Simon Trickett and Sarah Dugan

Simon is an experienced public sector leader who has worked in several large organisations in communications, business and strategy development and customer service roles. Simon has worked for Worcestershire County Council and has held director posts in NHS provider and commissioning organisations.

As well as a chief executive, Sarah is a registered general nurse, sick children's nurse and health visitor. She has a Masters degree in health and social are management and has held a wide range of senior positions within provider and commissioning organisations, with a particular interest in partnership working, integration and the development of positive learning cultures. 

The STP has been in operation for two years now, and it’s fair to say that at the beginning it wasn’t a natural way of working. Herefordshire and Worcestershire have similar rurality but, due to geographical distance, the two counties hadn’t worked together in any significant way and patient flow across the two counties was limited.

Much of the early work of the STP was about building relationships, deciding what we should do collectively and what delivers more value by remaining local. Because of the geographical scale and distances over which we work, there is a very strong desire to maintain a sense of place at county level. This meant that we needed to undertake further planning, focus on added value, and think about what we should do at the different layers of planning – what should be done at STP level, what should remain at each county level and what made sense to deliver at neighbourhood/locality level.

What’s different (and wouldn't have happened without STPs as the enabler) is the sense of cooperation and collaboration. It’s surprising how cohesive it has become, encouraging all partners, commissioners and providers to work together on common and shared issues and collective solutions makes for a really joint approach.

It’s surprising how cohesive it has become, encouraging all partners, commissioners and providers to work together on common and shared issues and collective solutions makes for a really joint approach.

   

Our approach is for all organisations (including the council) to collaborate in decision-making, and our style is consensual. Now, one accountable officer is in charge of the three Worcestershire CCGs, which helps simplify things further. Having the chief executive of a mental health and community trust take up the STP lead role was largely because, in the context of a lot of change, Sarah was one of our most respected senior leaders, had been in post a fair while and knew colleagues and the population. It was a pragmatic decision and the right decision.

An example of our collaboration was the 2017-18 winter plan. This had staff from organisations across our area working in other organisations, putting aside the divisions of commissioner and provider to work together as one team. Two years previously, that would have been unimaginable.

Full and wide engagement

The real strength of this STP is genuine engagement – including health partners, local councils, Healthwatch, voluntary organisations, and really strong primary care engagement. In the early days, we invested time in those relationships, working out how to enable primary care to get involved, develop a co-ordinated approach and let independent practices feel they have a say and are enabled to contribute.

Our local medical committee (LMC) has been extremely co-operative and supportive. Our STP chose to have both LMC representatives and the GP ambassador from the Royal College of General Practitioners locally on board from the start. They have done a lot to galvanise the voices of primary care, and that is really paying off. There’s a sense we really are all in it together, and a real strength from having strong non-statutory body input and a lot of support from the councils, as well as cohesive support from primary care.

The real strength of this STP is genuine engagement – including health partners, local councils, Healthwatch, voluntary organisations, and really strong primary care engagement.

   

Having lived through five to six years of clinical commissioning groups (CCGs), it’s clear that GP practices are more engaged in this approach to integrated care work than they probably ever were in strategic commissioning (perhaps because GPs understand population health). The level of engagement is much more evident – they see our neighbourhood team approach, they understand it and embraced it and are actively leading it moving forward.

In designing our neighbourhood teams in Worcestershire, we went to see the Buurtzorg Netherland and Swedish models, to learn how they empower clinicians to reframe the ways in which they offer care to make it truly patient centred.

 

Supportive relationships

If you achieve supportive and positive relationships, a lot more follows. Given our history as a challenged health economy, we had well-known issues around finance and care quality. If we’d had the performance of a more stable health and care system, there might have been no incentive to drive this. We knew we needed to change. 

NHS England in the West Midlands had a very proactive approach. They devolved some of their team to STP level, and we subsequently integrated their staff with our STP programme management office. That has helped cut layers, reduce duplication and given us access to their experience. They are used to overseeing change and delivery on this large scale.

 

Enablers of progress

Transformation is more feasible when you are able to double-run services with pump-prime funding for new services. We knew we would have to work hard to free up financial and staff resource to make this change happen. Autonomy is another significant enabler. NHS managers are trained to follow instructions and guidance but to progress with this new system based approach we need more autonomy and permission to work differently.

Transformation is more feasible when you are able to double-run services with pump-prime funding for new services. We knew we would have to work hard to free up financial and staff resource to make this change happen.

   

It has also helped that we’ve been encouraged to go at the right pace for us. Relationships are important. Nationally, we still face very tight deadlines, but getting the right people involved and committed takes longer, as does buy-in from primary care and across a bigger system. All of this needs flexibility. Trying to do this in 12-18 months wouldn’t be realistic.

As for resources for support, as a challenged system we can't pile in a lot of extra people or commission more support. We can’t afford new leaders so we have to re-align people’s day jobs to STP priorities. We have to work together and stop duplicating as a set of organisations. This has resulted in greater ownership of the changes.

This winter, our commissioners and the STP management team shared the workload and agreed common messages. If one organisation prepared a staff message about winter issues, all organisations in our system used it. That’s one practical example of people sharing the load.

With relationships in a better place, there is a greater sense that this agenda is everyone’s issue and priority.

 

Barriers and challenges

One challenge has been specialist acute services. With circa 800,000 residents, there are some things we can’t sensibly do in our STP, we have to partner with other STPs.

We started with a small list of services that we needed to provide once at STP-wide level. Now, we’re developing a list of more specialised services which we can work on with other STPs. For these, we have to look outside of our own boundary. The right size of STP can be irrelevant if you approach it creatively, thinking about what changes you need to make and who you need to work with to deliver.

We have to work together and stop duplicating as a set of organisations. This has resulted in greater ownership of the changes.

   

We still have significant performance issues. We are increasingly taking collective responsibility and working on how we support each other in performance and quality improvements. As an STP we can have better oversight of system outcomes, performance and an understanding of the challenges and creative solutions. Having written our plan, we take collective responsibility for our system. One of our acute providers has a significant £60m operating deficit. Others have smaller deficits and some have surpluses. Getting surplus providers to consider the option of shared control totals is challenging, they are financially prudent and understandably nervous of losing any pooled money forever.

This raises broader national system level challenges. Planning guidance has been helpful but there remains a tension between a board’s responsibility and accountability for its own organisation and delivery, whilst also being asked to look to more collective responsibility for the system.

 

The integrator approach in Worcestershire

Part of our work now is to find a way to get to being an integrated care system with collective responsibility. How can we grow the trust, confidence and oversight needed, while keeping organisational accountability and responsibility? We all buy in to the integrated care vision but don’t yet have the mechanics of getting from A to B safely, which we need to provide assurance for our board members around the safe transition process.

Our STP is adopting a model in Worcestershire where Worcestershire Health and Care NHS Trust becomes a 'host' for integrated community and primary care in Worcestershire for a period. Initially, some people felt nervous about the concept of local alliance boards and collective decision-making but we are now seeing the benefits of this way of working at neighbourhood level.

We decided that we needed a more formal but different way to get to an integrated care model and thought that using a local organisation in the NHS infrastructure could work well. When you look at the impact of VAT, regulation, employee T&Cs and liabilities, it seems as if you need an NHS trust infrastructure to host it all and enable the change.

Procurement laws still apply, so we formally adopted the model for a pilot period of 18 months to two years, and, following an option appraisal, the CCGs gave permission for Worcestershire Health and Care NHS Trust to be the ’home’ the new model would be built around. We agreed to go ahead in October 2017 and have been adapting the governance to make that work. It looks like our approach is going in the right direction.

Part of our work now is to find a way to get to being an integrated care system with collective responsibility. How can we grow the trust, confidence and oversight needed, while keeping organisational accountability and responsibility?

   

The Worcestershire Alliance Board has been running for almost three years. It was created to work closely on integrated care, partly based on co-production with people with complex needs, but we found its services
fragmented.

Our working groups brought professional staff from social care, the combined community and mental health trust and primary care together to co-produce and co-design our new neighbourhood teams. We got to the next level through collaboration, co-design and an Alliance model. Teams want to work in integrated ways but when staff come from separate organisations it becomes more complex.

 

A host, not a takeover

This area has always found it hard to deliver acute care because of its rurality and the distance patients have to travel. There isn’t a tertiary acute trust. We therefore built our plans to take advantage of our strengths, and existing infrastructure, in community and primary care through the Alliance approach.

Social care staff are aligned to these teams and we have really benefited from an integrated leadership approach. This helps to deal with the differences between NHS and council policies and terms and conditions and bringing them together under a single team leadership meant we didn't have to TUPE (Transfer of Undertakings [Protection of Employment] Regulations) them to various NHS trusts. It could also enable co-location and collaborative working whilst ensuring an underpinning governance structure. This is one example of what the trust does as a host integrator.

We also addressed primary care’s anxiety about core contracts – this enabled them to engage and provide leadership. This concept is not about organisations taking over anyone else, it’s about finding ways to enable integration to happen quickly. If you aren’t careful, process can dominate. We’ve got much further by getting clinical teams talking to each other more and co-designing solutions, this gets things moving. Our economy has done well on admission avoidance and supporting end-of-life care at home.

Teams want to work in integrated ways but when staff come from separate organisations it becomes more complex.

   

What will success look like?

If integration proves successful, our population should see a much more seamless, joined-up offer.

Success would mean acute specialist clinicians working with community teams outside hospitals, providing advice and guidance to our neighbourhood teams to enable better care and outcomes for local
people.

Success would involve more co-production with patients and service users helping to redesign services, and using more innovative digital technology. As this develops, we should see the growth of self-care and increasing individual resilience as people feel more in more control of their own condition, assisted by the right support when it’s needed.