Dr Kathy McLean: Accountability needs to be to the people we serve

Matthew Taylor

Hello. When I started working at the NHS Confederation some six months ago, I asked people for suggestions on who I could best speak to, to get the combination of experience, insight, plain good sense, that would help me climb up a steep learning curve. A name that came up again, and again, was Dr Kathy McLean.

I did speak to her. I've spoken to her since, and I've always found our conversations incredibly enlightening. Today, on Health on the Line, I'll ask Kathy about her new role as chair designate of Nottingham and Nottinghamshire ICS. Explore what she has learned from working at the centre and in trusts. And about her commitment to LGBTQ+ equality so that the leaders of tomorrow don't have to face some of the challenges that she's had to deal with.

Hi Kathy. Thanks so much for joining us. How are you?

Dr Kathy McLean

 I’m fine, thank you. It's lovely to have a chance to chat with you, Matthew.

Matthew Taylor

So, if I took you back 30 years or so, and you were then able to kind of project forward, do you think you'd be surprised by how little has changed? How much has changed? How things that you thought would change, haven't?

What, do you think you'd be surprised at in terms of how things have turned out?

Dr Kathy McLean

Well, I do remember 30 years ago, having conversations about the impending challenges really. We knew back then the demographic was changing. We knew that activity was coming down the line. We knew that we were pretty successful, not necessarily just in the NHS, but across the society, in helping people to live longer. This is a great thing. But we could see that the bulging in demography would mean that we ended up with many more people who would need a lot of help at the end of their lives.

And I say this from this angle because I was a geriatrician. So, I was working with people who are older and frailer and so on, and we could see that. And some of the great things that happened then were that people weren't continually living in institutions. They were able to live in their own homes or closer to the communities, but I would have expected 30 years on, surely, we will have changed. And so that we will have pushed back the tide really. We will have made it more manageable. We wouldn't have those pressures that I could see then in our A&E departments and so on. So, it hasn't changed as much as I thought from that point of view.

However, what has changed an awful lot, I think, are some of the things we can do in health for people, some of the technological advances, some of the digital things. So, I think there are some huge positives that I might not have been able to predict but also some things that I would have imagined then in my naivety, would have been considerably improved by now.

Matthew Taylor

I know because I was having these conversations 30 years ago, people would have been saying, look, we need to kind of try to shift resources more into prevention. We need to think about how we can treat patients more without having to go into hospitals because it's expensive and risky going into hospitals.

Do you think you would have been disappointed by how little progress we've managed to make in those agendas over the last three decades?

Dr Kathy McLean

Yes, absolutely. Because I think we could see then that there was much more needed to be done in the community. We tried in some small ways to do some of those things.

And if I look back somewhere in between 30 years and now, back to 2007, 2008, when Ara Darzi was doing his review, we absolutely looked at some of those things and talked about it then. And again, you know, sort of ten, 15 years on from that, we've not made the progress that we might have hoped. And I think in some ways, what's my leadership learning from this? You have to be brave when you can actually sort of see what needs to be done. You have to be brave. I have waited, it feels like decades, to get to the place now where we can start to see that integration across health and social care, and other parts of the system, might start to genuinely have an impact. But it is disappointing in many ways, but I'm a huge optimist. So, I'm always thinking we can still do something.

Matthew Taylor

Yeah, this is why I wanted to have this conversation with you, Kathy, because I think it is relevant because if ICSs are to succeed in the big way that I think you want them to, and I want them to, we do need to acknowledge how difficult some of this change is.

So, if you look across those years and you think, well, why haven't we achieved the shift upstream in terms of prevention, out from the acute sector into community services and other services, for example, that allow people to better manage themselves, manage their own healthcare, stay in their own homes.

I guess there will be three perspectives. One would say the fact that it hasn't happened maybe suggest the theory’s wrong. Maybe it's just not realistic. Maybe we'll never invest more in prevention, maybe in the end we're always going to think of the NHS as being fundamentally about hospitals, despite the fact that so much activity takes place outside of it. Another view would be, well, we've never really kind of had a run at it, things got in the way. Or a third view, which is if you're going to do it, it's really much harder than we thought. So, which of the kind of accounts do you think best grabs why it is that it's been difficult to achieve these things?

Dr Kathy McLean

I think there's a bit of each of them, but I would also add in that I think we have to get the incentives lined up. And what I mean by that is I think some of the times that we've come through in the last 20 to 30 years, we've actually put in place things which were counter the integration, counter that working as a system, counter the move things upstream because we've looked at short-termism.

And also, we set up a system of, to be honest, competition at one stage, and foundation trusts. We've had all sorts of different policies and financial regimes, which maybe haven't supported it, which is why I think right now, if we are to have a change in law, which is what the bill is going through parliament, if that actually happens, it's really making a big statement of now.

You need to integrate. Take out the financial barriers, we'll allow you to use the resource. I'm a big believer, in a sort of sense of, it's a bit like being a general practice on a bigger scale, in a way, a capitated sort of budget. Here, you have a population, you have an amount of resource, and it is down to the leaders across health and social care, voluntary sector and so on and so forth to, actually, deliver the very best they can and help people, not just in terms of hospital care, but actually stay well. Live healthier lives for longer, that sort of thing. But you have to move the resource around to do that.

Matthew Taylor

Do you think that we might look back and say the way that ICSs started to fully work in the shadow of covid, actually meant they had more impetus to address some of those longer standing issues? I think of health inequalities as one example.

Dr Kathy McLean

Absolutely. I think for most systems across the country, a very common theme as we emerge from the sort of first and second waves of covid was to say, "Hasn't everybody worked well together?" Having a sort of single thing to focus on helps. So there's a lesson there. How do we make sure we don't try and do too many things? How do we actually sort of focus the priorities? I think there's a big, big lesson. And I think it's something we've been guilty of for a long time, is we spread things too thin, we think we can do so many different tasks at once. And actually, we're much better if we're focused on a small number. We learned that from covid people had to get together. It was imperative. We never dealt with this before and people were developing things as they went along together. And I think when you look at any integrated care system, I've got some involvement in several, and it was the same story.

People in hospitals were suddenly working in a different way across the system with people from primary care, there were people in mental health trusts helping support staff in acute trusts, social care was working well together with everybody, we were working well with them.

And I just think that we must capture that, and we must maintain that momentum. If we lose that now, that really is a loss. And we must learn from that. And the inequalities became really clear. They were really highlighted. We knew about them, but they really stood out and that's given us something to really galvanize around to change that going forward.

Matthew Taylor

So, I want to come back to that idea of focusing on a manageable number of priorities when we talk about the dangers and opportunities for ICSs, in a moment. But just before we get there, I just want to ask you about your perception of the relationship between the centre and institutions and places. It can be quite a tired discourse at both levels. So, I've been in conversations in the centre, despairing at the massive variations in performance and standards of people out in the field. And I've also been in even more conversations of leaders of trusts, foundations or places tearing their hair out at the latest bit of unnecessary central interference.

As somebody who's worked in both places, how do we get out of this kind of rather tire debate? And beyond that, what do you think is the challenge for the centre going forward in a system of systems?

Dr Kathy McLean

I think that what we do have to remember is that the NHS part of our systems is funded nationally. It's determined in parliament, how much resource comes to the NHS. It is inevitable that there has to be an oversight of that. And if we try and think that we can get past that, that we need to get past that, we should get past it, we're having a sterile debate. It is as it is. And we need to, I think we need to accept that. So, one of the things I think has to happen really is a change of focus. I think we need to focus on outcomes, outcomes for our populations, for our citizens, citizens who at times become patients. And I think setting the framework of where we're trying to get to and for the more central bodies to turn more to how can we support. There's a certain amount of guidance and do once type of approach, but I think the more we can devolve out to the frontline, out to the communities, out to the neighbourhoods, where we know that people understand the issues. And they'll be really different. They could be different in the space of a few streets, so any thought that we can do that from a central region or a national central arrangement I think is wrong.

And I think that it will take time, but I think we need to devolve and then that trust that we talk about a lot at system level, relationships and trust, we need to build that. But we've always got the challenge, it's a national health service, and so you expect a standard. And one of our four things to be achieved by systems is to continuously improve quality. We have to have that. But I think the brave thing to do would be to start to devolve more and more out, closer to the frontline, into the systems as they develop.

Matthew Taylor

I completely agree with that. And I think I've probably said to you before Kathy, that I think one of the very common characteristics of improving systems is that they somehow manage to both articulate and critically balance, three types of kind of pressure for improvement. That's the top-down pressure, which is to do with strategy and standards and accountability. Lateral peer-to-peer improvement, which is to do with having a culture of challenge and support amongst the leaders and clinicians. So that's a cultural facet of a system, which is that the teamwork is teamwork oriented to continuous improvement and service. And then responding to pressures bottom up, pressures from the desire for patients, patients’ groups, communities.

And if you can balance those and articulate them, then you've got a good chance for a self-improving system. But what that requires is an appreciation of how these different drivers interact with each other. The thing that's really hard for the centre to understand is that when you push down from the top, it's not just that you push things down from the top and something goes in, but you generally push away the capacity of leaders to learn from each other and learn bottom up because they're being forced all the time to look up. And so, I feel, if ICSs are going to succeed, the centre is going to have to lose an empire and find a role to a certain extent.

Now you've been at the centre. If the centre is to hear what you've said about the importance of devolving, wherever you can. If it's to hear what I am saying which is about the balance needed for a self-improving system, it’s going to have to not just be about good intentions, but quite deep thinking, isn't it? About a different kind of role?

Dr Kathy McLean

Yes. And there are some positives definitely that emerge around the culture that's created, and we want a different sort of culture. But I think it's, in fairness, tricky whilst the bill is going through parliament and we're actually sort of building the structures and so on. I absolutely see that there's a certain amount of uniformity there.

But I think they will need to be some more trusting relationships built up, so that we're really clear what we're trying to achieve here. And give a bit, and maybe do it gradually, but I think sort of start to give something so that systems can actually develop for themselves. And in a way we talk about accountability, but the accountability needs to be to the people we serve. And a lot of that can be done at a local level. That's where we should be listening, but I do recognise it is tricky. I think that offering improvement, offering those connections, I think there's a tremendous amount we can each learn from others and also they can learn from us, whoever we are in these systems. Somewhere, somebody is doing what we all need to do, but nobody's probably doing everything. So, I really think we could really move to a much more of a horizontal learning.

And I think the centre, obviously they have to be accountable, but they could put more of their energies into how they help us with improvements and how they help point to where we should be looking. Somebody has done something interesting... point us to it! That's what I felt when I was in the centre. I have recognised, as I've come out back into more locally, that's not necessarily how people see it, actually. You have to be really, really careful on how you sort of put yourself in other people's positions so that they interpret it correctly. But I think there's a journey here, Matthew, to be gone on and the real value - I think I've talked to you a bit before about my inverted pyramid. I put an inverted pyramid with the ICB (integrated care board) and the integrated care partnership at the bottom, the pointy bit, and then build up from that and provide collaboratives, the places, the neighbourhoods, and right at the top of the widest bit of the inverted pyramid, are the citizens.

And that's the spirit of how I'm trying to work in my system, because I think that as soon as we have another hierarchical approach, we'll have lost that great possibility of actually making change in the communities at the frontline, preventing people coming into hospital, helping them to manage themselves.

Matthew Taylor

I thought something you just said is an interesting example of the kind of thinking that we need to be careful about. So, when I was at the centre, I would have absolutely said, look, there's great practice out there, as you said, let's find out where the great practice is, and then let's tell everybody to do it.

Unfortunately, that is I'm afraid, I think how the road to hell is paved with best practice, actually. And I think that's because when you actually bring people together who are leaders to discuss a piece of practice that appears to be successful, what actually happens is this... it is not that, a number of people sitting in a room, somebody says I'm doing something perfect and everyone takes out a notepad, writes it all down and then goes back and does it. What actually happens is the first person says, well, we're doing something and actually it's quite successful. It's not perfect, but it's going okay. But there are very specific reasons why we were able to do this.

And then the second person says, well that's interesting! I think there might be some elements of what you're doing that I could, there's some elements I couldn't use, but there are some elements that I can repurpose. And then the third person says that's really strange, I did exactly what you did three years ago and it completely failed! And actually, that's how we learn from each other. It's a much messier, grounded process than the civil servants idea of find someone who's doing it and tell everyone else to do it. And that peer-to-peer is about that messier kind of long-term conversation, isn't it?

Dr Kathy McLean

Absolutely agree. And I think networking between people, between systems, between people within it. Just an example that I did within our own system today was we brought together non-executives from the different partner organisations and the conversation that emerged is enormously helpful for us. What have we done? Well, all we've done is facilitate people getting together and having a conversation which really moves us on around some key themes. And I think the more we can do of that sort of thing, that's the sort of space and it's energising. People enjoy doing that sort of thing. And if they enjoy doing it, they're energised by it. They are more likely to go away and make a change as a consequence. So, I completely agree with you. You can't tell people, oh they've done it really well in Nether Wallop or wherever it was. You just do that now. That's never worked. You may get a few. A bit of uptake, but you never get the uptake you imagine surely everybody would be able to do this? But you have to sort of get interested in something and then start to look at it in your own context. How might you adapt it? What do you add on? Just the sort of things you were saying there. But we can facilitate that. I think we should be positive and optimistic about that. We can learn from abroad. We don't have to do it all from here. Some countries have been ahead of us in some of these things and we can take from anywhere, really.

Matthew Taylor

Yes, absolutely. And indeed, just to say that we at the Confed, are spending a lot of time thinking hard about what kind of resources and skills we need to precisely enable that kind of really powerful collaboration, facilitation, networking between peers. Really strengthening that kind of lateral driver of improving but also what you've just described, that gathering you've described, takes me to ICSs, and I have heard so many different accounts of what an ICS is.

So let me tell you my best shorthand, and then I'd be fascinated to know, Kathy, what you think of this. So, it seems to me that ICSs have got three fundamental roles, two of which are in inherently intention. The role that is not an intention as it were, is there's a kind of economy of scale, kind of set of issues. There's functional things. So, there might be things that it is just better to do at ICS level, whether it's kind of capital allocation or workforce strategy or IT or R&D. So, there might just be things where you can genuinely just add value by doing them at ICS. That's unproblematic, although it will vary from place to place.

The functional bit is complicated, but it's not complex. The complex bit is that on the one hand, ICSs have this role in convening and collaboration as you've just described, in some of the most eloquent accounts I've heard from ICSs that exist, about the difference they're making is to do with bringing people together and hosting different kinds of conversations.

But yet on the other hand, they are also going to have a kind of harder edged role in terms of allocation of resources, accountability, to a certain extent, some kinds of performance management, or at least holding some kind of framework. Is that do you think, an accurate account of ICSs? And how do you deal with this inherent tension between the warm collaboration and convening sides of things, and the slightly harder edged accountability and performance side of things?

Dr Kathy McLean

Yes. And I'm sure everybody's kind of working through some of these. So, I think you're right. I think there are a number of different facets, if you like, to it.

I think as well, it's worth thinking about what do we mean by an integrated care system? And that is not an integrated care board. An integrated care board, which is both an organisation and a board, will have certain things it has to do. It will have a role to help implement the strategy that is set by the integrated care partnership and so on and so forth.

But I like to think about the integrated care system as a collection of people, which is much broader. So, you've got Healthwatch, you've got voluntary sector, you've got various aspects of local authority that's not just relating to the health and wellbeing of people, but is actually broader around housing. It does relate to wellbeing, housing, and employment. And then there's education. There's research, as you say. So all the organisations... universities and so on, can be part of, in some way or another, that system. And I think it's really important that we have a distinction if you like. And then I think what is also really, really critical is if we're going to have places thriving, we must give primacy to those. And as you sort of rightly indicate, they're all different sizes, all the ICSs. For some, a whole ICS is somewhere else, it's a place. So, we have to be able to accommodate all of that, but it's going to really matter how you come together.

And an awful lot still is based on what are the relationships? Have you got trust between you? Are you able to, therefore, use the levers around the contracts or whatever it is that we might get to use, to actually move resources into the right part of the system, into the place that it actually can be used to reduce inequalities, to equal people up, to change the way that they live and so on.

I think we just need to be really careful that we don't get stuck with the wrong things. I think the performance management bit is one of my fears. And the way to handle that, I think, is to think much more about outcomes, is to make sure we don't, at the system level, start to duplicate what's already happening in organisations.

So, the trusts in any ICS patch have got boards, they've got a governance process. How do we add value at the system level? How do we not just replicate? How do we add value? And certainly, in Nottinghamshire, we've got a great outcomes framework, which we will be using alongside our inequality strategy and all of those things to make sure that we are focused on the things that really matter to the citizens and to the patients.

So, I think we're going to have to fight against just becoming performance management. And I do think we need to continue to engender that relationship between different parts of the system.

Matthew Taylor

I want to talk about one other thing, and this really isn't a kind of afterthought at all, but if we go back those 30 years, Kathy, there's one thing I think that you would have been delighted by in terms of the shift that's taken place. And that's the shift that's happened in terms of attitudes to the LGBTQ+ community. You're a member of the guiding group for the NHS Confederation's LGBTQ+ Leaders Network. Talk to me a little bit about the progress that has happened over those 30 years, because am I right in thinking that you would have been pleasantly surprised at how much progress has happened since the nineties, but also tell me what work do you think still needs to be done?

Dr Kathy McLean

Yes, I do think the world has changed from the one in which I set out in when I was just qualified, and it is in many ways, unrecognisable. I think of my own trust at UHDB, we have a thriving network of LGBTQ+, and it is remarkable when I look back, it would never have been the case 30 years ago. You kind of hid these things. I mean, genuinely, that's what I did. And also, I knew plenty of other people who would just sort of try and come and seek some advice. And it is much more open now. It is in a better place, but we're not there. We don't have necessarily really open discussions at boards about it. And you could argue, why would you do that? It's a personal thing, but actually it just shows that we're not really as far down the path as I would really like us to be. I mean, I'm impressed with the progress we have made, but I think there is more to do. And I think it's more complex than it was, people are understanding better about different aspects of people's lives. There’s the trans community, there's people who've got different protective characteristics, perhaps that overlap. All sorts of things. I think we've got an awful lot of education to do amongst ourselves. And I think we need to be really able to speak about these things and allow people to bring their whole selves into the workplace.

And then also think about it in terms of our citizens and our patients. How do they feel? Do they feel welcomed for their whole self? Are they treated with respect in that way? So, yeah, lots and lots of progress, Matthew. I feel I've some sad stories I could tell from when I was younger, but it's a lot better now. And I'm really, really pleased to see that and keen to do whatever we can do to advance that across all of our communities.

Matthew Taylor

Yes, and I think it's important to grasp hold of those things that we can say there has been genuine progress, but as you say, still work to be done. Well, Kathy, our first conversation I think, was on zoom just after I'd been appointed. Our second long conversation was at the Health Service Journal awards in a kind of peculiar building in Battersea Park. Our third one has been on this podcast. I can't wait for our fourth, and hopefully it will be in the wonderful city of Nottingham. Kathy. Thank you so much for joining me.

Dr Kathy McLean

Thank you, very welcome.

Outro

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