How important is integration at place level?

MATTHEW: Hello, and welcome to Health on the Line from the NHS Confederation, the organisation that represents members from across the health and care sector in England, Northern Ireland and Wales. In a moment, I'll be speaking to Stephanie Cartwright. She's group director of place for Walsall Healthcare NHS Trust and the Royal Wolverhampton NHS Trust.

Stephanie's going to be helping me unpack the concept and practice of place leadership. The prompt for our conversation is a new report we're publishing today at our ICS Network Annual Conference. That report looks at the state of integration at place level and what we can do to enable places to be more effective.

And at the end of the show, I'll be bringing you another in our new Leader in Six feature, a series of quick-fire questions to a NHS leader that just helps us to get to know them a bit more. So I'm delighted that Stephanie Cartwright is joining me. Welcome to Health on the Line, Stephanie.

STEPHANIE: Thank you very much, Matthew. Good to talk to you.

MATTHEW: So let's start with an obvious question. But one that I suspect people listening will have in the back of their minds, may be afraid to ask because it's so obvious, but let's get to it. So Stephanie, how do we define Place?

STEPHANIE: So Place is where people live their lives. So if I, if I speak from the perspective of the Black Country, we've got four Places: Dudley, Sandwell, Walsall, Wolverhampton. So people connect with that. They live in Dudley, they live in Walsall, they live in Sandwell. So it's familiar to people. That's how I would first describe Place.

The second way I would describe Place is where we come together to plan and develop the services for those people that live within that Place. So, it's about how we work together to deliver services, it's about how we develop partnerships together across the Place. And we enable that through formal agreements to make Place work from a perspective of making progress for that local population.

MATTHEW: Now, one of the things we argue in the report is that Place is the best level for integration to take place. 

Walsall is a prize winning Place for its integration activities. So, tell us how integration works in practice in Walsall.

STEPHANIE: So I think the first thing to say is that on a day to day basis, we do as much business as possible through Place. And when I use the term we, I mean the partnership of the NHS, the local authority, the voluntary sector, primary care, housing partners. And we, determine that the best possible way to develop services and integrate services is to ensure that we're working together and we enable that through a partnership agreement.

So there's a formal agreement in place in Place that enables people to work together and that's, that brings with it an associated governance mechanism. Which makes it much easier to be able to do as much business as you can through Place, but it is something that we put effort in, it's something that we all work to as partners.

And the reason that we do that is because it puts the population at the center what we do. So it takes the ethos that we're all looking after the same group of people that live within that Place. So it gives us a greater enabler to be able to work together, to integrate those services. It is also about recognising that we will achieve more for our population if we work together than if we work in silos.

So that is why, from our perspective, working together at Place is so much more effective because we're all working together on that same population that we're all there to serve for different reasons in some, ways, but by coming together, it enables us to provide those services in a better way.

The other thing it recognises is that, this is where people are living their lives on a day to day basis, and it's about how the organisations work together to complement the lives that they're living rather than expect people to sort of change their lives to fit the organisations. So it's very much focused on organisations working together around that person at the center. 

MATTHEW: And one of the things that really hit me when I was in Walsall was that , you know, health, health provision is central to what you're trying to do at Place level. You're working on the same issues that everyone else is working on: trying to reduce unnecessary emissions to hospital, hospital discharge, trying to straighten community services, prevention, et cetera, all that good stuff. But health isn't necessarily in the driving seat, is it? I mean, I don't know whether it's still the case, but I think when I came to Walsall, it was actually the chair of your Place partnership was from the housing sector, from the housing association?

STEPHANIE: So the chair of our - we've got an independent chair within the Walsall Together partnership. His background is around the voluntary sector so we have that level of independence means that it's not dominated. So you're absolutely right to say that a lot of it is about health and it's about health and care and the provision of enabling people actually to lead as healthy a life as possible, but by having that independent chair, it means that everybody's voice is equal.

And I think that's a really important point to make about Place and the value of Place is that it's not dominated by any particular partner. There is a risk that particularly with big public sector statutory organisations, they can dominate. And I think that's what in some areas may have happened in the past.

And that level of independence enables us to all sit around the table as a partnership of equals.

MATTHEW: Yes, absolutely. And there's a real opportunity there, but I think it's a challenge for many in the health sector and, and it links into issues of accountability because, of course, local authorities are accountable. They have elections, they are responsive to voters in a way in which the health service is not.

You know, we, we are not locally democratically accountable and an awful lot of what we do in the health services dictated by national organisations by NHS England, the Department of Health, et cetera. So what's the accountability challenge at Place because I, I've often said in the past Stephanie that both Places and also integrated care partnerships kind of exist in a slight accountability vacuum. It's not really clear who they're accountable to.

STEPHANIE: The way I would answer that firstly is that they're accountable to each other. So I think there can be sometimes a myth that Place based partnerships are, you know, they're very much about working together. They're very much about relationships across partners, but it's also about dealing with the tough stuff as well together.

So, and particularly in the times that we're seeing now around some of the financial challenges that are hitting all of the sectors that are part of the partnership - that actually really tests, I think, the value of the partnership and how it's able to work through that. 

So we all have our part to play to make sure that we're making a difference and there's only a value in a Place based partnership if you are making a difference for the local population that you're there to serve. So ultimately you could say that you're accountable to all of the population. We are there to make sure that their lives get better as a result of our partnership.

But we are accountable to each other. What I do think will happen is that in the future, when Place based partnerships, and this obviously links to your report that's coming out, and also the national messages that we're now seeing, is that Place is very much becoming a stronger and more essential part of the NHS.

It's a need to have rather than a nice to have. And I think as it's developed over the last few years, which is why some Places are at different levels of development, it has been very much about a partnership of the willing coming together to make a difference. My personal view is I think that's going to change and that actually the accountability is likely to be much stronger in the future from a more formal perspective than it is now.

But is the accountability in Place now? It absolutely is. And we hold that accountability across each other. 

MATTHEW: And tell me about how this works with trusts. So, you know, one of the issues we wrestle with at the Confed is there are those who like to assert a kind of dichotomy between systems, Places, and neighbourhoods and trusts, and that trusts really want autonomy and only really to be managed by national institutions, that they are ambivalent at best about notions of being more accountable locally working more in partnership, how does it work in your part of the world?

STEPHANIE: So I think in the Black Country, we've got some really strong models. This is ultimately a culture shift. And this is referred to in the, in the Darzi report, as we all know. This is a huge culture shift for the way that the NHS and trusts have worked previously to how they need to work now. We all know that there are a lot of people going into hospital, attending hospital, in hospital, that don't need to be there.

So from our perspective, with the NHS Trust in the Black Country, the solution to actually managing demand, and ensuring that the people that they are seeing and treating are the ones that they need to, are the solutions out in Place. Because a community first NHS is not just the community services that NHS trusts run, a community first NHS is the wider community, whether that's in the primary care or if it's in the sector, some of them will be NHS provided services.

So it's a culture shift, but it's also the solution to the demand that they're seeing and some of the challenges that the Trusts are seeing. So it's a turning point for Trusts to work in a slightly different way, to work with their partners and actually realize that an NHS Trust can't solve some of the issues that we're facing at the moment alone.

The only way that things can get better is actually if we do work together with the partners and see the value that everybody brings. to the care that we're giving to the population.

MATTHEW: So in the Black Country you've got four different Places and what's fascinating to me when I visited you is that the way you do things in Walsall, the way you do things in Wolverhampton, in Sandwell, and in Dudley are, quite different. So tell me about that dynamic. In some systems, the financial challenges, and you are very financially challenged in the Black Country, has meant that systems have withdrawn a bit from Place. It's kind of felt like, look, we've got so little money, A) we can't really fund the infrastructure of Place, and B) the decisions we've got to make are so tough, we kind of have to make them at a kind of system level.

So, in the kind of challenging financial context you're in, with four different ways of working at Place level, how is kind of the system tolerating that level of difference, and is the system still bought into the idea of devolving to Place?

STEPHANIE: So, I would say the first answer is yes, they are. There's a reason that I think the Black Country system works slightly differently to some of the other areas with regards to Place, and also this is the same reason as to why they're different, is that they are genuinely Place led.

So, in my work with other systems across the country, I can see that there's a heavy system influence and leadership into the way that Places are developing, the way that their structures are. And there's probably more consistency across the Places. Now there are consistencies across our Places.

There are similarities with partners. But what there is is, there's Place difference. And it's recognised that the value the Place difference brings. Because if you think, we talked about local authorities, we've talked about primary care, we talk about the sector. They all operate within Place. So we've developed the Place based partnerships in the Black Country based on those local partnerships.

And that integrity is protected. That value shines through. So what that will enable is that as devolution starts to develop and there's more delegation down to Places, those partnerships are already embedded and there will be more opportunity to enable those partnerships to work on solutions together. Because of the history that those partnerships have got, if you take Walsall Together, for example: Walsall Together came together as a partnership before Walsall was told to create a Place based partnership. And there was similarity with Sandwell and Dudley as well. One Wolverhampton was slightly later, but it's all about a partnership of the willing.

And I would give credit to the system on this because it enables the Place based partnerships to be led by that local leadership that's across those partner organisations. With regards to the finances, again, as I said earlier, this is where a Place based partnership to a certain extent receive its biggest test because it's not just the NHS that are under financial scrutiny and challenge, it's also our local authority and as a consequence our voluntary sector partners as well and primary care.

We're all facing financial challenges. The size of the figure might be different, but the financial challenges are relative to the size of the organisations. There is a commitment and determination across the Black Country that the solutions can be found in Place by working together and actually identifying who is the best provider or partnership or organisation to provide the services to those patients, because it's not always as we've historically seen.

So this, we, we very much across the Black Country see the Place-based partnerships as the solution for some of the financial challenges. But I don't, I don't want that to go without recognition that they can provide tension, particularly when organisations are battling with their own financial planning with regards to approaching deficit management, et cetera. And so it takes a higher level of determination to keep that partnership together and focused on the solutions together.

MATTHEW: Yes, and I think, you know, we consistently say at the Confed, we need to slightly reduce kind of national accountability and oversight in order that we can strengthen lateral local accountability and oversight. It's not about wanting to be less accountable. It's wanting the accountability locus to shift to that Place and, and to that neighborhood level.

But you talked about solutions Stephanie, you know, we are in the process of developing a 10 year plan for the NHS. I believe that at the heart of that plan needs to be a radically different kind of model of care. How unified are you in Walsall about your vision for the future of healthcare?

How transformative is that vision? Are you all signed up to where you want to be over a kind of five to 10 year period?

STEPHANIE: Yes. So Walsall Together currently is refreshing its strategy alongside the national messages that are coming out ahead of the NHS plan. So we're not waiting for the NHS plan to tell partnerships what to do with regards to developing the neighbourhood NHS. In many ways. the changes that are coming is music to Place based partnerships ears, because this is what they've been working on and this is what they've been trying to prove is that the solutions lie within the Place and within the neighbourhoods that they're developing and they're supporting.

So there is unity across the partners. There is actually, you know, a high level of ambition. There's a high level of motivation to be able to deliver and there's also a high level of appreciation of the opportunity that this will now provide because Place based partnerships have been working on trying to do a lot of what the NHS plan is going to say.

So in all of the kind of workshops, et cetera, that I've participated in, I can hear my colleagues talking in the same way. This is a real opportunity that people are really ready to respond to.

MATTHEW: So one of the kind of insights that I'm kind of coming towards, I think, is that if you look at the literature around business transformation, you know, a commercial business transformation or, actually in, in the public or third sector, what you'll see is that, business transformation is difficult, generally it fails actually, but when it succeeds, a big part of the reason it succeeds is because change happened in a coordinated way across many, many domains. So you have to think about, you know, your digital and IT strategy, your financial incentives and flows, your investment, your stakeholder and public engagement, et cetera, et cetera. If you really are going to transform things, we have to do them on multiple fronts together.

And actually, as I go around the health service, I see so much great practice, but a lot of it feels quite fragile because it's only in a bit of the system or the Place and it's not connected to all the other things that need to drive transformation. What's your sense of the scope for transformation and do you think Place is the level where we're most likely to be able to do it?

STEPHANIE: Yes. I think that the level of transformation and the level of change is significant and I would agree that this is the biggest change that the NHS has seen within its history. Is it required? Yes. Does everybody that that I particularly work with and my connections across the Places and across the system agree that this is required?

Yes. So there is a strong sense of a partnership of the willing on this. and almost, like I say, a sense of, of relief that things are coming to change, but there's also an acknowledgement of the size of the task. And this is where particularly some of the statutory organisations are going to have to become much more flexible to be able to develop some of the systems and processes across the partnerships, because it can be some of the bureaucracy that we have seen previously can be stifling to innovation.

So alongside the messages and the requirements of how things need to change, needs to be a shift in culture across the whole of the NHS, particularly with regards to becoming much more flexible with regards to how it develops solutions. And we need to do as much as we can to enable innovation and to enable transformation and try where possible not to stifle through traditional bureaucracy because the change is across the board.

So the transformation change that's required in Place and in neighbourhoods to really deliver integration and to really deliver a community first neighborhood NHS, actually needs a change at every single level to enable that to happen.

MATTHEW: You mentioned neighbourhoods, Stephanie, so kind of a final question in a way is, is this neighbourhoods question. So just as Place bodies will encourage systems to devolve to Place, so neighborhood teams will encourage Places to devolve to neighbourhoods. Now, in that discussion about neighbourhoods, which the Confed is really deeply involved in with government, one of the things we want to emphasize is that neighbourhoods are not just about kind of multidisciplinary teams that are geographically slightly closer to the front line. It's about a very different approach, and in particular, it's about a different relationship with the community and with the voluntary sector. What is the kind of of Walsall approach to neighbourhoods. And, and do you agree that the essence of neighborhood working really has to be, I mean, I'm a, talked about this for years in different contexts, but in a sense a kind of a blurring of the boundary between the statutory and the community and voluntary in order to be able to develop models of care that really work, particularly work for people with long term multiple conditions and social challenges as well.

STEPHANIE: Well, absolutely. So the Black Country is one of the most deprived areas across the country, but even within each Place, you've got areas of affluence and you've got areas of deprivation and that's in all four. So the neighbourhoods is exactly where we need to focus a population health approach.

So the statutory organisations need to flex to those neighbourhoods rather than the neighbourhoods flex to what works for an organisation. So organisations need to adapt their services to work at a neighbourhood level because neighbourhoods are familiar to those people that live within them. So it has to be dominated and dictated by the neighbourhoods that are familiar to the people that are living in with them to enable those community connections, to enable that interaction with the community and voluntary sector.

And this links back to the finance question as well, the level of investment and the return on investment from, you know, a pound or 10 pounds that goes into the community and voluntary sector compared to what might go into a statutory organisation - the difference is immense on the return on social value.

So the neighbourhoods are incredibly important, but we have to make sure that we work to what is familiar from a Place perspective on what those neighbourhoods mean. My fear is that there'll be some areas will move to what suits the organisation. So organisations will say that they'll work at a neighborhood level, but it will be around how they arrange their services and what works.

And it has to be around the people that live within that neighborhood because it has to be about the connection with that sector. And they work at a neighborhood level.

MATTHEW: Absolutely, Stephanie. And that's why the work we've done on neighbourhoods we've done in partnership with local trust, because we felt that from the very beginning, it was important that any recommendations around neighborhood working came not just from a health service affiliated organisation, but from an organisation whose focus is on on the community, on social capital, on kind of asset based community development.

Well, look, Stephanie, I have I really enjoyed this conversation. Thank you so much for helping us to produce this report about Place leadership. If anyone's interested in that, as I'm sure you are after listening to this conversation, you can find out - you can read the report on the NHS Confederation website.

So Stephanie, thank you so much for joining me today on Health on the Line.

STEPHANIE: Thank you very much.

MATTHEW: And now, to wrap up, another NHS Leader steps up to the plate for Leader in Six. A brand new segment of Health on the Line. It's very simple: six quickfire questions to get us better acquainted with the people who lead our health service. So I'm delighted to be talking to Tracey Bleakley, who's chief executive of Norfolk and Waveney ICS. So Tracey, your six questions start now. What is the most pressing issue for you right now? 

TRACEY: Transforming new models of care over the next five years. Fantastic opportunity with two new hospitals. So that's going to really focus our minds, but our care models are not fit for purpose. We have an aging demographic, and we need to focus on that. 

MATTHEW: Brilliant. Uh, what is the thing that's happening in your system, innovation or improvement, that you're most proud of?

TRACEY: Our team's looking at population health and prevention using AI, actually. Uh, the work that they're doing at the moment around CVD, stroke, obesity, um, the front door for children's mental health is making such a massive difference. I think huge untapped potential and it's going to make a big change to the way that we provide health and social care.

MATTHEW: Tell us something about yourself that's nothing to do with your day job. 

TRACEY: Stupidly, I've got an acre garden on top of this job, which is absolutely ridiculous. And there are days when I don't feel on top of it and it feels overwhelming. And then I realised it's like the job and actually it's going to be okay.

And it's still doing wonderful things, regardless of whether I'm in any kind of control. And just doing a little bit sometimes makes a massive difference. 

MATTHEW: And you grow vegetables and stuff as well? 

TRACEY: Yes, I have the most fantastic pumpkin to carve in a couple of weeks. Really proud of that.

MATTHEW: Brilliant. If you were king of the NHS for a day, what is the one reform you would introduce?

TRACEY: Actually, it's a wider societal one, if I can get away with it? 

MATTHEW: Yeah, okay. 

TRACEY: Um, I'd like us to talk about death and dying better as a society because of my background in palliative care. If we can do that, we can transform the care that we give to people all through their lives and end of life.

And you know what? If you accept that dying is a part of life, people live better and they make the most of their lives. So I think that would completely transform what it is to be human as well as health and social care. That's what I would do. 

MATTHEW: Brilliant. And then, outside of your own system, who's the health service or other leader that you most admire and why?

TRACEY: So I was thinking about this. Over the past 10 years, Kate Granger, actually. So we don't think about Kate as much as we did, but Hello My Name Is was the most fantastic movement that she started. She started it by walking in the shoes of a patient because she became a patient herself. She was the most wonderful person.

I was privileged to get to know her. Still in touch with Chris, her widow. And I think for me, it just shows that anybody, anywhere can make a real difference if we think about what things are like for our patients and we can make that change. 

MATTHEW: Yeah, now we have to start and finish with patients and their experience.

Last question, what are you currently enjoying in terms of a box set, podcast?

TRACEY: Um, there's a new film on Prime called Wilding and it's about the work that's gone on at Knepp. So there has been a book, it's been going on for years and years about rewilding and agricultural land that isn't producing particularly good crops.

Charlie Burrell and Isabella Tree, um, it's, it's so beautifully produced, it moved me to tears because it's so wonderful and, I think it just goes to show they've been working on this for decades and the change that they've made and how they've tried to roll that out and I just, it's just a wonderful watch.

MATTHEW: So you're going to be wilding your acre garden? 

TRACEY: I think it's doing that itself, to be honest, while I'm here with you. 

MATTHEW: Thank you, Tracey.

I'm afraid that's all we've got time for on this edition of Health on the Line. We'll be back with our next episode in a couple of weeks. But in the meantime, please do follow us and leave us a rating or review wherever you get your podcasts. Thank you. 

Presenter: You've been listening to Health on the Line from the NHS Confederation. Visit nhsconfed.org for more information about us and to register for events and webinars that delve deeper into the issues explored in this podcast.