint working overall and patient outcomes.
Building trust and listening
We have to build the trust, create the narrative and business case for staff and stakeholders, get community engagement right, listen to what the public say and meet their challenges.
I believe talking about ACOs and ICSs is a big distraction for the public, and only helps to further confuse the people we serve. The discussion should be around how we work in partnership, not about structures. We should convince the public about the benefits of working in partnership and collaboration and we need to avoid driving the discussion around structures.
The key thing is building trust between leaders, the community and politicians. We receive constant questions about our motivations for proposed changes and both STPs and accountable care have become a poor brand in the eyes of the media. We need a clear narrative about why this work is happening. In my view, STPs should deliver four things:
- Better outcomes for patients: A move to place-based care should be about improving outcomes for patients and must of course involve full consultation with staff and the public. There are also opportunities to improve the practical support that partners offer each other, for instance improving clinician-to-clinician communications or exploring how a community and mental health trust can support an A&E under pressure.
- Better workforce planning, recruitment, retention and culture: Workforce planning on an individual organisational basis risks wasting good resources. It needs system-wide work with all stakeholders and, in particular, the local universities to plan for and train the right future workforce. We should benchmark better early warning retention rates.
- Better shared use of resources: Corporate and back office services such as human resources, medicines management, estates and IT can be shared more effectively. We have been working on this for many years and, supported by the Carter review, the STP provides a context to take this forward faster.
- Getting commissioning more consistent: As a former fire officer, I cannot see why the NHS has a competitive commissioning model. If we reduce that commissioning waste, we can build better services and pathways, and STPs will have more success in achieving the Five year forward view’s integration agenda
The discussion should be around how we work in partnership, not about structures. We should convince the public about the benefits of working in partnership and collaboration and we need to avoid driving the discussion around structures.
Enablers of collaboration
What gets partners on board to work as a collective? The biggest driver often is finance. Whilst that is important, in my view it should be patient outcomes. We must make the best use of our resources for delivering more services and drive better outcomes for all our patients. Through the STP, we can achieve these joint objectives of greater efficiency and better outcomes.
As a public service, and to be true to our values and the NHS constitution, we have to take the public and community with us on the STP journey. This may mean changing some things more slowly, for example NHS structures. Crucially, we also need the support of our local politicians, MPs and local councillors, elected as they are to be the voice of the public.
As far as structures go, whether you have one, two or three NHS provider trusts or boards doesn’t matter – improving patient outcomes is the aim and that can be achieved through integrated care partnerships, just as well as through structural integration. We should also be very clear that there are potential risks in consolidating too far or too quickly – we may get some economies of scale by having fewer boards and fewer single organisations but if providers become too big then boards may struggle to assure themselves about the quality of care they provide as it will be too far from the decision-making.
Short-term contracts also form a barrier and I would welcome longer commissioned contracts over five and ten years. In the fire service, I knew my budget for the following year to 1-2%. In the NHS, providers can lose anywhere up to a third of revenue if losing a major contract – how can we plan for serious investment in estates, IT and workforce if we can lose big contracts in that way?
As far as structures go, whether you have one, two or three NHS provider trusts or boards doesn’t matter – improving patient outcomes is the aim and that can be achieved through integrated care partnerships, just as well as through structural integration.
My learning from our experience of working within the STP to date has been:
- be clear on your decision-making structure
- be clear on the narrative to staff and the public
- have measurable short, medium and long-term goals and keep your focus on them
- if there is a leadership issue in the STP, consider the benefits an independent chair of the STP might bring
- partnership and collaboration are not totally free – ensure you allocate resources to make it work
- STPs should ask if we have the right level of trust in the room to be open and candid with each other?
What will the future look like?
If STPs and ICSs work, we may see many fewer trusts, where that is appropriate. Hopefully, the flow of patients between different types of trusts will be smoother and patient records will flow.
The key point I keep coming back to is that our aim, through working collaboratively, is to support better health outcomes and reduce health inequalities within systems and between geographical areas – achieving better outcomes per patient per pound.