Adam Doyle: ICSs aren’t just about holding people to account but helping people to change

Matthew

Hello. So, another week and we have another new prime minister. We at the Confed have congratulated Rishi Sunak on his appointment as new Conservative Party leader and Prime Minister. And let's celebrate the fact that he is the first British Asian person to hold this office.

But as we head into what is largely expected to be one of the worst winters for the NHS for decades, his new administration must act quickly and decisively to support both health-service and social-care staff through the difficult weeks and months ahead. That means taking immediate action to help to mitigate the considerable risks the NHS is facing ahead of winter.

The fact that, at the time of recording, with winter upon us, we still don't know how the £500 million discharge fund is going to be spent does not, I'm afraid, suggest the government fully gets it when it comes to the reality facing NHS leaders and the communities they serve.

It's important that in the upcoming fiscal event we see measures to shield the most vulnerable people and communities from the impact of any cuts or further efficiency savings. Indeed, wouldn't it be good if we could bring the fiscal and growth agenda together?

As former Chancellor, the Prime Minister should understand the link between health and wealth. Confed’s recent analysis showed that for every pound invested in the NHS, £4 comes back in wider economic activity. So, as well as delivering for patients, the NHS can and should be viewed as a vital building block for economic growth.

We know that our health leader members and their teams will always do all they can to improve efficiency and productivity in the NHS, as well as driving down waiting lists as much as possible. Something which the new Prime Minister showed commitment to tackling during his summer leadership campaign.

But the new government must recognise that these efforts are being hampered by budgets that have been hit very hard by inflationary pressures. They've already left the NHS, facing a £7 billion gap in its budget next year compared to that set out in last autumn’s spending review. We've got new teams in the Department of Health and Social Care, as well as the Department for Levelling Up, Housing and Communities, and they're going to need to get their heads round big new briefs as quickly as possible.

After months of policy U-turns and blight, we do need to see clear and decisive action. And as we all know, one of the biggest pressures is still workforce. So we've welcomed the continued support for major national advertising campaigns for a career in the NHS. Nursing is the largest profession in the health service with a huge variety of roles, and nurses make an incalculable difference to the communities they serve every day.

We're hearing all the time from our health leader members that they're profoundly concerned that the government has repeatedly failed to invest in the health and social care workforce. We know that the pressures on social care are mounting, particularly as rates of pay for further and social care staff. That's why we're desperate to hear how the £500 million discharged fund is going to be spent.

The need for the new Prime Minister to act to expand the numbers of staff being trained to work in health and social care is now critical and long overdue. Indeed, this should be part of a fully costed workforce plan, which we still expect to see before the end of the year.

Workforce is, of course, one of the many issues being juggled by leaders of our new integrated care systems. And in this edition of Health on the Line, I have a great conversation with one of those leaders, Sussex's Adam Doyle.

Matthew

Well, I'm delighted to be joined by Adam Doyle, who's the CEO of Sussex ICB. Adam, how are you?

Adam

I'm good, thank you. Matthew. Thank you for having me today.

Matthew

I think it's quite typical of your workload at the moment, Adam, thatyou were slightly late to join us because there was something that cropped up in your system. You've got to go promptly at the end of our conversation because you’ve got a meeting. I guess things are quite frenetic right now.

Adam

Yeah, I mean, it's a busy time, isn't it? We've got winter to work through also to make sure that all the ICB things put in place since the 1st of July are working and also we're planning our five year strategy. So yeah, busy, exciting, lots to do. And I'm really, really enjoying the role.

Matthew

Just for people who don't know. Tell us a bit about the characteristics of your ICS. I think it's kind of one of the biggest non-urban ones, I mean, there's the big one, Manchester, North East, the London ICSs but you're one of the larger ones outside the conurbation, aren't you?

Adam

Yeah, I think we're sort of seventh largest in the country, really in terms of population size. So just under 2 million people live in Sussex. It's made up really of three identifiable areas, which is East Sussex, West Sussex and Brighton and Hove. And a lot of people you speak to, don’t often say they live in Sussex, they sort of identify to their place and often their town, within each of these places We've got a real mixture because obviously we've got a significant part of the coastal strip of the south east of England, some significant areas of rurality and then some urban areas within that, particularly towns like Crawley, towns like Brighton. You can't say Brighton, it's Brighton and Hove. They are two very separate places. I often get remarks about that from people.

Matthew

Do people still say Hove, actually, Adam?

Adam

That is still a joke you often hear in the coffee shop? Yes, Matthew, so I think it is how people live their lives, they sort of identify with where they live. So yes, we've got areas of high affluence, areas of significant deprivation and of hidden health inequalities, because of course, when people look at Sussex, they don't often look at it as a system that might have significant areas of deprivation. And often when you aggregate up the overall population of Sussex, it looks to be relatively healthy. But of course, in those kinds of systems, you have to be really careful about making sure you look at where there are areas of hidden deprivation and hidden poor outcomes.

Matthew

And you've heard me, I think, use this phrase split-screen thinking for how we need to try to think about the urgent issues we face informed by the destination we want to go towards, the vision that we've got.

And I want to talk about winter and the pressures. And obviously, you know, we're proud that you're a member of our board at Confed, representing systems and that you speak a lot to other system leaders. So, you can talk not just about your own system, but what you're hearing from others.

But before we get into the winter stuff, I'm interested to know when you took the role on Adam, what's the kind of big vision that you've got? We get through winter, you know, maybe circumstances become a bit easier. Who knows? Maybe we get a government that gives us the investment we need. Where would you like your system to be in five years? What would be the things that would be different about it?

Adam

Okay, so that's a great question. And, I made an active choice to apply to be the Sussex ICB CEO.

My history was I was leading all of the CCGs and did quite a bit of a turnaround work with many of our partners to get that system into much better shape. But I made a choice to want to stay, and I was really privileged to have secured the role because I do believe in integrated care.

I'm a physiotherapist. I worked in a lot of deprived communities in my early sort of training and then when I qualified. And I was frustrated at times by the lack of integration; it's what sort of drew me into management. You know, the naivety of youth, where you think that actually you can change the world.

But this job does give us the chance to do that. So,the exciting part of this job and the exciting part about integrated care, as I see it, is you get to work with a vast array of statutory and non-statutory partners that work across the broad spectrum of public sector services. And for me, that's our vision. Our vision is to create health through other people's hard work, ideas and input.

As I see our five year forward plan that we will be putting together, we are describing a plan that is based on resilient communities where we bring together all of the assets that we can bring to bear in a local neighbourhood to support that community and for those communities to support themselves.

So, you really want to start with what are the assets the individual has? So, what can they draw on? What are the other organisations around where somebody lives that we can draw on? So that's a real inverted way for how the NHS would work. So we're a partner with all these other people that at times have better ideas than us.

I see the integrated care part, the integrated care partnership, part of my role all about brokering relationships, putting people together. And being very humble about why haven't we changed these things at this point and seeking support, seeking ideas from people. So, for me, that's the really exciting part of the role.

Of course, though we have to recognise the NHS is under pressure. I've also got a responsibility to make sure that in my own system all our NHS services are working as well as, as productively as value based on our communities as possible. But I see those two things as complementary. I don't see them as two separate things. But of course, what drew me to the role was bringing everyone together. But what gives me that licence to deliver that is ensuring that every day the NHS is doing the best that it can for its community.

Matthew

So, thinking about that in the way that you described Adam, which is the kind of broader local shift and then the shifts in the health service. Let’s take those in order.

For me, one of the opportunities of ICSs is a kind of symmetrical proposition. And I've spoken to you about this in the past, and I know that you have enthusiasm for this, which is, on the one hand, what’s sometimes called health in every policy. How do we work with our partners, particularly in local government, but also in business and third sector, to recognise that only 20 per cent of people's health status depends upon the work of the NHS and to have an approach which recognises the importance of education, of planning, of employment, of welfare to health. So how do we get our partners to recognise the importance of everything we do in terms of shaping the social determinants of health?

And the symmetrical proposition of course is your fourth mandate as an ICS leader, which is the economic, social, environmental impact of the NHS, the NHS itself being a good local citizen.

So, do you think that kind of symmetrical proposition frames what you're trying to do in terms of those relationships beyond the health service?

Adam

First of all, I think it's really, really important to recognise and we hear it often, don’t we, what are the things the NHS can actually do to get to get people's health into better shape? And in many respects, it's quite limited because we're dealing with people in crisis or where they need to have an intervention. But I think the key part is, I think we have to be quite humble as an NHS, to recognise the perspectives of all of the other organisations.

So, I met with East Sussex Fire and Rescue last week. I'll be honest with you, they’re doing 10,000 checks a year, safety checks, for our community. I don't think we as an NHS are leaning as well into that initiative already. So, and the reason I say that is, people are out there doing things and I think we should be connecting ourselves better into that.

Therefore, there are things we have to do to recognise what are the features of ill health and what are the drivers behind that. In Sussex we've got six and they’re the things that people would expect about alcohol consumption, obesity, smoking, the things we know about. But I think we've got to get past naming those and saying,  what are the policy things we can do locally and what are the policy things that we can do nationally? And I think  ICS leaders have  a dual role. What is within my gift in terms of licencing to work with my locally elected politicians? Versus what is my ICS role with my fellow colleagues to say: “National bodies, if we don’t change this national policy, it therefore means we won’t be able to shift the dial on these matters.”

So, I see there are sort of two roles for us, but when I look at other things that we signed up to as a country, so we signed up to the 17 goals to transform our world as part of the UN Sustainable Development Goals. And actually, if we go back to the basics here, we still have people in the UK in poverty, we still have people in the UK without good educational outcomes. We still have people in the UK without good access to appropriate housing. We still have people who therefore do not have a voice to help shape their lives in the way they need to.

So, we've got to recognise that if we don't tackle those things, ill health will just happen. So, I think we’ve made the moral case. We've made the economic case. I think now there's a leadership behaviour and frame that we need to work on.

I think we also need to recognise that historically that has not been seen as success for the NHS because of course in the old days the NHS was about delivering an NHS service. But I've seen a significant change of mindset in a number of leaders in my own system, and nationally, to really want to get involved in these early interventions.

And there are things that already we're seeing across the ICS network, across organisations within ICSs about giving people access to employment through things like the apprenticeship levy or working to Sure Start programmes. So I think we're starting to consider economic improvement is built on people being meaningfully employed, therefore getting greater economic output. And we are the largest employer in many of our systems with a significant vacancy rate. So I think we have to look at ourselves and say, are we really working in the most effective way to get that done?

And I think we need to move away from a thousand flowers blooming in that space and be really clear about how does the NHS work to really get economic regeneration and improvement of a local system and the people who are best placed to advise on that is our local authorities, because they’re the ones who’ve been working with local enterprise initiatives for many years.

So, I'll go back to humility and humbleness is required, I think, in our leadership working across our systems.

Matthew

And I know that one of the things you've been thinking about is the question of people of working age who aren't in work and whether health and care is an important component of that. And you'll know, of course, that we at the Confed published a report a few days ago about the economic value of health and care in investment. And a lot of that argument was to do with the fact that we've got, what, an extra two or 300,000 people who've dropped out of the labour market since covid. And we have really, really tight labour markets. We find it hard to recruit ourselves. But health and care is one of the biggest reasons why people of working age aren't in work. So that's a very kind of concrete issue with the potential for, for very much for a kind of win-win outcome, isn't it.

Adam

Yes, it is. I mean, so there's a few signature moves that my own system want to make as part of our strategy going forward.

So, we're starting to consider things like, okay, should we, we're really fortunate to have three really thriving universities in Sussex, but we do lose people once they've graduated from their health and care roles because it's quite expensive to live here. So therefore, should we, for example, say things like we will guarantee a role for everybody who wants to work in Sussex and we'll find for the first three years accommodation for you at subsidised level.

So,  we're thinking that through; now that’s an idea. Can we pull it off? Well, that requires us working with a number of different sectors that we're not so used to working with. But in many respects our universities are used to providing accommodation for people, so let's speak to them about how they done that. And so that's one about, you know, that the clinical, those training to get into where we’ve got significant vacancies in our system.

But secondarily to that then our other signature move needs to be a hyper local employment offer for those who are currently out of work. So  we're thinking of something, should we pick, you know, 18 to 25 and say, for example, we will offer you a six-month role in our NHS above minimum wage to get some skills and should we just be really bold about that and then and almost hold a very open sort of market place and we will just find work for people because we know that a lot of these people have got great skills. They've just not been able to find a role yet in society. So can we do that?

We haven't yet got that completely nailed down. But we're really clear in Sussex, it will be a community resilience strategy based on neighbourhoods, underpinned by workforce, underpinned by data and information. So if we're going to say that we're going to need something pretty bold in that space, but it has to be done with and through the partners, not against them. And people have already advised me, oh Adam, that's a great idea but I would do it this way not that way. And we have to just be really, really open to hear perspectives of people that are also struggling with the same problem, but have also tackled it and got better results than we have.

Matthew

How really interesting. So that's this kind of reframing our role and reframing what we mean by health policy within a locality.

But then there's the question of the shift in the health service. And I describe this as three shifts:One is from incentivising activity to incentivising outcomes. The second is from focusing on demand to focusing on need, which is really the kind of health inequalities dimension. Then thirdly, the need ultimately to shift resources upstream out of acute proportionately into community prevention, primary.

Now we've been talking about those kind of shifts for a long time, but they're hard to accomplish. And just this week I was in Northern Ireland and Jim Mackey came over, did a really powerful presentation about his work, some really powerful data. But the question I asked Jim was how do we avoid a kind of contrast between something like his strategy, the elective recovery strategy, which focuses on acute, puts more resources into acute and in some ways could be seen to be kind of reinforcing the way the health service works. How do we do that? Because we have to do it, but at the same time try to actually shift the way the health service works in this kind of way we've been talking about, but we haven't achieved it. That's a really difficult balancing act, isn’t it Adam?

Adam

You've heard me speak about before. But I speak a lot about perspective taking of all of our roles.

So first of all, Jim has done a fantastic job trying to get our elective recovery into a much better shape. And let's be really honest with you, a day one issue post pandemic, how many people were waiting are still waiting today. So in reality, those people are waiting on a list and we want to get them seen as quickly as possible.

But I don't see the world in such binary terms, though. I think as we look at it, we would all accept that the leadership challenge - one of the reasons we have people in those lists is because we haven’t intervened upstream. I think we recognise that. But they are on the list, and we want to get them seen as quickly as we can.

So, therefore we've got to balance those two things out. My take is we need to be open about activity because activity does talk to productivity without measuring it and we only focus on the outcomes. I think the fact is  a) impossible in the current political climate where there is an accountability of the NHS to government and there is an ask about how productive we are being.

So I think we have to find a way of describing the activity piece, linking it to the outcome. In my system, for example, we’re one of the most productive systems getting through our elective care list but we're still just below middle of the pack of ICSs about elective care performance because we have a long backlog.

But as I look at it, I feel really comfortable speaking to Jim about what more can I get done? But we're really getting through the activity and we're looking at our waiting lists through outcomes and in those dialogues, it's been a really healthy debate and challenge.

But I think we do get ourselves caught a bit when we say we're going to take resources out of the acute and put them in the community. It just almost sets the system up to have an argument.

So what we're describing in our system, and what I’m hearing all across the country, is we want to see a clinical transformed model of care where people who do work in hospitals are going to start doing more similar work in the community.

I don't see it so much as if we're going to take the money from X and move it to Y. I think it's more about where is the activity best going to be done and best going to be held? Linked to that, we've got to also challenge ourselves about the digitisation agenda. How much are we pushing innovation? What we're not saying is we're going to take an acute model and put it in the community.

I think the biggest challenge that we have now is galvanising our clinical leaders to be really open to really changing. And you see it all across the country. When I speak to ICS leaders you see some great things, but we don't do it as a natural course of action. It relies on leaders being quite brave to really push the envelope. And I think the next five years should be about really challenging ourselves about how we how we organise ourselves clinically.

I feel able to say that as a clinician because I still look at my own profession and go, I think that physiotherapy could work really, really differently. But it needs all the professions to come together and get right what is now a forward-looking clinical model of care, in a resolute community. And of course hospitals exist. We will always need them. But do we need everything happening in hospitals the way it happens now? Most definitely not.

Matthew

I'm really glad that you talked about leadership because I just want a moment on that before we do talk about winter.

I think it is essential that ICSs do offer a different kind of public sector leadership and I don't think we should underestimate how challenging that is. So, you know, we at the Confed have just launched a really ambitious and quite kind of left field leadership development programme for ICS leaders. And that's kind of based on this idea that we do need a different kind of leadership.

But what I find interesting is, I talk to ICS leaders about this and they completely get it. They recognise ICSs have to be enabling facilitative problem solving, value adding, not bureaucratic. But yet, when I ask leaders how do they try to make change happen, it is quite interesting how quickly we revert to the language of control, regulation and command.

So there's something really challenging, important, but also exciting about how do we understand how leaders lead in a complex environment where it's not about exercising control, which is what we already know, when we're anxious as leaders, I'm a leader, you revert to trying to exercise control, but how do we achieve change in a complex, risky environment without reverting to those kind of traditional models of control?

Adam

So I think it's really important. As a leader, I look at my leadership toolbox and I have to choose which implement to use depending on the situation.

I naturally fall to a collaborative style, these days, I wasn't always that way. When I was first developing as a leader, I had a view of it that was sort of a little bit like, okay, I'm in charge and here's how we do stuff. And, you know, there were some great things I managed to achieve doing that, but somethings I didn't achieve as well as I could.

I learned very early on in my leadership journey that, first of all, no matter who you're dealing with, at whatever level in an organisational system, people need to feel that you think they matter and you need to genuinely think they matter and they need to feel heard, and that's whomever you're dealing with.

So, I think therefore we have been at times, the NHS, quite insular in how we look at things. And what I, what I've learned is going out and listening to what it is like to be a director of children's services in 2022, what it is like to be a head teacher in 2022, what it's like to be,, dealing with housing issues at district and borough level in Worthing in 2022, is an important thing to keep doing because we all take views of things we all try to have, have long-held beliefs about things and just enabling yourself to keep seeing the perspective of others is really, really important.

But of course, you've then got to find a way of corralling everyone together around a vision. I find that increasingly easier when you know people well. So there is a relational part to this job that I find that is really, really key.Some people say to me, well, why do I find it easy? I don't think I find it easy, but I find it easier the longer I've been here. I've been in Sussex for six years. So there's a longevity of relationships that just get tested at times that you build from.  

I think we have to recognise that all systems need time for those relationships to build, need time to take perspective. But then they have to be quite bold on a vision that people can get around. We started in our patch about communities and actually we landed on ‘resilient’ communities because the resilient word meant so much to our partners and it meant that they could therefore bring more of theirassets to bear to respond to that.

So that's one part of the of the leadership tool. But there are days where also I have to say to some of my NHS colleagues, I'm looking at the productivity numbers, I’m looking at your performance, I’m looking at the quality indicators, can we please have a conversation about that? ButI think that's about recognising I have a statutory role - leading the ICB. But there's a way you do that, I think, which is to try to enable to hear but also be clear about expectations. But my, but my overriding view is, is if you do that with the way of treating people well, treat them as you would expect to be treated it doesn't mean you can't have a difficult conversation or convey a difficult message.

My learning as a leader is you've got to be able to convey a message where people can hear it and do something about it. And therefore, knowing the individual you're dealing with and therefore tailoring it so that they can hear it so they can do something about it is the most important thing, because then doing something about it means it improves the outcomes for patients.

So that's that, that's as I look at it. But I do see there are times for different conversations, different tone, different style depending on the problem. But I think we all as leaders need to make sure we've got rounded toolbox so that we're able to use a different wrench or spanner or screwdriver, depending on the situation.

Matthew

Absolutely fascinating, Adam. Now, I could talk with you for hours, but you've got to go to a meeting very soon. So on winter, we haven't got much time left to talk about winter. But just tell me, I know you've spoken to other ICS leaders about winter. Tell me how you're seeing winter. And tell me, Adam, what do you see as being the critical things that ICSs need to focus on if we're going to get through the next few months, minimising patient risk and harm?

Adam

So first of all, it's really important that ICSs are value adding to those who are delivering care in very, very challenging circumstances.

I think it's important also that ICSs work with their organisations, to give them what they need if they can give it.

So if it's staff, if there are resources that people need, I think we've got to be seen to help. So this is not just about holding people to account. This is about getting on the ground, helping people to change things.

If your frailty pathways are not right, you need to quickly redesign them with your providers and get this sorted out. If your fall service isn't really up to scratch, then it's not about, what does the contract say, it's about, okay, let's pull people together to get it right.

And the third thing I think is really important that a lot of people are worried about is the risks they're carrying. So therefore hear those concerns and then bring clinical leaders across the spectrum of all organisations and professionals from local government together to have an honest conversation about today, where do we feel the greatest risks are? What risks are we prepared to bear on behalf of each other to give our patients the least risky outcome on a day-by-day basis? That's not a monthly thing, that's a battle with them for that.

So I do think that having the winter system coordination centres in place, properly staffed that can be seen to be value adding to organisations is really key and I think, be high on the challenge but high on the support. And recognise yourself - I tell all ICS CEOs, recognise your own anxieties, recognise those of your team and manage those because no busy chief executive of a trust, PCN clinical director, community psychiatric nurse needs us to be adding more pressure because we're anxious. Our job is to manage that, work well with our regional teams to help to manage what regions and national teams need, but really help to clear the way to let people get on.

Matthew

Yeah. And I think we both heard, didn't we, last week Amanda Pritchard’s really strong message, which was that as long as systems have developed a kind of common truth about risk, and as long as they base their strategies robustly on data and obviously protecting patients, then she'll do what she can at the centre and working with regulators to give systems the space to do what they need to do to manage risk best. And I thought that was really powerful when she said that. Adam, thanks so much for spending time with us. You know, and good luck in the weeks and months ahead. Thank you.

Adam

Thanks, Matthew.