From fourth objective to system change

At the NHS Confederation, we see the government’s objective for ICSs to support broader social and economic development, as a vital and progressive aim. That’s why we are proud of the work our strategic policy team member Michael Wood has been doing with NHS and local economic leaders up and down the country. It’s also why our soon-to-be-unveiled Confed impact goals include our own version of this objective. In systems, places and neighbourhoods the contribution made by the NHS to wider local development is the quid pro quo for other agencies acting to improve the social determinants of health.

However, we shouldn’t underestimate the task of turning the fourth objective into concrete and impactful policy and action. At a fascinating seminar the other day (supported by NHS England and NHS Improvement and chaired by Michael), the range of good practice examples was notable but also the variety of ways this objective is being interpreted and the different stages ICS have reached. It led me to share with the group an analogous process of change: getting big business to take its responsibilities towards climate change seriously. This is a journey that has gone from isolated pioneers like the Body Shop, to the point at COP26 last December when it sometimes felt that the business community was more willing to endorse radical action than governments.

Intent

…even the longest journey must start with a single step

The first step can be no more than a statement of intent. This might be signalled in a mission statement, a leader’s speech or signing a joint declaration. This may not in itself achieve a great deal, but, as the saying goes, even the longest journey must start with a single step. Just as 20 years ago, most corporate leaders would have seen talk of environmental responsibility as irrelevant or a dangerous departure from shareholder value, some health Ieaders as yet have little to say about the ICS’s fourth objective. After all, it is not what they are judged on. The virtual absence of this agenda from the most recent NHSEI planning guidance will have reinforced the sense that social, economic and environmental impact is still marginal to core business. In such a context, simply acknowledging the objective can be important.

Voluntary regulation

At this point, words turn into some action. In terms of climate change, it is when a company starts to explore how its own actions are contributing to global warming. If there are way of doing things that are less harmful or more beneficial than current practice - while not being too disruptive - then leaders will agree they should be pursued. Actions at this stage can be radical. One NHS example is a commitment to avoiding elective recovery worsening inequality. In West Yorkshire, people with learning difficulties have been placed nearer the top of the list, while in Coventry and Warwickshire an assessment is made of social and economic as well as medical need. For example, a sole family breadwinner whose condition makes them unable to work could be given greater priority. As public health practitioners often point out: if the NHS is serious about its social contribution it could start by tackling the inverse care law.

Partial engagement

This is the stage when some parts of a company or organisation start to do things differently even while others continue business as usual. In banks, for example, customer concern about climate change might lead to actions in the retail division, while the less visible but more significant investment arm continues to resist change. An example in health might be an HR department taking genuine steps to recruit from under-represented areas or improve the quality of staff experience, while procurement policies under finance continue to require the purchase of goods and services from the lowest bidder regardless of their employment practices.

A new business model

For the NHS, the critical pivot is from meeting demand to meeting need, and from incentivising medical activity to incentivising health outcomes

At this stage, leadership is crucial. Now the commitment to action is seen to have direct implications for the organisation’s business model. In terms of environment, this might be the point at which a farmer commits to organic methods or a car maker to build only electric models.

For the NHS, the critical pivot is from meeting demand to meeting need, and from incentivising medical activity to incentivising health outcomes. This shift would require, among other things, a long-term commitment to ‘leftward shift’ of resources into community, primary and public health.

System leadership

In reality, few health organisations can transform their business model without change in the wider public service and socio-economic context in which they operate. Just as the most impactful business leaders have sought to show leadership beyond their company in their wider sector or geography, health leaders genuinely committed to ICS objective four will need to bring their health and other local partners with them. This is, of course, the big vision and opportunity that ICSs offer.

These four stages have a sequential logic to them, but life is rarely that orderly. Some further lessons can be taken from the shift in business attitudes to climate (which is far from complete). First, any progress is worthwhile because each stage makes further ones more possible. However, secondly, over-claiming is a mistake and can lead to cynicism or backlash. For example, asserting that the organisation is at the business model stage when only embarking on voluntary regulation. Finally, although it is generally harder to do, it is possible with determined leadership to concertina the stages and go swiftly from limited commitment to effective action.

I realise this is all very general, but given that work on the NHS’s wider impact is still in its infancy, a basic framework like this might help structure conversations and set expectations.  After all, while this fourth ICS principle may be the one least well understood in traditional NHS terms, it’s likely to be the one our partners truly judge us against.

Matthew Taylor is chief executive of the NHS Confederation. You can follow Matthew on Twitter @FRSAMatthew