Exploring ICS progress two years on

Matthew Taylor

Hello and welcome to the latest edition of Health on the Line from the NHS Confederation. I'm Matthew Taylor and in this episode I'll be discussing the Confed's new report about the state of ICSs with our ICS Network chair, Dr Kathy McLean, no stranger to Health on the Line, and also of course herself, an ICB chair of two health and care systems, Nottingham and Nottinghamshire and Derby and Derbyshire.

But first, we've also recently shone a light on the area of women's health, which shows clearly the costs of poor women's health services, both on women directly, but also on the wider economy. And we've got a new report coming out by one of my colleagues, Bridget Gorham, our health economics policy adviser. 

And Bridget joins me now. So Bridget, you spent nearly a year on this analysis with London Economics and Create Health Foundation and the report comes to some worrying findings. Just tell us a bit about what inspired the report. 

Bridget Gorham

Yeah, sure. So in 2022, England launched its first ever women's health strategy. And at the time it was very exciting because for so long women's health concerns had been neglected and many women just felt that their needs weren't being addressed by the health and social care system. And they felt that the strategy was finally giving their needs a platform. 

On International Women's Day in 2023, the Department of Health announced a £25 million investment for the establishment or expansion of women's health services throughout the country. So this was kind of like us seeing that the DH was putting their money where their mouths were and advancing on the implementation of this strategy. 

However, the fine print of the funding elucidated that the funding was not only non-recurrent, but it really wasn't a whole lot of money once it was divided equally across the 42 integrated care systems. And as we are approaching March 2025, that funding will be completely depleted with no plans on the horizon to fund it further. 

So we have conducted this research to really make the case to the centre that women's health is not only a just investment, but also an economically savvy investment? 

Matthew Taylor

Yeah, so let's go to that point. There's a lot of talk at the moment about economic inactivity. We did a big report by BCG about that, Wes Streeting made an announcement at a Labour Party conference that the trusts with the highest number of people on the waiting list for economic inactive would be prioritised. So this is a space that a lot of people are in.

I think your findings showed that conditions particularly suffered by women or exclusively suffered by women also have a big role in leading to women of working age being economically inactive. Yeah, definitely. So the report shows two really stark findings. So the first one is that there is an £11 billion loss to the economy each year due to heavy and painful periods, endometriosis, fibroids and ovarian cysts.

And it was just astounding when we came to that finding because it's tremendous. Similarly, the menopause, which impacts a select group of women at any point in time, is estimated to cost the economy £1.5 billion each year. And those are solely costs due to absenteeism, so days off work. So this isn't accounting for things like unpaid labour, presenteeism, or lower productivity in the workplace.

So we can imagine that those are really only a sliver of the overarching cost to the economy.

Matthew Taylor

And what about multiple conditions, Bridget? I have a personal take on this. My wife developed long-COVID around the time she was also going through the menopause. I hope she doesn't mind me being so personal about it. There must be an element of this, which is the combination of some of these conditions and experiences with other illnesses. 

Bridget Gorham

Definitely. In terms of multi-morbidity, we found that there were several correlations between gynaecological conditions, poor physical health, and mental ill health, with nearly half of the women reporting that while they did not take time off work as a result of the gynaecological health condition, they would have liked to. 

And of those with long-term physical or mental health conditions, 83 per cent of the women reported that the condition had a negative impact on their ability to go to school, college, or university, perform work for a family business, look for work or look after their family and home. 

Matthew Taylor

So Bridget, if Wes Streeting, having read this really powerful report, was to say, okay, I'm going to make some money available for this; I've talked to Rachel Reeve, she thinks it's a priority as well. But Bridget, where should we put our money first? Your money is limited. What would you prioritise for investment? 

Bridget Gorham

Yeah. So I think the first thing I would prioritise is the women's health strategy, because as I mentioned, we have a ten-year strategy. It lays some really great foundations for improving the health and care of women across the country, but we only have two years of funding to support it. And so one of the recommendations in the report is precisely that funding, more robust and sustainable funding is allocated to support the implementation of that strategy. 

Matthew Taylor

Finally, Bridget, I just want to say as Confed chief executive, I'm incredibly proud of this piece of work and incredibly grateful to you and you've shown enormous commitment to this work. It was your idea and you've followed it through and it's incredibly impressive. 

But what further do we need to do in terms of understanding issues around women's health and how we can improve quality of services to women? 

Bridget Gorham

So as the report says, this is a very nascent conversation. I think it's the third report of its kind to highlight the potential return on investment of additional funding in women's health services or research. So really, there's so much more to be done in the realm of women's health economics. This report specifically focuses on gynaecological and reproductive health services because the women's health strategy is so focused on reproductive health.

But as we saw yesterday, the research around cardiovascular disease and women going under-diagnosed, under-treated, and underrepresented because they are not involved in clinical trials, they don't get the same access to lifesaving treatment. And they frequently have symptoms such as high blood pressure that are dismissed by doctors. So I really think gender bias in medicine is not only scientific or biomedical, but it's also social, cultural and political and we need a kind of full reset of the system to really close this gender health gap.

Matthew Taylor

Thanks Bridget. That's fascinating. 

If people, I'm sure they will, after hearing this conversation, want to go and read the report straight away, I guess it's going to be on the NHS Confederation website. Just tell people what they should put into Google if they want to read it. 

Bridget Gorham

The title of the report is Women's Health Economics, Investing in the 51 per cent.

Matthew Taylor

Bridget, thanks so much for joining me on Health on the Line. 

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Before we get into the next part of Health on the Line, I've got a bit of a favour to ask. If you're a regular listener, in which case, thank you, or if you're tuning in for the first time, in which case, well done, I'm really keen to hear what you think about this podcast. In a way, I'm turning the microphone on to you so you can have your say. If you could spare just five minutes, it really is just five minutes to complete a short survey.

You can help me, you can help us at the Confed make health on the line better, more relevant, more useful to you. You'll find the link in the show notes. I really look forward to hearing from you. Now, back to the programme.

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Two years on from the establishment of integrated care systems, how is it feeling for ICS leaders on the ground? What are the key challenges, the barriers to progress, particularly on tackling health inequalities? 

As we at the Confed of all 42 systems and our membership, we conducted a comprehensive survey of ICS leaders, which revealed many things, including that nine out of ten ICS leaders are committed to shifting more care out of hospitals, but are concerned about a lack of long-term funding and planning, as well as feeling trapped in a short-term cycle of having to make budget cuts rather than focusing on delivering care transformation. 

So, as you can see, this goes right to the heart of how we're going to achieve the three shifts that Wes Streeting talks about. Kathy McLean, as I said, our ICS Network chair joins me now. Welcome, Kathy, to Health on the Line. 

Kathy McLean

Good to be here.

Matthew Taylor

So Kathy, ICSs are entering their third year as formal partnerships. There's a lot in this report. What do you see as the key takeaways from the research? 

Kathy McLean

Yes, and it was great that so many ICS leaders responded, so I think we've got a good feeling from them. So the things I take away, and I suppose the thing that pleasantly surprised me was the enthusiasm which still comes through for the mission. 

But I think that we also hear from them that it is very difficult at moment and these are challenging times, but they remain committed to the core purpose as to why systems were set up and the new arrangements to lead those were put in place. 

Matthew Taylor

So we often talk at the Confed about what we call split-screen thinking, which is how is it you address the immediate issues in one screen, but do it in a way which takes you to where you want to get to in the long term. And this issue of balancing the short and the long term is one of the most recurrent themes in the report and one of the most kind of recurrent challenges that ICS leaders talk about. 

Kathy, tell me how you, from the perspective of an ICB and ICP chair, how do you deal with this short-term, long-term challenge?

Kathy McLean

Yes. And it is, as you say, Matthew, it is one of the big issues that comes up and I think has felt even more pressured. 

So in terms of the way that I see it and in my systems, you have to accept it. It is a reality. There are some real challenges in the present and we have to work and put things together so that they actually address those, whether they are related to operational challenges, appointments in general practice, or the sort of looming financial challenge, which I think really does impact on the way that leaders across systems are able to actually deliver for the longer term. 

But at the same time, we have to have discussions that allow us to keep focused on that future because we're well aware that if we don't, we won't actually resolve any of the issues for the future and we will end up in a worse position in three, five years’ time. So as you say, Matthew, it is a sort of split screen or as some of us talk about managing today and developing tomorrow. 

We have to do that. And it's a real challenge in terms of bandwidth for individuals. But actually the future bit is in some ways the bit that was the reason we all went into this and we are staying true to that ambition and our four purposes. 

Matthew Taylor

Yeah, I heard Wes Streeting speak recently and one of the lines in his speech really intrigued me. He said, we pay the NHS to be busy. We don't pay the NHS to achieve outcomes. And certainly I know that visiting you in Nottinghamshire and looking particularly at the data that you use, that one of the things that felt to me were a part of this kind of longer-term thinking was trying to focus much more on population health and having the kind of data you need to be able to focus on population health. 

Kathy McLean

Absolutely. And interestingly, I have today just been reviewing our latest version of our outcomes framework and it's absolutely vital that we do that and have that in a granular way because every community is different. And our four purposes, the second one is there to reduce inequalities. 

The first is to improve outcomes. And I think only by having that really quite detailed population data about outcomes, but about risk factors allows us then to use the resource we have to target it to reduce those inequalities, to help people and link really to one of those three shifts, which is moving things more into the community and the second one around prevention and moving upstream. 

Because once we know where our deprived and most challenged communities are, certainly there are plenty of examples and some of these have come out in the confederation report on the state of ICSs and our own experience that show where you can do that, you make a big difference and start to impact actually on the requirements on the NHS, which if we don't do that, we will not long term easily be able to meet. 

Matthew Taylor

And of course it's all three of the Secretary of State's shifts because this is using digital, using data to enable us to identify those people and think about how we can organise services better around them. 

Now you mentioned resources. Clearly, there's an ever-growing concern about the state of the NHS's finances. This year we read that five months into the year, the NHS is already kind of getting close to the 2.2 billion pound deficit that was kind of predicted for the year. 

We are hearing from systems, and there's a bit of this in the report as well, that these financial pressures mean that systems are having to think about cutting back and cutting back in some cases on precisely the things you need to invest in if you're going to achieve those transformations.

How worried are you about the impact that the current financial situation is going to have on those long-term aspirations? 

Kathy McLean

Well, to be honest, I am quite worried about that. I was heartened to see that in the responses, colleagues were pretty confident about the ability to become more productive. And I think that's helpful. And indeed, every system is working on that. But I am worried that we are not able to put sufficient in the upstream parts of our systems when we know that the return on that investment is multiple times just doing something, treating somebody. 

So getting upstream, getting some of that early diagnosis even is very, very helpful. And we've got good examples of one of the ones I like to go and see locally is our targeted lung health checks. We've found huge numbers of stage one and two lung cancers and other cancers through that process and it's really taking it right out into those deprived communities, allowing it to be easily accessible. 

But maintaining doing some of those things and even more primary prevention requires some resource. We are through integration able to leverage support from the voluntary sector, but I think colleagues are feeling this really to be very difficult at the moment. And you mentioned resources. We have many different interpretations of the word resource, but there's the actual money, there's the people, there's the equipment. 

And I think it's fair to say that short-term planning doesn't help system development. And we would, I think it came through the report from colleagues that a multi-year settlement, something that gave us a bit better understanding of what we should expect in the future, allows us to plan and use that resource over a number of years. 

Matthew Taylor

Yes, that is, as you say, Kathy, one of our recommendations. You mentioned there some good practice in one of the systems that you oversee. One of the things that was great - I thought - about the report, was a good practice everywhere from Suffolk and West Yorkshire to Frimbley and Humber and Gloucestershire and London. 

Do you sense as chair of the ICS Network, Kathy, is it giving people the space to learn from each other? Now systems is three years old. One of the things I hope that the network can be is a place for real opportunities for peer learning across the network. Do you sense that's happening more? 

Kathy McLean

Yes, I mean, I see this is absolutely one of the benefits of networking and, you know, the Confederation being able to support that through its members. 

So my sense is that there is a tremendous amount of good practice. As you say, there's quite a bit in the report that there's many others. You know, I saw there really good practice in Bedford around warm homes and so on. 

And some of that work's gone on in Nottingham, oral health in Norfolk and Waverley and many, many other examples. And some of it getting into our fourth purpose; West Yorkshire doing work in housing and all sorts of things. 

So the problem I think, as you allude to is, people are so busy managing today that it's quite hard work to find that capacity and that time in order to actually spend it learning from others, perhaps going to visit. 

I recently visited Kent and Medway. I know you yourself get out and about. And I think it really brings it home when you go and talk to people and hear what they're doing and the opportunities to do that. Take the idea, if not the specifics, take the idea to somewhere else and apply it. 

And my sense is that everybody's always very keen to share. Nobody's hugging it to themselves. They are very happy to show it to other people, in fact, proudly show it to other people. I think the problem is having the time to implement more locally. If we could, I do think we would make more rapid progress. And I think the Confederation has got a significant role it can be playing. 

Matthew Taylor

Yeah. Well, as you know, Kathy, you've probably heard me say this, that I think that the most dynamic systems, organisations with a capacity for continuous self-improvement have a characteristic. 

And that characteristic is that they align and balance top-down drivers of improvement, strategy, resource allocation, capacity to intervene when things go wrong; lateral drivers that are to do with kind of leadership, capacity, peer learning, professionalism, culture; and then bottom-up drivers that are to do with responding, responding to the choices and voices of the public and patients that we serve. 

It feels a lot of the time as though there is so much that comes top-down, partly because of the kind of political nature of the NHS, that it squeezes out that time that we would like to spend learning laterally from each other, responding bottom up to our communities. I felt one of the first times I ever met you, you explained your kind of inverted pyramid, which seeks to put patients and the public at the top, as it were, of accountability.

I kind of asked this question because there's still work to be done, isn't there, Kathy, about clarifying the accountability relationships between ICBs and NHS England, including addressing variations in people's experience of regions. What would be your reflections of the report on how we get that right? 

Kathy McLean

Yes, I suppose it wasn't a really huge surprise to me that people were feeling it wasn't as clear, perhaps, as it should be. And I think in fairness, that was also reflected in Lord Darzi's report that perhaps there isn't absolute clarity and as you say, it's not exactly the same experience everywhere. 

And of course, integrated care systems are all of a different size, different geography, different makeup. So you might argue they may have different relationships than with NHS England and indeed other regulators. 

But I do personally feel that we do need some clarity. think uniformity of approach, or at least more uniformity of approach would be very helpful. 

But I also think that oversight should not simply focus on whether or not a system is delivering on its here and now. I would like to see that we are held to account for the four purposes, that's why we were set up, and to be held to account for the progress we make on reducing inequality as much as our ambulance handover times would be welcome. 

And I think that there's still probably a varied view across systems as to what the best way of managing the oversight would be. And obviously NHS England have got some of their own statutory duties, which they must fulfil. So I think we have to be pragmatic, a bit of clarity and also devolving to us to do the things that we can and hold systems together using the totality of our resource, clarity about those aims. 

I think that would go a long way for all of us to be able to make progress.

Matthew Taylor

And one element of this, of course, is also how the NHS system of oversight relates to CQC. And we have an interview with Penny Dash in our next edition, which is around the CQC review that she's done, which I hope will also kind of help to make things a bit simpler and clearer. 

You mentioned devolution, Kathy. I was fascinated to see that Andy Burnham, the mayor of Greater Manchester, has taken over the role of chair of the ICP there, following the example of Oliver Coppard, the chair of South Yorkshire, who's the chair of his ICP. 

I felt for a while that the complement to this idea of mission-driven government in Whitehall, to the idea of thinking about health and economy together, is to strengthen the profile status role of ICPs as bodies that bring together the health service and local government and third sector and potentially even private sector partners.

You've obviously have experience of ICPs as well as the ICB. Do you share that view that there's a real scope here for ICPs to step up to be more significant actors in the system? 

Kathy McLean

Yes, it is interesting and I'm obviously aware of the mayor's roles and indeed where I am one of the new mayors, you know, has just relatively recently been voted in. So that's the Nottinghamshire and the Derbyshire, D2N2 as we call it, for East Midlands Combined Authority. 

So I see great possibilities for integrated care partnerships. I chair the Nottinghamshire one, but I think that whether or not you do it through that particular route or any other, I think the relationship between the statutory bodies, that's the health statutory bodies, the devolved administrations and the local authorities, I think they have to work really, really closely together. Whether or not every single one needs to do it the same, don't have a view at the moment on that, but I do think that we need to use that vehicle or a similar vehicle to really be working together for the same aims. 

Once we're working together for the same aims, we can make sure, and I see examples all the time are brought to me about how things have actually been duplicated and that is wasteful. We don't have that extra resource to be wasteful. 

So I think there are real learnings to be done from the early examples, South Yorkshire as you say and now Greater Manchester. And it will be very interesting to work with mayors to see how they want to do it. They don't all have health specifically in their powers, but everything kind of leads to health, whether it's transport, employment, skills, education, kind of leads to better or worse health outcomes. So we've all got a vested interest, I think. 

Matthew Taylor

Yes, and I think there's real scope here for strengthening the dialogue between systems and places and the centre. I did a fringe meeting, in Liverpool, at Labour Party Conference with Andrew Gwyn, and I took him on one side and reminded him that sitting in the department is a proposal based upon a recommendation from Patricia Hewitt's review to establish a national ICP-ICB forum, where ICP and ICB leaders can come together and meet with officials and ministers across Whitehall to talk about this wider population health agenda. 

He promised me he would try to search it out in his inbox. So we hope to see progress in relation to that. 

But that takes me to place. And I think this is a tricky issue, isn't it? Because we've always said in the Confed that ICSs should see themselves as empowering bodies seeking to give as much freedom to places, to trusts, to collaboratives, you know, within a proper strategic and accountable framework. And place bodies, I think, are going to be really important in the future. 

But one of the things we've picked up, I think it's mentioned in the report, is it's not always the case that this kind of relationship between system and places is going right. And some systems have had to cut back a bit on their kind of place infrastructure.

What do you see as the right relationship between system and place?

Kathy McLean

So, obviously, I subscribe to the view that place is vitally important. Again, though, this variation. Place in some of the very large systems is like the size of a whole system. So, I think if we go back to the concept that place relates to geography, you can get past that. So, it kind of doesn't matter. Whatever is recognised locally as the place, I think is fine, but it's really helpful if it aligns with either unitary authorities or upper tier or lower tier authorities, I think that really is helpful. 

And I think that devolving as much as we can to them, because at the end of the day, may, you know, we all have a strategy, we all need to move on some of those things, but that will be delivered very, very differently depending on the local communities and within place. I think it's really important that we have the concept of local neighbourhoods as well. We've called them different things over time, but basically, relatively smaller neighbours that people recognise. 

Today I received from one of our primary care networks a very proud document describing all they've achieved in the last year. You know, my job is simply to promulgate that and ask them, what more could we do to support you? That's the approach we need to take. But I think we can help set strategy, engaging people in that. 

But the delivery's got to happen locally. And if we don't feel brave enough, you know, in line with the inverted pyramid, which is what we subscribe to where I'm working, is we give primacy really to that place and neighbourhood.

Matthew Taylor

It's also really important, don't you think, Kathy, to bring this back to patients. My sense is that one thing we have to acknowledge in the health service is that in many ways we are still a health service that tends to view patients as people who are well but have got something wrong with a bit of their body when in fact most of the demand that is driving the health service – I don't really like the word demand; it's almost like we're blaming the public for having needs – but most of the demand is coming from people who have long-term conditions, multiple conditions, often a combination of physical, mental, and social challenges. 

And actually to build a more holistic, more proactive health service, which really develops a relationship with those people, supports them, and empowers and enables them to live their best and most healthy lives, that's why it seems to me we have to rethink how we do things in neighbourhood and place, so how we need to bring together primary, community, social care, community-based mental health services to really change the offer. That feels to me to be absolutely at the core of all of this. 

Kathy McLean 

I absolutely agree with that. I I've seen examples of where communities have had real challenges, but ultimately the members of those communities have become effectively the leaders. 

We've got this marvellous family mentoring scheme where those who've been mentored become the mentors themselves. So they sort of graduate almost through that process, but they understand their local communities. They understand the people and they understand the challenges that they have. So they kind of can learn and then give back if you like. 

And all of that is nothing like the costs of running a big acute hospital. It's just that we don't necessarily get it going and give it sufficient airspace and small amounts of resource and the enormous dedication some people put into these things. 

Social prescribing, I've seen some marvellous examples of all of that. But it's at risk when we're struggling with money. I think the voluntary sector at the moment are feeling the squeeze too because they are very dependent on little packets of money, but they add up to quite a bit all over. And I think that's something we need to watch out for. 

But local delivery of the, and I agree with you, I never liked the term demand, I think this is people who need something. It's not a demand. It's actually how do we help them become more self-sufficient and get into that prevention piece? Again, we'll do that through local general practices, primary care. These are great agents for prevention. 

Matthew Taylor

Yes. And I fear we may carry on using the ‘demand’ word, partly because I'm hearing, which is encouraging, that the Treasury is starting to understand that the really big fiscal challenge for the country is the medium- to long-term demand curve for health and care. And unless we can bend that demand curve, in a sense, all bets are off because health will just carry on eating more and more public spending and more and more of our economy. 

So just two final questions. The first is, Patricia Hewitt said in that report 18 months ago that the paradox was that the previous government created ICSs but did not create circumstances in which they could flourish. How hopeful are you listening in particular to Wes Streeting talking about his shifts, reading Darzi, that notwithstanding the immediate challenges we've discussed, that we are moving to a world where we will enable ICSs to do the job they were created to do? 

Kathy McLean

So a bit like those who filled in the survey, I am also an optimist and I am really encouraged to hear that the shifts that Wes Streeting talks about are aligned to the things that we've been discussing and we were set up to do. I think there are some immediate challenges which feel really tough, I have to say, at the moment. 

I think partly because we have such a backlog waiting to be dealt with, and I can't see any other way than doing that in hospitals or other such facilities, and we have to get through that. We have to manage the emergency pathway. 

But I am very optimistic that we've been set up with a remit to integrate, a remit to think about equality and equity, and a remit to think about the wider determinants of health. 

I think one of the things I was reflecting recently is when we set up, we put a lot of effort, and prior to the legal changes, system working had been going on for a few years, we put a huge amount of effort into relationships. And I know many of my colleagues continue to do that.

But I think we need to revisit that and think about that as an ongoing development because people change. And without the right culture and the right relationships, all the legislation in the world will not make this happen. 

But overall, I am optimistic, partly because I don't see another option in terms of an approach to making sustainable change for the future. 

And we want our NHS to be able to respond when it needs to respond. But much of health of the nation relates to those wider determinants. 

Matthew Taylor

Yes, and you know, it is a cliche, but I completely agree with you about relationships. And one of the things I've noticed going around the country is I go to systems and something that really seems to be symbolically powerful is when I go to a system and one of the people the system wants to present to me is not actually from the health service. 

I went to Walsall and they wanted me to hear from the person who ran the housing association who chaired their place board.

I went to Durham and they wanted me to hear from the director of adult social care who was also a key member of the place team. 

So I think you're absolutely right that kind of sense of genuinely shared vision. 

So Kathy, last question. You're chair of the ICS Network and we're delighted to be working with you. What's your ambition for that network over the next few months? 

Kathy McLean

So that's a very good question and I'm constantly reflecting on this and talking to members of the Confederation. 

I would like it to become somewhere where we have a genuine opportunity to share best practice, that people get an increasing sense of going to look and see and join up. I think there are lots of interactions that do go on that are not just happening when we're meeting as a network, but between bilaterally and in smaller groups. And I think we should be encouraging all of that. 

I think a sort of a real sense of improvement. We do some of that sharing, but I think we could do more of that. And I think that we need to help and support people through these difficult times so that they keep the faith with the possibility, as we've just been talking about, that optimism about what we could all do together moving forward. 

And I think we have to accept we're all in different stages of development. We've all got different stages of development of our places and neighbourhoods. And leadership is sometimes not always as stable as you would like it to be. And I think we need to help each other through that network, partly through that network, to be as good as we can be, but also to remain sort of resilient, I think, so that we get through this next phase and can do the things that we've all actually signed up for. 

Matthew Taylor

Well, Kathy, what a great way to end our conversation. Thank you so much for joining me on Health on the Line.